Using ethnography to generate culturally-based       interventions    Stephen L. Schensul PhDUniversity of Connecticut Sch...
What is ethnography?   Documents of the “worldview” of residents of the    target communities (the emic view)   Focuses ...
What are culturally-based           interventions?Identification of and building on: a set of collectively held beliefs a...
The need for cultural connection   Salience   Community participation   Community resources   Sustainability
EXAMPLES FROM INDIA
The Problem: HIV in India   2.5 million people are HIV+ in India   The gender ratio has shifted over the    last decade ...
The Study Communities    “Slum” area in the northeast     quadrant of Mumbai    700,000 people    66% migrants, primari...
Key Concept: Gupt Rog (Secret illness”)Men’s major concerns in terms of their sexuality focus on performance issues (kamjo...
Gupt rog     as a marker of sexual riskBaseline survey data showed: Over half (53.2%) have at least one  symptom A signi...
AYUSH ProvidersAYUSH (“life” in Hindi, Urdu, andArabic) is a new acronym for Ayurveda,Yoga and Naturopathy, Unani, Siddha,...
AYUSH Providers   Providers in the study communities    are ayurveda, unani, and homeopaths   Holistic traditions of tra...
Allopathic        System and Sexual Health   Nearby hospitals, three urban health    centers and two health posts almost ...
Cultural and local opportunities   A salient set of concepts about sexual    health concerns and treatment seeking   Pre...
Challenges to Addressing Women’s           Sexual Risk   A subset of women:    • Do not speak openly about health      pr...
Culturally-based symptom:    safed pani (“white [vaginal] discharge”) Most common presenting complaint among  women in th...
Interrelationships of Women’s Lifesituation and sexual risk with safed pani       Violence                                ...
WOMEN’S HEALTH CLINIC         •   Established in 2008         •   Criteria SYMPTOMS               –Safed pani             ...
Services provided at WHC                Health education                History, external &                 internal per...
WHAT FORMATIVE RESEARCHMETHODS WILL ALLOW US TO IDENTIFY THESE CULTURAL,COMMUNITY AND COGNITIVE        ELEMENTS?…and do so...
Ethnographic Methods     Method           Explore   Define   ConfirmKey Informants          X         XGroup interviews   ...
Research Model   (Horizontal Domain Modeling)         PEERS              KNOWLEDGE                  SEXUAL        PROTECTI...
Vertical ModelingDomainInterview/            DOMAINObservationSemi-structured             Factor              FactorInterv...
Qualitative Research         Quantitative Research   Describes the nature of         Measures the quantity    the phenom...
Creating qualitative (textual)                data   From observation and interviewing to    recoding with “jottings” or ...
ATLAS.TI
Secondary data   Census   Voter roles   Prior research studies   Governmental surveys   Demographic and Health Survey...
Interviews with key        informants (cultural experts)Key informants are individuals with special knowledge about women ...
Results                    (from Sri Lanka)   The importance of virginity and    sexuality   Male to male sexuality   C...
Group interviews   Any discussion occurring between    the ethnographer and more than one    individual in the community...
Results   Development of rapport   Identification of social networks   Description of key features in the    community...
Mapping and observationMapping of behavioral scenes Meeting places Lovers lanes Recreational settings Work settings S...
Results:         Coupling Behavior   Opportunities to meet: Transport    from work in Mauritius and tuitions in    Sri La...
Social Mapping1. Local residents asked to   draw landmarks and   high risk sites in their   area to identify these   locat...
Map of Study Area
Study site 1Digitized Map of StudyArea                 Study site                 1                     Study site        ...
In-depth Interviewing (IDI)   Focus on the lives of individuals   Minimalist questions guided by the    research model p...
Results   How the focal topic (sexual risk) fits    into the lives of youth in Sri Lanka,    young women workers in Mauri...
FREE-LISTING AND CONSENSUS           MODELINGFree-listing: Respondents to list all  sexual behaviors they know……..Consensu...
Results for 21 Female Youths: Cognitive    Organization of Intimate Behaviors   Expressing      Partying                  ...
Results for 29 Male Youths: Cognitive       Organization of Intimate Behaviors                                            ...
Social Network Analysis(1) Ethnographic mapping of social     networks (family, friendships, work     groups, voluntary or...
Betty Knox Building Network (UCINET)
Sister         Mother’s Network for               Mother      -in-Law                         Childhood                   ...
