The document describes how ethnography was used to inform culturally-based interventions in India. It summarizes how ethnographic research identified key cultural concepts in local communities, such as "gupt rog" among men and "safed pani" among women, which were used as entry points for public health programs. Focusing on these emic perspectives allowed the design of interventions that were salient, engaged community participation, and had potential for sustainability.
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Using ethnography to generate culturally based interventions_schensul_5.3.12
1. Using ethnography to
generate culturally-based
interventions
Stephen L. Schensul PhD
University of Connecticut School of
Medicine
CORE Group Spring Meeting 2012
Wilmington, DE
2. What is ethnography?
Documents of the “worldview” of residents of the
target communities (the emic view)
Focuses on local communities, making it possible
to have face-to-face interaction (participant
observation) with residents
Uses qualitative and quantitative methods
(mixed methods)
Describes cultural (behavioral guidelines) and
patterns (continuity through generations),
cultural change (dynamics), and intracultural
variation
Concerned with the impact of global, national and
state (macro) policies and institutions on
phenomena in local communities (micro)
3. What are culturally-based
interventions?
Identification of and building on:
a set of collectively held beliefs and
behavioral guidelines
that have some continuity from one
generation to the next
that provide a relevant and salient
context within which an intervention
program can be linked
(“a hook on which to hang intervention”)
4. The need for cultural connection
Salience
Community participation
Community resources
Sustainability
6. The Problem: HIV in India
2.5 million people are HIV+ in India
The gender ratio has shifted over the
last decade from 5 males to 1 female to
1.7 to 1
Women’s greatest risk for HIV/STI is
transmission from their husbands
Men are significant underutilizers of the
public health care system for sexually
transmitted diseases.
The focus has been on the “high risk”
7. The Study Communities
“Slum” area in the northeast
quadrant of Mumbai
700,000 people
66% migrants, primarily from
Northern States
Mix of Muslims (54%)
and Hindus (46%)
Primarily day laborers
Mean income of US$75
per month
How do we involve a general community in the effort
to prevent what they have yet to experience?
8. Key Concept: Gupt Rog (Secret illness”)
Men’s major concerns in terms of their
sexuality focus on performance issues
(kamjori), the nature of semen adequacy
(dhat), and STI-like symptoms (garmi)
Etiology focuses on semen loss through
nocturnal emission and masturbation
Consequences are described in terms of
inability to satisfy wife and other women,
threat to masculinity
Treatment primarily by non-allopathic
providers
9. Gupt rog
as a marker of sexual risk
Baseline survey data showed:
Over half (53.2%) have at least one
symptom
A significant relationship between the
presence of gupt rog symptoms and
extramarital sex among married men
Significant relationships between the
presence of gupt rog symptoms and
antecedent behaviors including alcohol use,
intimate partner violence and risky activities
with friends
10. AYUSH Providers
AYUSH (“life” in Hindi, Urdu, and
Arabic) is a new acronym for Ayurveda,
Yoga and Naturopathy, Unani, Siddha,
and Homeopathy
11. AYUSH Providers
Providers in the study communities
are ayurveda, unani, and homeopaths
Holistic traditions of traditional
(primarily herbal) medicines have
evolved to a focus on symptoms and
heavy use of “English medicine”
(antibiotics)
219 private practice providers;
majority of patient visits are by men
Primary resources for men with gupt
rog
12. Allopathic
System and Sexual Health
Nearby hospitals, three urban health
centers and two health posts almost
exclusively focused on maternal and
child health
Negative and dismissive view of gupt
rog
Few men sought care at the
dermatology/STI clinics in area hospitals
13. Cultural and local opportunities
A salient set of concepts about sexual
health concerns and treatment seeking
Preliminary data, which shows
significant association between gupt
rog and risky behavior
A public allopathic system seeking
ways of engaging men into treatment
for HIV/STI, but little understanding of
gupt rog
Traditional practitioners who address
gupt rog, but have limited training in
sexually transmitted infections
14.
15. Challenges to Addressing Women’s
Sexual Risk
A subset of women:
• Do not speak openly about health
problems (especially sexual health)
• Have health concerns but secondary to
husband’s and family’s
• Have limited ability to make
independent decisions regarding sexual
and reproductive health
• Limited mobility
How to access and engage women?
