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.

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

5. EXAMPLES FROM INDIA

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

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

23. Vertical Modeling
Domain
Interview/ DOMAIN
Observation
Semi-
structured Factor Factor
Interview/
Observation
Ethnographic
Survey/Structured Variable Variable
Observation

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

26. ATLAS.TI

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

35. Map of Study Area

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

43. Betty Knox Building Network (UCINET)

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”