In the November issue of The Scholar-Practitioner, formative research findings from the Research and Sexual Health: Theory Into Action (RISHTA) Project ¹ were presented. These findings provided the basis for the development of a culturally specific intervention program on the prevention of sexual risk among married men living in the slum communities of Mumbai, India.

The intervention program, guided by the Narrative Intervention Model (NIM), targeted three levels: (a) community, (b) health care providers, and (c) male patients. This article provides a description of the NIM and the preliminary findings based on implementation across three slum communities in Mumbai. (See related articles in the October and November issues of The Scholar-Practitioner.)

Narrative Intervention Model (NIM)

The Narrative Intervention Model (NIM) is a theory-driven interdisciplinary approach addressing men’s sexual health symptoms and their link to cultural, relational, and psychological factors that increase men’s risk for HIV/STI.

Derivations of the Model
The NIM integrates principles and strategies from psychologically based cognitive-behavioral approaches to sexual risk prevention and risk reduction (Azjen & Fishbein, 1980; Becker, Rankin, & Rickel, 1998; Fisher & Fisher, 1993; Kelly, 1995) and culturally sensitive approaches to counseling and therapy (Ivey & Ivey, 2003).

The theoretical underpinnings of NIM are based in psychology (Azjen & Fishbein, 1980; Bandura, 1986; Bronfenbrenner, 1989, 1999; Vygotksy, 1978; Wertsch, 1991), anthropology (Kleinman, 1986; Pelto & Pelto, 1997), and sociology (Berger & Luckman, 1966).

Elements of the NIM
NIM incorporates elements of cognitive-behavioral change models, empirically supported in risk prevention and reduction research (Azjen & Fishbein, 1980; Becker & Robinson, 1998; Fisher & Fisher, 1993; Kelly, 1995), but designed to address the shortcomings of existing models through the integration of culturally specific cognitions or narratives.

Focus of NIM
These narratives are constructed and based on formative research with the population and adapted to the specific focus of the patients’ presenting problems. Such an approach is consistent with established cognitive-behavioral change models that incorporate scripts or messages established by the researcher or interventionist and require adaptation to the needs of individuals.

Limitations of Existing Models
The limitations of existing models are the lack of attention to social-cultural aspects of health risk and the primary dependence on Western models of psychology. (For more detailed discussion, see Schensul, Nastasi, & Verma, in press; Schensul, Verma, & Nastasi, 2004.)

Requirements of the NIM Model
The narrative approach requires that interventionists make use of a social construction process, in which ideas/beliefs linked to risky sexual behavior are challenged through the introduction of alternative culturally rooted views. Risk-reduction narratives are constructed through dialogue.

Through the use of focused interpersonal interactions, trained providers attempt to help individuals to (a) identify the narrative related to the presenting problem (construct the narrative), (b) critically examine the psychological and social-cultural factors that influence or maintain the problem (deconstruct), and (c) create a revised narrative that leads to solving the problem (reconstruct).

Development of a Personal Narrative
This construction-deconstruction-reconstruction process leads to the development of a personal narrative that supports the development of health-promoting and risk-reducing behaviors related to HIV/STI prevention and treatment.

Thus, a primary limitation of extant cognitively oriented approaches—failure to focus adequately on social and cultural factors—is addressed directly through the use of narrative. If carefully orchestrated by trained personnel, this process can lead to the development of perspectives that support health-promoting behaviors (see Nastasi et al., 1998–1999; Weissberg, Caplan, & Harwood, 1991).

Goal of NIM
NIM involves attempts to change existing normative beliefs and behaviors of patients or consumers, as well as providers and interventionists. The confrontation of existing norms can potentially result in resistance or reactance that in turn negatively impacts outcomes (see Karno & Longabaugh, 2005).

NIM Characteristics
NIM is characterized by supportive interpersonal interactions (e.g., empathy, acceptance, warmth), used in combination with confrontation, advising and directing to elicit cognitive conflict (discrepancies in ideas), and reframing of existing ideas. This combination has been shown to enhance patient involvement and outcomes (Moyers, Miller, & Hendrickson, 2005).

