Dr. Bonnie Kaul Nastasi

The purpose of this article is to describe a culture-specific pilot intervention program designed for married couples living in the slum communities of Mumbai, India. The program is part of a 5-year community-based research project called RISHTA (Research and Sexual Health: Theory to Action), a Hindi and Urdu term meaning relationship. The project, funded by the National Institute of Mental Health (S. Schensul, PI; B. Nastasi, Co-PI; #1-RO1-MH64875, 2001–2006), is 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, the University of Connecticut’s School of Medicine and the Institute for Community Research (Hartford, CT); and India-based agencies, the International Institute for Population Sciences, the Population Council, Nair Medical College, Rajiv Gandhi Medical College, the National AIDS Research Institute, OSB Diagnostics, the 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.

Background
The RISHTA project initially focused on sexual risk among married men. The interest in intervening with married couples grew out of (a) recognition of the importance of marital relationships and gender roles in understanding both men’s and women’s sexual risk in India, (b) concern for the increasing incidence of HIV and other sexually transmitted infections (STIs) among women, and (c) the link of HIV/STI risk among women in India to male-female transmission within marriage, based on the work of others and confirmed by our own formative research with married men, women, and couples living in the slums of Mumbai.

Our formative research was designed to investigate the cultural, relationship, and psychological factors related to HIV/STI risk among married men and women, using in-depth semistructured interviews with married men, women, and couples; structured surveys with men and women; and STI testing for both men and women.

Drawing on findings from formative research and previous intervention work in South Asia (Sri Lanka, Nastasi et al., 1999; Silva, Schensul et al., 1997; India, Schensul, Nastasi, & Verma, in press), the RISHTA team developed a seven-session pilot intervention for couples using the narrative intervention model (NIM). The NIM is a theory-driven interdisciplinary (psychology, anthropology, public health) approach to prevention and risk-reduction of HIV/STIs.

We posited that behavior (specifically behavior related to sexual health) is influenced by the interaction of biological, psychological, and social-cultural factors. Through repeated experiences, individuals develop narratives or scripts that guide their behavior. Culturally based narratives become the focus for intervention.

Through the use of focused interpersonal interactions, trained interventionists 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).

The 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. 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. Early work in the RISHTA project indicated the feasibility of NIM-based interventions implemented by community educators and medical providers for addressing sexual risk among married men.

Couples Intervention
Our initial step involved pilot testing of the couples intervention for feasibility, acceptability, and social validity. Pilot testing was especially critical because of the novelty of couples intervention within India and the target community. Concerns focused on the willingness of married couples to participate in mixed-gender group discussions about marriage, gender roles, sexuality, and sexual relationships.

Preparation for the intervention involved collaborative development of intervention content and process, as well as training of intervention staff to facilitate group processes and implement the NIM. Staff preparation involved ensuring that staff members were comfortable with the content and the challenges of addressing sensitive issues in mixed-gender settings.

The couples intervention targeted skills related to communication and negotiation, coping with tensions and conflicts in marriage, and sexual risk reduction within the marital relationship. Sessions were conducted in group format in a community setting and involved 21 couples.

The first three sessions were conducted with wives and husbands separately, and the remaining sessions were conducted jointly with husbands and wives. Sessions were facilitated by RISHTA field staff (two women, two men), who participated in the development of the intervention program with support from an experienced social worker.

Sessions with women were co-facilitated by female staff, male sessions by male staff, and joint (couples) sessions by female-male dyads. Initially five sessions were designed to address the following topics: (a) roles and responsibilities in marriage; (b) tensions in marriage; (c) sex in marriage; (d) negotiating roles and responsibilities in marriage (joint couple session); and (e) negotiating tensions in marriage (joint couple session).

Participants requested two additional sessions focused on sexuality and sexual risk, which were also delivered by the same intervention staff. Sessions of 60 to 90 minutes duration were held weekly in a centralized and easily accessible community location.

Evaluation of the pilot intervention focused on feasibility, acceptability, and social/cultural validity of conducting a couples intervention in the community context. In particular, evaluation focused on the capacity of field staff to implement and facilitate single- and mixed-gender group sessions, as well as the appropriateness of activities for married couples, response of couples to session content and activities (participation, acceptability), perceived effectiveness by couples, and relevance to their everyday lives.

Evaluation strategies included participant observation (by a same-gender field staff member), structured group feedback activity at the conclusion of each session, and individual feedback from a sample of participants following each session. Evaluation data indicated a high level of feasibility.

Recruitment through a community network of participants in the RISHTA project yielded a sample of 21 couples: 16 of the couples participated consistently across the seven sessions.

All the female and male participants indicated a high level of interest and enthusiasm toward the program. They participated actively in session activities, including single- and mixed-gender discussion and role playing. Participants were supportive and cooperative in group activities.

They indicated a high level of agreement regarding the appropriateness of session topics and activities and relevance to their daily lives. For example, they indicated willingness and confidence in using newly learned skills with actual application at home. The participants consistently indicated that the program would be worthwhile for the community in general and encouraged offering the program to a broader audience (e.g., through street plays and repetition of the program).

Participants indicated a strong interest in extending the program to include more sessions focused on negotiating sexual relationships, issues related to sexual risk, communication in marriage, and coping with tensions and daily responsibilities.

In conclusion, our work thus far has demonstrated the feasibility and social validity of conducting a community-based culture-specific couples intervention focused on risk reduction related to transmission of STIs within marriage. This represents an important first step in efforts to address HIV/STI risks among married women. We are currently awaiting review of a proposed full-scale project focused on reducing sexual risk among married women and couples in India.

Note: For additional information about the RISHTA project, contact Dr. Bonnie Nastasi at bnastasi@waldenu.edu.

References
Nastasi, B. K., Schensul, J. J., deSilva, M. W. A, Varjas, K., Silva, K. T., Ratnayake, P., & Schensul, S. L. (1998–1999). Community based sexual risk prevention program for Sri Lankan youth: Influencing sexual-risk decision making. International Quarterly of Community Health Education, 18(1), 139–155.

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.

Silva, K. T., Schensul, S. L., Schensul, J. J., Nastasi, B. K., deSilva, M. W. A., Sivayoganathan, C., et al. (1997). Youth and sexual risk in Sri Lanka. Women and AIDS Research Program Phase II Research Report Series No. 3. Washington, D.C.: International Center for Research on Women.