Healing traditions and men's sexual health in Mumbai, India: the realities of practiced medicine in urban poor communities

Assessing the Effectiveness of Multilevel Intervention Sequences on "Tension" Among Men Living with HIV: A Randomized-Control Trial

BACKGROUND

Tension (often times called "Tenshun" in Hindi) is a cultural expression used to convey feelings of distress and common mental disorders in India and among South Asia communities. This study compared the effectiveness of different intervention sequences in reducing tension among alcohol-consuming men living with HIV in India.

METHOD

This secondary data analysis paper utilized data from a randomized trial study titled "Alcohol and Antiretroviral Therapy (ART) Adherence: Assessment, Intervention, and Modeling in India." The multilevel interventions, including individual counseling (IC), group intervention (GI), and collective advocacy (CA), were conducted sequentially over three cycles at three ART centers. Additionally, another ART center, serving as a pilot site, received all three interventions simultaneously in the final cycle. Participants completed surveys assessing demographic characteristics, tension, and other variables including HIV stigma, a 4-day ART adherence, HIV symptoms, and depressive symptoms at four time points: baseline, 9 months, 18 months, and 24 months. General linear mixed models were employed to assess the intervention effects on tension.

RESULTS

Out of 940 participants, 666 reported experiencing tension, including 54% reporting high tension. At site 1, the GI-CA-IC sequence resulted in a slope of -0.06, indicating that this sequence reduced tension from T1 to T4 compared to the control group (p < 0.01). Additionally, the pilot site where the intervention package was conducted simultaneously had a slope of -0.06, indicating that the intervention package also reduced tension compared to the control group (p < 0.01). Conversely, the CA-IC-GI sequence resulted in a slope of 0.07, indicating that this sequence resulted in significantly higher tension levels than the control group (p = 0.008) contrary to the expectation that the sequence would reduce tension.

CONCLUSION

This study contributes valuable insights on the issue of tension among alcohol-consuming men living with HIV. The significant reduction in tension observed at the site using the GI-CA-IC sequence, which began with a group intervention, underscores the importance of intervention order and the importance of group intervention within multilevel intervention programs for tension reduction. Further research is needed to validate these observations and broaden our understanding of effective tension management strategies among people living with HIV in diverse settings.

TRIAL REGISTRATION

URL: clinicaltrials.gov.

REGISTRATION NUMBER

NCT03746457.

Nearly half of adults with symptoms of sexually transmitted infections (STIs) did not seek clinical care: A population-based study of treatment-seeking behavior among adults in Rakai, Uganda

Understanding treatment-seeking behavior is critical to the treatment and control of sexually transmitted infections (STIs), yet current data on STI treatment seeking in low-resource settings is rare. This population-based study aimed to describe STI treatment-seeking behavior and identify factors associated with seeking treatment at a clinic among adults with STI-related symptoms in rural Uganda. The STI prevalence study (STIPS) conducted a survey and STI testing among all consenting adults aged 18-49 in two communities in rural south-central Uganda. Of 1,825 participants, 962 individuals self-reported STI symptoms in the past six months; we present descriptive data on treatment seeking and STI prevalence among these individuals. We used multivariable Poisson regressions with robust variance to determine the sociodemographic and symptom-related factors independently associated with seeking STI treatment at a clinic and assessed the association with previous clinic treatment seeking and current STI diagnosis. Forty-three percent of adults who reported STI-related symptoms in the past six months said they did not seek any treatment. Among those who did, 58% sought treatment at a private clinic, 28% at a government clinic, 9% at a pharmacy/drug store, 3% at a traditional healer, 2% at a market/shop, and 5% at another location. Among both males and females, having multiple STI related symptoms was positively associated with clinic treatment seeking (males = PRR: 1.73, 95%CI: 1.36-2.21; females = PR: 1.41, 95%CI: 1.12-1.78). Approximately one-third of males and females who reported previously seeking clinic treatment for their symptoms were diagnosed with a curable STI at the time of the survey. In this setting, nearly half of adults with STI-related symptoms are not seeking clinical care and many who report having sought treatment for recent STI symptoms have curable STIs. Future studies should explore barriers to care-seeking and strategies to improve STI services.

