Stephen L. Schensul

Men’s Extramarital Sex, Marital Relationships and Sexual Risk in Urban Poor Communities in India

The objectives of this paper are to (1) understand the nature of men’s extramarital sexuality in three low income communities in Mumbai, India; (2) explore the associations between marital relationships and extramarital sex; and (3) assess the implications of the research results for intervention. Results are based on survey data collected from 2,408 randomly selected men from the three study communities and a matched subset of 260 randomly selected men and their wives who responded to a female version of the mens survey. These surveys produced a unique data set, which allows sociodemographic, attitudinal and behavioral variables from husband and wife and variables that are the product of husband and wife interaction to be utilized to predict mens extramarital sex through multiple sequential logistic regression analysis. Results indicate that mens extramarital sex is significantly associated with husbands and wifes age, wifes perception of domestic violence, husbands education and place of birth, husbands alcohol use, wifes willingness to engage in marital sex, and types of marital sexual acts. These results confirm the need to move from the individual to the couple as the unit of research and the need for intervention to reduce the risk of HIV/STI transmission within marriage both in India and internationally.

Multilevel Perspectives on Community Intervention: An Example from an Indo-US HIV Prevention Project in Mumbai, India

This paper explores the meaning and applicability of multilevel interventions and the role of ethnography in identifying intervention opportunities and accounting for research design limitations. It utilizes as a case example the data and experiences from a 6-year, NIMH-funded, intervention to prevent HIV/STI among married men in urban poor communities in Mumbai, India. The experiences generated by this project illustrate the need for multilevel interventions to include: (1) ethnographically driven formative research to delineate appropriate levels, stakeholders and collaborators; (2) identification of ways to link interventions to the local culture and community context; (3) the development of a model of intervention that is sufficiently flexible to be consistently applied to different intervention levels using comparable culturally congruent concepts and approaches; (4) mechanisms to involve community residents, community based organizations and community-based institutions; and (5) approaches to data collection that can evaluate the impact of the project on multiple intersecting levels.

Reflecting diversity and complexity in marital sexual relationships in a low-income community in Mumbai

This paper describes findings from a study on spousal communication and sexual decision making among women and men from a low-income community in Mumbai. The study explored the link between contextual, individual and socio-economic factors, sexual behaviours and communication to highlight sexual health consequences for women and men. It utilized a combination of qualitative and quantitative methods including a community profile survey, focus group discussions, repeated in-depth interviews, pile sorting and the sequencing of sexual behaviours. Family structure and duration of marriage were found to influence the quality of marital sexual relationship. Early experiences of violence and coercive sex limited womens participation in, and enjoyment of, sex. Respondents revealed a normative sequence of pre-coital sexual behaviours; those reporting sexual violence invariably violated this sequence. Womens experiences of sexual violence revealed lower perceived equity compared with men. Respondents reporting an absence of sexual violence revealed increased satisfaction in sex and highlighted positive aspects of the marital relationship.

Community-Based Sexual Risk Prevention Program for SRI Lankan Youth: Influencing Sexual-Risk Decision Making

This article describes the design, implementation, and evaluation of a sexual-risk prevention program focused on the development of individual competencies and cultural norms promoting healthy sexual decision making. The community-based peer-facilitated intervention targeted adolescents and young adult men and women in Sri Lanka, who participated in small-group activities targeting sexual knowledge, attitudes, and practices; risk perception; and sexual-risk decision making. The intervention and evaluation tools were based on formative research data collected from members of the target population. Researchers from Sri Lanka and North America collaborated with local community health workers and community members in formative data collection and program development. The pilot intervention project was successful in improving sexual-risk perception and decision making, and (for women) knowledge of condoms and sexual terminology. The use of group process showed promise as a tool for fostering negotiation of perspectives and consensus building regarding sexuality and sexual risks. The lessons learned from this project can inform the development of culture-specific sexual-risk prevention programs worldwide.

Sexually transmitted infections in men in Mumbai slum communities : The relationship of prevalence to risk behavior

Objectives: The objectives of this study were to identify sexually transmitted infection (STI) prevalence, assess behavioral and symptom correlates, and develop intervention strategies. Goal: The goal of this study was to conduct one of the first community-based surveys of STI prevalence and risk behaviors among married men in India. Study Design: In 2003, 2,408 randomly selected married men, aged 21 to 40 years, were administered a survey instrument with urine and blood samples collected from a random subset of 641. Results: The most common current STI was gonorrhea (3.9%) with 6.1% of men being positive for an acute STI and 9.7% antibody-positive for Treponema pallidum or herpes simplex virus type 2. Risk behaviors were not associated with laboratory confirmed STIs, but did show an association with mens concerns about sexual performance derived from traditional Indian systems of medicine. Conclusion: Culturally based symptoms can serve as effective markers for men involved in risky sexual behaviors and provide an opportunity to engage these men as they seek care for these symptoms at community-based service points.