Facilitating the Goal of Long-Term Change
Furthermore, the content of NIM is structured to facilitate long-term cognitive change through the use of the following empirically supported strategies (Kumkale & Albarracin, 2004):

1. Messages are created based on formative research with the intended audience and adapted based on individual concerns, thus ensuring culturally and personally relevant messages. 
2. Messages are presented to patients who are motivated by current concerns to receive information.
3. Messages are presented in a manner that is consistent with patient language and educational levels.
4. New messages are presented in combination with discounting cues to facilitate cognitive conflict. 
5. Repetition of messages occurs within sessions and through multiple contacts.

Required Skills and Training of the Interventionist
The successful use of NIM, as with other empirically supported cognitive-behavioral interventions, depends on the skill of the interventionist or provider. 

Human interactions cannot be completely scripted, so even with highly scripted approaches, the skill of the implementer in adapting to the dynamics of human communication is critical. Such facility has been addressed in two ways in the RISHTA Project:

• Development of multiple “common scripts” or narratives based on the presenting problem and contributing biological, psychological, relational, and social-cultural factors (singly or in combination). 
• In-depth training and ongoing support of providers/interventionists to develop facility with application and adaptation of common scripts based on the presenting problem and contributing factors.

Such training involved modeling and role-playing with feedback, follow-up visits to provide individual consultation and training, and periodic follow-up training sessions conducted in groups.

Multiple-Level Application

In the RISHTA Project, the NIM was applied at multiple levels: (a) development of a community education campaign through media (posters), performance by local artists (street plays), and discussion groups and individual contacts initiated by the project field staff; (b) training of health care providers; and (c) patient care by health care providers.

The formative research findings (described in the November issue of The Scholar-Practitioner) guided the development of the narratives for implementation of NIM at all three levels. This article focuses on the application to provider training and patient care.

Application of NIM to Provider Training and Patient Care
Formative research with married men and providers in the participating communities indicated that several psychological, relationship, and social-cultural factors were related to men’s concerns about sexual health problems (gupt rog, or secret illness).

These factors include (a) perceived etiology of gupt rog, (b) culturally based definitions of masculinity, (c) quality of marital relationship, (d) engagement in risky lifestyle or behaviors, and (e) perceived consequences of gupt rog.

Symptom Reporting and Physician Preparation
In addition, factors related to treatment included symptoms reported by men, history of treatment-seeking, and doctors’ approaches to treatment, which were predominantly characterized by prescribing “English” medicine (antibiotics) and giving advice (e.g., “counseling” to avoid commercial sex workers). The goal in applying NIM was to prepare doctors to extend their approaches to include the following stepwise process:

1. Construction/Assessment. Systematic assessment of the patient’s concerns (e.g., history taking) that addressed psychological, relationship, and social-cultural factors as well as physical symptoms; and physical examination and lab testing and/or referral for testing as deemed necessary.
2. Deconstruction/Diagnosis. Syndromic identification of STIs based on World Health Organization (WHO) standards; and identification of specific psychological, relational, and social-cultural factors relevant to the patient’s concerns based on the narrative constructed in the first step.
3. Reconstruction/Intervention. Providing syndromic treatment consistent with WHO standards, confronting beliefs and behaviors that increase the patient’s sexual risk, delivering risk reduction messages, and developing with the patient a new narrative and strategies for promoting healthy decision-making and behaviors.

Participating Providers
Participating providers included allopathic providers (two doctors and two interns at a government-funded male health clinic established in partnership with a local medical school for the project in one community) and 25 private non-allopathic providers located in a second community.

Providers received formal training from project staff and local experts prior to initiation of the intervention, as well as ongoing support in NIM, delivered in groups or individually for the duration of the intervention. Providers responded positively to the initial training and regularly requested additional training and support. Participating doctors were asked to implement NIM with all male patients who presented with sexual health concerns.