Exploring terminology for puerperal sepsis and its symptoms in urban Karachi, Pakistan to improve communication, care-seeking, and illness recognition

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols.

Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study

Background and Objectives:

Sexual health disorders are an important but less researched public health issue in India. We aimed to estimate the prevalence of sexual health disorders and their associated factors among adult men in a rural community of Haryana, India.

Materials and Methods:

A community-based cross-sectional study was conducted among adult men aged 18–60 years using a multistage stratified random sampling. Information pertaining to sociodemographic characteristics, lifestyle and sexual practices, and self-reported sexual problems were collected. Sexual health disorders were defined based on International Statistical Classification of Diseases-10 classification of mental and behavioral disorders. Step-wise logistic regression was carried out to identify factors independently associated with sexual disorders.

Results:

At least one sexual health disorder was reported by 81% of the men. The most commonly reported disorder was self-perceived defect in semen (64.4%), followed by loss of libido (21%), masturbation guilt (20.8%), erectile dysfunction (5%), and premature ejaculation (4.6%). Factors significantly associated with sexual health disorders among all men were being never married (odds ratio = 2.04; 95% confidence interval: 1.51, 2.77), smoking (1.57; 1.16, 2.14), cannabis use (4.20; 1.68, 10.48), diabetes (2.40; 1.22, 4.73), and hypertension (3.17; 1.12, 8.92).

Interpretation and Conclusions:

A high burden of sexual health disorders was identified among the rural men. Wider recognition of this issue is needed among the health-care providers and policymakers.

Utilization of alternative systems of medicine as health care services in India: Evidence on AYUSH care from NSS 2014

AYUSH, an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homeopathy represents the alternative systems of medicine recognized by the Government of India. Understanding the patterns of utilization of AYUSH care has been important for various reasons including an increased focus on its mainstreaming and integration with biomedicine-based health care system. Based on a nationally representative health survey 2014, we present an analysis to understand utilization of AYUSH care across socioeconomic and demographic groups in India. Overall, 6.9% of all patients seeking outpatient care in the reference period of last two weeks have used AYUSH services without any significant differentials across rural and urban India. Importantly, public health facilities play a key role in provisioning of AYUSH care in rural areas with higher utilization in Chhattisgarh, Kerala and West Bengal. Use of AYUSH among middle-income households is lower when compared with poorer and richer households. We also find that low-income households display a greater tendency for AYUSH self-medication. AYUSH care utilization is higher among patients with chronic diseases and also for treating skin-related and musculo-skeletal ailments. Although the overall share of AYUSH prescription drugs in total medical expenditure is only about 6% but the average expenditure for drugs on AYUSH and allopathy did not differ hugely. The discussion compares our estimates and findings with other studies and also highlights major policy issues around mainstreaming of AYUSH care.

Multilevel Perspectives on Female Sterilization in Low-Income Communities in Mumbai, India

Surgical sterilization is the primary method of contraception among low-income women in India. This article, using qualitative analysis of key informant, in-depth interviews, and quantitative analyses, examines the antecedents, process, and outcomes of sterilization for women in a low-income area in Mumbai, India. Family planning policies, socioeconomic factors, and gender roles constrain women's reproductive choices. Procedures for sterilization rarely follow protocol, particularly during pre-procedure counseling and consent. Women who choose sterilization often marry early, begin conceiving soon after marriage, and reach or exceed ideal family size early due to problems in accessing reversible contraceptives. Despite these constraints, this study indicates that from the perspective of women, the decision to undergo sterilization is empowering, as they have fulfilled their reproductive duties and can effectively exercise control over their fertility and sexuality. This empowerment results in little post-sterilization regret, improved emotional health, and improved sexual relationships following sterilization.