Treatment Seeking, Vaginal Discharge and Psychosocial Distress Among Women in Urban Mumbai

Vaginal discharge (safed pani in Hindi, meaning “white water”) is one of the leading symptoms for which women in India seek care. Treatment-seeking for safed pani is disproportionately high among poor women, representing a physical, emotional and financial burden for low-income families. Safed pani is only rarely indicative of a reproductive tract or sexually transmitted infection. The discrepancy between symptom reports and observed pathology has led some researchers to characterize safed pani as a culturally based expression of more generalized negative life situation. Data are drawn from two prevention intervention studies (2002–2006 and 2007–2012) conducted in economically marginal communities in Mumbai. Results show that husbands as problem generators and spousal abusers and women’s greater perceived empowerment and reported tension are significantly associated with safed pani. These results provide the basis for identifying women at greater risk for psychosocial distress and providing supports at the locations at which they seek treatment.

Community-Level HIV/STI Interventions and Their Impact on Alcohol Use in Urban Poor Populations in India

This paper describes an Indo-US, research and intervention project for HIV/STI prevention and sexual risk reduction in urban poor communities in Mumbai, India in which formative research established the importance of reduction in alcohol use as one of the central features of the intervention. As a part of formative research, in-depth interviews with married women and men indicated that alcohol had a direct negative effect on marital relationships, violence, household economics and men’s involvement in extramarital sex. The project utilized diverse community intervention mechanisms over the course of a three year intervention effort. Comparison of pre-post intervention, cross-sectional samples showed a significant drop in overall use of alcohol in the study communities. Analysis of a longitudinal panel sample identified sub-groups of married men based on their demographic, behavioral and attitudinal characteristics at baseline who stopped drinking during the intervention period. Results also demonstrated that a reduction in men’s alcohol use during the intervention period was associated with a reduction in sexual risk behavior and related variables.

Factors associated with HIV/AIDS sexual risk among young women aged 15-24 years in Nigeria

The growing rate of sexual risk-taking among young people contributes significantly to the spread of the HIV/AIDS epidemic in Nigeria. This study, explores the influence of socio-demographic, HIV/AIDS awareness and female empowerment on the sexual risk behaviors of unmarried Nigerian women aged 15-24. The data presented in this paper was drawn from the 2003 Nigeria National Demographic and Health Survey. The sample consisted of unmarried women aged 15-24 in the dataset. Data was collected through a structured and interviewer administered questionnaire. Multivariate logistic regression models were used to identify the most important predictors of sexual risk behaviors. Sexual risk-taking is relatively high among unmarried young women. Among those who are sexually active, 80% indicated that they did not use a condom during their first sexual encounter. Regression analysis revealed that younger age, lower HIV/AIDS prevention and transmission knowledge, lower knowledge of where to obtain condoms, lower material standard of living and greater intimate partner violence were significantly associated with sexual risk-taking in this population. Findings revealed that the sexual behavior of unmarried Nigerian women aged 15-24 is influenced by a complex matrix of factors. Identifying specific processes and contexts that promote the concentration of risk among sub-sections of young unmarried women aged 15-24 years in Nigeria should be a research and intervention priority.

A Model for Translating Ethnography and Theory into Culturally Constructed Clinical Practices

AbstractThis article describes the development of a dynamic culturally constructed clinical practice model for HIV/STI prevention, the Narrative Intervention Model (NIM), and illustrates its application in practice, within the context of a 6-year transdisciplinary research program in Mumbai, India. Theory and research from anthropology, psychology, and public health, and mixed-method ethnographic research with practitioners, patients, and community members, contributed to the articulation of the NIM for HIV/STI risk reduction and prevention among married men living in low-income communities. The NIM involves a process of negotiation of patient narratives regarding their sexual health problems and related risk factors to facilitate risk reduction. The goal of the NIM is to facilitate cognitive-behavioral change through a three-stage process of co-construction (eliciting patient narrative), deconstruction (articulating discrepancies between current and desired narrative), and reconstruction (proposing alternative narratives that facilitate risk reduction). The NIM process extends the traditional clinical approach through the integration of biological, psychological, interpersonal, and cultural factors as depicted in the patient narrative. Our work demonstrates the use of a recursive integration of research and practice to address limitations of current evidence-based intervention approaches that fail to address the diversity of cultural constructions across populations and contexts.

A methodology for building culture and gender norms into intervention: An example from Mumbai, India

This paper responds to the call for culturally-relevant intervention research by introducing a methodology for identifying community norms and resources in order to more effectively implement sustainable interventions strategies. Results of an analysis of community norms, specifically attitudes toward gender equity, are presented from an HIV/STI research and intervention project in a low-income community in Mumbai, India (2008-2012). Community gender norms were explored because of their relevance to sexual risk in settings characterized by high levels of gender inequity. This paper recommends approaches that interventionists and social scientists can take to incorporate cultural insights into formative assessments and project implementation These approaches include how to (1) examine modal beliefs and norms and any patterned variation within the community; (2) identify and assess variation in cultural beliefs and norms among community members (including leaders, social workers, members of civil society and the religious sector); and (3) identify differential needs among sectors of the community and key types of individuals best suited to help formulate and disseminate culturally-relevant intervention messages. Using a multi-method approach that includes the progressive translation of qualitative interviews into a quantitative survey of cultural norms, along with an analysis of community consensus, we outline a means for measuring variation in cultural expectations and beliefs about gender relations in an urban community in Mumbai. Results illustrate how intervention strategies and implementation can benefit from an organic (versus a priori and/or stereotypical) approach to cultural characteristics and analysis of community resources and vulnerabilities.