Results   Identification of focal people in sub-    group (e.g. opinion leaders)   Delineation of the movement of    inf...
Ethnographic Survey Instrument Content:  Closed-ended items based on qualitative   data gathering at the domain, factor a...
Results   Prevalence of the focal and related    issues in the population   Identification of antecedents and    consequ...
Focus Group   Formal meeting   Selected individuals invited who    generally are not linked   Facilitator and a recorde...
Results   Formal participant input   Modifications that fit the community’s    social and cultural dynamics   Opportuni...
Conclusion: Time and              Resources   Many social scientists and public health    researchers want to study “fore...
Using ethnography to generate culturally based interventions_schensul_5.3.12
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  • 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
  • Using ethnography to generate culturally based interventions_schensul_5.3.12

    1. 1. Using ethnography to generate culturally-based interventions Stephen L. Schensul PhDUniversity of Connecticut School of Medicine CORE Group Spring Meeting 2012 Wilmington, DE
    2. 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. 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. 4. The need for cultural connection Salience Community participation Community resources Sustainability
    5. 5. EXAMPLES FROM INDIA
    6. 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. 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 monthHow do we involve a general community in the effortto prevent what they have yet to experience?
    8. 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 masturbationConsequences are described in terms of inability to satisfy wife and other women, threat to masculinityTreatment primarily by non-allopathic providers
    9. 9. Gupt rog as a marker of sexual riskBaseline 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. 10. AYUSH ProvidersAYUSH (“life” in Hindi, Urdu, andArabic) is a new acronym for Ayurveda,Yoga and Naturopathy, Unani, Siddha,and Homeopathy
    11. 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. 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. 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. 14. 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?
    15. 15. 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
    16. 16. Interrelationships of Women’s Lifesituation 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
    17. 17. WOMEN’S HEALTH CLINIC • Established in 2008 • Criteria SYMPTOMS –Safed pani –Genital itiching –Burning micturition –Lower abdominal pain –Genital ulcers –Inguinal swelling
    18. 18. 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
    19. 19. WHAT FORMATIVE RESEARCHMETHODS WILL ALLOW US TO IDENTIFY THESE CULTURAL,COMMUNITY AND COGNITIVE ELEMENTS?…and do so in an expeditious (reasonabletime and resources) manner!
    20. 20. Ethnographic Methods Method Explore Define ConfirmKey Informants X XGroup interviews X XObservation X X XSocial Mapping X XCognitive mapping X XSocial networks X X xIn-depth interviews XSemi-structured XinterviewsSurveys XFocus groups X
    21. 21. Research Model (Horizontal Domain Modeling) PEERS KNOWLEDGE SEXUAL PROTECTIVEFAMILY BEHAVIOR BEHAVIOR COMMUNITY ATTITUDES
    22. 22. Vertical ModelingDomainInterview/ DOMAINObservationSemi-structured Factor FactorInterview/ObservationEthnographicSurvey/Structured Variable VariableObservation
    23. 23. 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
    24. 24. 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
    25. 25. ATLAS.TI
    26. 26. Secondary data Census Voter roles Prior research studies Governmental surveys Demographic and Health Surveys (DHS-Macro International) CDC surveys Medical/clinical records
    27. 27. 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
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. Mapping and observationMapping of behavioral scenes Meeting places Lovers lanes Recreational settings Work settings SchoolsObservation of behavior Daily schedules Subgroups/cliques Coupling
    32. 32. 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
    33. 33. Social Mapping1. 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
    34. 34. Map of Study Area
    35. 35. Study site 1Digitized Map of StudyArea Study site 1 Study site 3 Study site 2 Study site 1
    36. 36. 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
    37. 37. 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
    38. 38. FREE-LISTING AND CONSENSUS MODELINGFree-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 affinityAnalysis using ANTHROPAC
    39. 39. 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 LickingSweet Kissing the body Holding Cuddling 1 2talking the body hands Hugging Kissing Rubbing Feeling on Touching bodies Kissing each other the body with tongue Initial Stages Later Stages
    40. 40. 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 lettersHoldinghands Hugging Kissing Licking the bodythe body Cuddling Feeling on Rubbing each other bodies Touching Kissing Kissing the body w/ tongueInitial Stages Later Stages
    41. 41. 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
    42. 42. Betty Knox Building Network (UCINET)
    43. 43. 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
    44. 44. 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
    45. 45. 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
    46. 46. 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
    47. 47. 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
    48. 48. 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
    49. 49. 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”

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