16. Culturally-based symptom:
safed pani (“white [vaginal] discharge”)
Most common presenting complaint among
women in the study community and in South
Asia
Varying in viscosity, color and odor put of
limited predictive value in determining
pathology
Associated with other psychosomatic
symptoms (“weakness,” body pains,
“tenshun”) and pregnancy/delivery
Only a small number are found to be related to
sexually transmitted infections
Provides the opportunity to engage women at
the health point-of-service
17. Interrelationships of Women’s Life
situation and sexual risk with safed pani
Violence Hu EMS
Hu/Wi Comm. Safed pani STI know
Self-Esteem
Disempowerment Risk
Perception
Tenshun .358 .140
Negative Life HIV/STI
Situation .217 Risk
18. WOMEN’S HEALTH CLINIC
• Established in 2008
• Criteria SYMPTOMS
–Safed pani
–Genital itiching
–Burning micturition
–Lower abdominal pain
–Genital ulcers
–Inguinal swelling
19. Services provided at WHC
Health education
History, external &
internal per speculum
examination
Cervical, vaginal
swabs taken
Syndromic
management per
NACO guidelines
Condom Promotion
Counselling services
Partner Notification &
Referral
Women called for
follow up and lab
20. WHAT FORMATIVE RESEARCH
METHODS WILL ALLOW US TO
IDENTIFY THESE CULTURAL,
COMMUNITY AND COGNITIVE
ELEMENTS?
…and do so in an expeditious (reasonable
time and resources) manner!
21. Ethnographic Methods
Method Explore Define Confirm
Key Informants X X
Group interviews X X
Observation X X X
Social Mapping X X
Cognitive mapping X X
Social networks X X x
In-depth interviews X
Semi-structured X
interviews
Surveys X
Focus groups X
22. Research Model
(Horizontal Domain Modeling)
PEERS KNOWLEDGE
SEXUAL PROTECTIVE
FAMILY
BEHAVIOR BEHAVIOR
COMMUNITY ATTITUDES
24. Qualitative Research Quantitative Research
Describes the nature of Measures the quantity
the phenomena of phenomena
Builds models in Primarily deductive -
deductive-inductive tests current knowledge
interaction
Unit of analysis is
Multiple units of analysis usually the individual
Emphasizes validity Emphasizes reliability
Usually uses
convenience, snowball
Random sampling
and quota sampling procedures
25. Creating qualitative (textual)
data
From observation and interviewing to
recoding with “jottings” or audio
recorder
Transcribing jottings/recordings into
typed text
Entering the text into a computer
software program (Atlas.ti, Ethnograph)
Coding the data
Analysis
27. Secondary data
Census
Voter roles
Prior research studies
Governmental surveys
Demographic and Health Surveys
(DHS-Macro International)
CDC surveys
Medical/clinical records
28. Interviews with key
informants (cultural experts)
Key informants are individuals with
special knowledge about women in the
populations under study:
Community leaders
Reproductive and family health workers
Work and school administrators
Leaders of women’s
organizations
Community organizers
29. Results
(from Sri Lanka)
The importance of virginity and
sexuality
Male to male sexuality
Culturally specific sexual practices
Role of family, peers, community
Gender differentiation
Changing societal dynamics
Difficulty of access to services
30. Group interviews
Any discussion occurring between
the ethnographer and more than one
individual in the community
Naturally occurring groups (women
gathering at water sources, men at
tea stalls, youth at school recess)
Focus on broad features of the
community
Identify variability
31. Results
Development of rapport
Identification of social networks
Description of key features in the
community
Collection of attitudes and opinions
Documentation of what is on
peoples’ minds
32. Mapping and observation
Mapping of behavioral scenes
Meeting places
Lovers lanes
Recreational settings
Work settings
Schools
Observation of behavior
Daily schedules
Subgroups/cliques
Coupling
33. Results:
Coupling Behavior
Opportunities to meet: Transport
from work in Mauritius and tuitions in
Sri Lanka
Opportunities for intimacy: Beaches
and gardens in Mauritius/lovers
lanes, jungle, toilets and rice paddy
in Sri Lanka
Opportunities for risky sex: hostels
in Mauritius and 3-wheelers and
CSWs in Sri Lanka
34. Social Mapping
1. Local residents asked to
draw landmarks and
high risk sites in their
area to identify these
locations on a
conceptual or actual
map.
2. The process provides
ethnographic data on
the community and
introduces researchers
to further key
informants.
Places where people go for
drinking and sex
36. Study site 1
Digitized Map of Study
Area
Study site
1
Study site
3
Study site
2
Study site 1
37. In-depth Interviewing (IDI)
Focus on the lives of individuals
Minimalist questions guided by the
research model promoting
respondent narratives (stories)
Sampling frame selected on
knowledge (from key informants) of
major variations within the
community
Emphasis on discovery
38. Results
How the focal topic (sexual risk) fits
into the lives of youth in Sri Lanka,
young women workers in Mauritius,
married men and women in urban
India
The range of variation in sexual
behavior, IPV, marital
communication, women’s health
The discovery of new domains and
factors to revise the model
39. FREE-LISTING AND CONSENSUS
MODELING
Free-listing: Respondents to list all
sexual behaviors they know……..