Data collection (pre-intervention, immediate post-intervention, and 6-month follow-up) was from a randomly selected sample of patients from the male health clinic, trained private providers, and untrained allopathic and non-allopathic providers in a third community.

Preliminary Support for NIM

The 2½-year intervention concluded December 2005 and will be followed by 6 months of post-intervention data collection at the patient, provider, and community levels. Preliminary analysis of data collected from providers and patients to assess intervention acceptability, integrity, and outcomes (at 6-month follow-up) revealed the following findings:

1. The allopathic providers in the government-funded male health clinic, compared to non-allopathic private providers, more consistently delivered treatment consistent with NIM (i.e., showed higher levels of treatment integrity). They were more likely to incorporate aspects of NIM into both assessment and treatment.
2. Patients receiving treatment from trained providers (allopathic or non-allopathic), compared to those receiving treatment from non-trained providers, showed positive changes on self-reported measures of overall life satisfaction, communication with spouse, STI knowledge, and reduction in spousal abuse.
3. Patients attending the male health clinic, compared to those attending private non-allopathic providers, showed positive changes on self-reported measures of sexual health problems, perceptions of masculinity, self-assessment as sexual partner, overall life satisfaction, and reduction in spousal abuse.

Conclusions

• These preliminary findings provide initial support for the effectiveness of a culturally based narrative intervention delivered by public allopathic and private non-allopathic health care providers.
• The differences in outcomes between public allopathic providers and private non-allopathic providers were not surprising, given the differences in integrity of treatment delivery.
• The greater variation in delivery of NIM by private providers is indicative of one of the common challenges of conducting intervention research in real-life settings (or in scaling up from random-controlled trials research) in which the researchers have limited control over implementation across individuals. 
• By contrast, the RISHTA team had more control over implementation of the male health clinic, established specifically for the project and staffed by doctors and interns from a partner medical school.

References

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Schensul, S. L., Nastasi, B. K., & Verma, R. K. (in press). Community-based research in India: A case example of international and interdisciplinary collaboration. American Journal of Community Psychology.

Schensul, S. L., Verma, R. K., & Nastasi, B. K. (2004). Responding to men’s sexual concerns: Research and intervention in slum communities in Mumbai, India. International Journal of Men’s Health, 3, 197–220.

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Endnotes

¹ The 5-year project, Research and Sexual Health: Theory to Action (RISHTA), a Hindi and Urdu term meaning “relationship,” funded by the National Institute of Mental Health (S. Schensul, PI; B. Nastasi, Co-PI; #1-RO1-MH64875; 2001–2006), was designed to address the issue of HIV-related risks among married men and women in India. Partner agencies in the project include U.S.-based agencies, University of Connecticut School of Medicine and Institute for Community Research (Hartford, CT); and India-based agencies, International Institute for Population Sciences, Population Council, Nair Medical College, Rajiv Gandhi Medical College, National AIDS Research Institute, OSB Diagnostics, Tata Institute of Social Sciences, and CORO for Literacy (a community-based organization). The interdisciplinary research and intervention team includes professionals from psychology, anthropology, social work, medicine, public health, population sciences (demography), and epidemiology.

Dr. Bonnie Kaul Nastasi, director of Walden University’s School Psychology specialization and full-time faculty member in the School of Psychology, received her doctorate in school psychology from Kent State University. In addition to Walden, she has taught graduate courses in psychology at Illinois State University, the University of Connecticut, and the University at Albany (SUNY). She served as associate director of interventions at the Institute for Community Research in Hartford, CT, for 6 years. Her areas of specialization are school and community mental health promotion and health risk prevention (drugs and sexual risk); mixed-method (qualitative-quantitative) research; and promoting school psychology internationally. She currently spends 3–5 months each year in India working on a community-based sexual risk prevention project directed toward married men and women and health care providers in the slum communities of Mumbai (Bombay). She also has conducted community-based prevention research in Sri Lanka focused on adolescent mental health and sexual risk prevention for youth and young adults. For additional information about the RISHTA Project, contact her at bnastasi@waldenu.edu.