New STEPs in India – The Snowball Effect Rosy Chhabra, Psy.D. Carolyn Springer, Ph.D.

Focus on India 3.5 million people living with HIV in India (revised) –Estimated adult prevalence.0.36% –Men 0.43%, Women 0.29% Heterosexual contact (86%) –89% are between years –30% are between years –40% PLWHA are women Maharashtra (20% of PLWHA) is one of six Indian states classified as “high prevalence.” We focused our initial work with youth in schools of Mumbai in Maharashtra State

Some STEPs to make the way….  Collaborate with local CBO (DAIRRC) in Mumbai (DAIRRC: Drug Abuse Information, Rehabilitation and Research Center)  Assess needs and feasibility with focus groups  Design the new curriculum  Build on ideas from existing US programs (PATH, and Keepin’ It REAL)  Tailor the new program to Indian culture  Form Advisory Committee  Create an IRB committee and FWA for DAIRRC  Design a training program for 50 teen trainers

STEP I (PILOT) Focus on HIV Prevention  Aim was to educate Indian youth aged about HIV  Target age was years (8th grade).  Train undergraduate college students (17-21 years) using ‘Train-the-Trainer’ model to teach children in school.  Program effectiveness was measured by a series of knowledge, attitude, and behavior-related questionnaires.  ANOVA was used to analyze pretest and post-test scores with each scale as the within-group measure and group (experimental vs. control) as the between-group measure. STEP I was funded by World AIDS Foundation: WAF 256 (01-036)

STEP 1: Some Results! (n=1846) (N=1846) A higher score meaning greater knowledge of HIV infection (Significance level ** p = <.001) (N=1542) Lower Score means greater agreement with positive statements about PWHAs (Significance level ** p = <.001) (N=1545) Lower score - more confident about utilizing newly learned skills (Significance level ** p = <.001) (N=1544) Lower score means less likely to follow peers (Significance level * p<.01)

LESSONS FROM STEP I  High acceptance rate and success suggests need to reach more schools and more students  Increase intensity by increasing sessions from 6 to 10  Need longer training time / booster sessions for trainers  Collect more detailed demographic/session information  Assess substance use, intention and risky behavior along with self efficacy and social support  Need to lengthen follow-up to assess the retention and reinforcement of the information  Building on our success of STEP I, we put the ingredients together to address the synergistic effects of alcohol use and HIV/AIDS (STEP II)

2 nd “STEP”: FOCUS ON ALCOHOL ABUSE and HIV/AIDS  The target age increased to yrs (8th and 9th grades)  Plan to reach 100 schools, 60 students/school (n=4000)  10 sessions over 10 weeks and a 6-month follow-up  Wider range of program effects are measured: knowledge, alcohol use, risk taking behavior, self-efficacy, communication skills, intentions of substance use  Results available from first 40 schools (about 3000 students) from Mumbai, Maharashtra  In the experimental group: The mean age was 13.9 ; 52% males and only about 14% had ever attended any kind of HIV prevention program STEP II is funded by National Institute on Alcohol Abuse and Alcoholism: R21 AA014826

RESULTS FROM STEP II - FIRST WAVE OF 40 SCHOOLS (1) (N=2117) A higher score meaning greater knowledge of HIV infection (Significance level ** p = <.001) (N=2113) A higher score means more able to define values regarding risky behavior (Significance level ** p = <.001) (Data analysis was conservative – only students who answered all items on any particular scale were included)

RESULTS FROM STEP II - FIRST WAVE OF 40 SCHOOLS (2) (N=2097) Higher score means more able to deal with peer pressure (Significance level ** p = <.001) (N=2105) Lower score means less risk taking behavior (Significance level ** p = <.001)

RESULTS FROM STEP II - FIRST WAVE OF 40 SCHOOLS (3) (N=2109 ) Higher score means a higher self efficacy (Significance level ** p = <.001) (N=2060) Higher score means improved communication skills (Significance level ** p = <.001)

OVERALL PROGRAM IMPACT  higher level of knowledge of HIV/AIDS  higher levels of self efficacy  feel more able to express their own views  higher awareness of peer behavior and influence  less risk taking  more confident about communicating their thoughts and feelings  less likely to indicate use of alcohol in the next 3 months

So what happened next?

Snow…..starting….. Added another city (state) – the Silicon Valley of India –Bangalore in Karnataka (11% of cases) High HIV prevalence (similar to Maharashtra) –Formed alliance with another CBO (ISBHT) –The same process of advisory board, IRB/FWA setting, program and data management training –So far we have completed the program in 20 schools and have recruited over 2000 students

Snow…. Falling fast and plenty! Next Stop – Himachal Pradesh –A highly “vulnerable state” with low knowledge and low prevalence –Small mountainous state of 6.2 million –Primarily a rural state and has exclusive districts with tribal populations –Socially disadvantaged –360 AIDS and 1492 HIV cases since 1992 –To date, program was completed in 24 schools (n=>1900)

Snow is getting heavy….! Based on need, Advisory Board’s insistence and epidemiology of CVD in India –We added a cardiovascular health education program for the control group –Assessed family history, overall health history (including general and mental health) –Completed in over 44 schools (n=3900)

Still falling…. From Bangalore schools (n=832, 414 males) Results showed that CVD program is successful One health history questionnaire showed that : –Youth with positive family history of coronary heart disease reported significantly higher somatic symptoms, increased anxiety/depression and stress –Positive family history of essential hypertension was also associated with higher somatic symptoms, greater anxiety/depression, higher hostility and higher reports of headaches. –Positive family history of stroke – increased self reports of allergies and stress.

And getting heavier….. Local CBO’s trained in STEP programs – got together in HP and have started an assessment of teachers and parents in the schools as well They have data on teachers from 18 schools (n=600) on knowledge, attitudes/beliefs and confidence in teaching HIV prevention programs and related skills Writing a new grant proposal to include a teacher training program in future STEPS

Starting to roll now… The local CBO in HP, Bangalore and Mumbai also completed focus groups with parents of adolescents regarding STEP program 8 focus groups conducted We are writing a program to teach STEP as a complementary program for the parents as well.

LESSONS LEARNED  Strategies of successful technology transfer and implementation  Involving community and sharing responsibility increases success and sustainability of programs  Program replicates on a larger scale in affected urban area  Need to expand to reach other areas of India  Need to involve teachers in a program to increase sensitivity and comfort level  Education program for parents needed to increase general awareness is important for sustainability  The successful cultural adaptation of the STEP model shows the feasibility of adapting this model for use in reaching adolescents in other parts of the world

New snow falling???? Given the support of the community along with success and receptivity of current STEP programs we will consider adaptation to: –Street children –High school dropouts –Youth in between high school and college –Children of the prostitutes –College students –Others?