Consensus modeling: Sexual behaviors
are placed on index cards and
respondents are asked to sort by
affinity
Analysis using ANTHROPAC
40. Results for 21 Female Youths: Cognitive
Organization of Intimate Behaviors
Expressing Partying Penis
feelings/thoughts Having Penis
in vagina in anus
3 Sex
Writing
letters Caring for Oral sex Oral sex
each other Moaning/
groaning (M to F) (F to M)
Giving Talking to
gifts each other
Fingering
Going out
on a date
Licking
Sweet Kissing the body
Holding Cuddling 1 2
talking the body
hands
Hugging Kissing Rubbing
Feeling on Touching bodies
Kissing each other the body
with tongue
Initial Stages Later Stages
41. Results for 29 Male Youths: Cognitive
Organization of Intimate Behaviors
Having
Moaning/ sex
Going Penis in
out on a Partying groaning vagina
date
Oral sex Penis
Talking to (F to M) in anus
Expressing each other Oral sex
feelings/ (M to F)
Sweet
thoughts
talking
Caring for
each other Fingering
Writing
letters
Holding
hands
Hugging Kissing Licking
the bodythe body
Cuddling Feeling on Rubbing
each other bodies
Touching
Kissing Kissing the body
w/ tongue
Initial Stages Later Stages
42. Social Network Analysis
(1) Ethnographic mapping of social
networks (family, friendships, work
groups, voluntary organizations)
The identity of the people in groups
How people define membership
Rules for inclusion/exclusion
(2) Ego-centered networks focused on
index/focal individuals
(3) Full relational social networks in a closed
network in which the
44. Sister Mother’s Network for Mother
-in-Law
Childhood
Health Decisions
Sister
Mother
Husband -in-law
Mother (ego)
Neighbor (B)
Friend B
Neighbor A
Friend A
Community
Outreach
Worker
45. Results
Identification of focal people in sub-
group (e.g. opinion leaders)
Delineation of the movement of
information among group members
and between groups
Group facilitation and barriers to
behavior change
46. Ethnographic Survey Instrument
Content:
Closed-ended items based on qualitative
data gathering at the domain, factor and
variable levels
Variability in the response to items
Administration:
Structured interview
Questionnaire
Sampling:
Random
Systematic random
Clustered random sampling
47. Results
Prevalence of the focal and related
issues in the population
Identification of antecedents and
consequences through bivariate and
multivariate hypothesis testing
Numerical data to policy makers
Baseline data for evaluation of
intervention impact
48. Focus Group
Formal meeting
Selected individuals invited who
generally are not linked
Facilitator and a recorder
Objective to achieve consensus on a
specific topic:
--Research results
--Translation of results into an
intervention
--Intervention plan
49. Results
Formal participant input
Modifications that fit the community’s
social and cultural dynamics
Opportunity for multiple meetings
providing on-going modifications and
input
An evaluative tool for the intervention
50. Conclusion: Time and
Resources
Many social scientists and public health
researchers want to study “forever”
Funders want implementation and
results immediately
Rapid techniques (RRA, RAP) have been
developed
But “what’s the hurry”
The key is not so much time/resources
but finding that “cultural hook”
Notas del editor
This map shows the results for the 21 female youth participants. This pattern was not that different between AA and Hispanic girls and so the overall pattern for girls is shown. Here, we see a far fewer number of overall clusters indicating that girls tended to group their behaviors into fewer piles. Here, the transition cluster of kissing actually went more closely with the initial stage behaviors, and there is no transitional cluster between the initial stage behaviors and the later stage clusters. Also, feeling on each other clustered with the heavy petting behaviors, and fingering with the oral and penetrative sex behaviors. So, these “transition” behaviors are being specifically placed by females as conceptually closer to one set of behaviors or another, rather than distinctly on their own, perhaps indicating that they are less viewed as “transition” behaviors. 1 2 3
Similar pattern seen regardless of race group. Stress level of 2-D representation higher for boys than girls (.178 vs .132, with <=.15 as desirable stress level). So, indicates that it was harder to find clustering and to represent clustering in 2-D for boys than for girls. 1 2 8 6 7 5 4 11 3 9 13 12 10