Community Gender Norms Change as a Part of a Multilevel Approach to Sexual Health Among Married Women in Mumbai, India

Inequitable gender norms in societies and communities negatively contribute to women's sexual and reproductive health. While the need for change in gender norms is well recognized, the task is highly challenging in terms of intervention design, implementation and assessment of impact. This paper describes a methodology for identification of gender norms, the design of community level intervention, community participation and the assessment of intervention impact in a low income, predominately Muslim community of 600,000 people in Mumbai, India. Formative research focused on in-depth interviews with women, men and couples yielding gender normative statements and assessment of community resources to facilitate change. A Gender Equity Scale (GES) based on this formative research was developed and administered annually for a three-year period to random, cross-sectional samples in the intervention and control communities, and to community based, non-governmental organizations (NGO) staff and Imams (religious leaders) in the intervention community. NGO staff disseminated gender oriented messages to their female constituency through their regular outreach activities and through special events and festivals in the community. Imams disseminated gender messages through lectures on social issues for men attending Friday prayers. The results showed that the NGO staff and Imams, assumed more gender equitable attitudes across time. The intervention was associated with a significant improvement in attitudes towards gender equity in the intervention relative to the control community. Men showed a dramatic change in more positive gender attitudes, while women lagged behind in their GES scores. The meaning of these results are explored and the implications assessed for the generalizability of the methodology for other countries, cultures and communities.

A model for translating ethnography and theory into culturally constructed clinical practices

This 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.

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.

Alcohol use, sexual risk behavior and STIs among married men in Mumbai, India

This paper examines the relationship of frequency, type of alcohol use, sexual risk behaviors and sexually transmitted infections (STIs) among married men living in economically marginal communities in Mumbai, India. The findings indicate that men who consume alcohol daily were four times more likely to have had extramarital sex in the past 12 months. In terms of sexually transmitted infections, men who were daily drinkers were four times more likely than those not consuming alcohol in the last month to have gonorrhea (NG) and Chlamydia (CT) infection and three times more likely to have had a past history of exposure to herpes simplex virus-2 (HSV-2) and/or syphilis as determined by biological testing. These results demonstrate that men with daily alcohol use are at greatest risk for STIs and need to be targeted for community outreach, de-addiction services and sex risk reduction education program in India and elsewhere.

Determinants of alcohol use, risky sexual behavior and sexual health problems among men in low income communities of Mumbai, India

This paper summarizes the main results of the survey component of a mixed methods study of alcohol and sexual risk in a general population of young men 18-29 residing in low income communities in the Greater Mumbai area. The survey included demographic variables, and scales and indices measuring work related stress, social influence, exposure to alcohol in childhood, and currently, hyper masculinity, exposure to media and pornography, risk related leisure time activities and alcohol and alcohol/sex expectancies. Measures of alcohol use included frequency/amount/contextual use of six different types of alcohol, a general estimate of frequency and amount (AUDIT), and an estimate of total ml. alcohol consumed in the past 30 days, based on estimates of alcohol content in all types of alcohol consumed, by unit of consumption (glass, peg, bottle) etc. Sexual outcome measures included types and number of partners ever and in past year with and without alcohol, and a critical event with most recent partner (with or without alcohol) and culturally specific indicators of sexual health related to sexual risk taking. A cluster sampling protocol and the use of a screener produced a sample of 1239 men, 1071 thirty day drinkers and 161 nondrinkers. Logistic regression analysis (binary and multinomial) showed relationships between predictor variables and alcohol consumption and alcohol and sexual risk indicators as well as two of the sexual health indicators associated with extramarital sex. Risk behaviors are associated with higher levels of alcohol consumption in this low risk general population of married and unmarried men. Implications for intervention include: (a) reducing or eliminating home drinking, to reduce early childhood exposure; (b) including alcohol in sexual risk and HIV prevention programs; (c) improving couples (married or unmarried) communication to reduce men's search for sexual alternatives, and (d) treating garmi as an indicator of sexual risk taking rather than STIs.

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.

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 men's 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.