Gender Concepts, Marital Relationships and Sexual Risk Behavior in

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Gender Concepts, Marital Relationships and Sexual
Risk Behavior in Mumbai, India Stephen L.
Schensul, Sumitra Sharma, Shubhada Maitra and
Nela Pinto
September 2003
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The Context

• India, with a population of 1.07 billion, is the
  second largest country in the world, with a
  rapidly rising rate of HIV/AIDS (currently 1.7,
  4 million cases, 5-1 male-female ratio)
• Mumbai, with a population estimated at 14-17
  million, is one of the largest cities in the
  world, and one of Indias HIV epicenters
• Economic migration from rural areas in all parts
  of India has created large urban and peri-urban
  slum communities
• The project area consists of three such
  communities in the northeast portion of Mumbai
  with an estimated population of 700,000
• It is a mixed Muslim-Hindu area, with male
  literacy at 70 and female literacy at 50

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Implementing Organizations

• The International Institute for Population
  Sciences (IIPS), Deonar, Mumbai a deemed
  university and an apex institution for demography
  in India (Drs. T.K. Roy, G. Rama Rao, S.
  Niranjan, and S. S. Narvekar, Sumitra Sharma, Ms.
  Shubhada Maitra and Mr. Rajendra Singh)
• The Center for International Community Health
  Studies (CICHS) of the University of Connecticut
  School of Medicine, Farmington, CT USA (Drs. S.L.
  Schensul Abdelwahed Mekki-Berrada and Ms. Nela
  Pinto)
• The Institute for Community Research (ICR),
  Hartford, CT (Dr. Bonnie Nastasi)
• Horizons Program, Population Council, New Delhi
  (Dr. Ravi Verma)

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Project Funding and Implementation

• National Institute for Mental Health (NIMH)
  funding for
• Male Sexual Concerns and Prevention of HIV/STD
  in India (2001-2006)
• Office of AIDS Research (OAR) supplement
• Assessing Womens Risk for HIV/STD in Marriage
  in India (2002-2004)
• Phases
• Preliminary research (2001)
• Formative research (2002-2003)
• Baseline survey (2003-2004)
• Intervention (2004)

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Problem to be addressed

• HIV prevention and intervention strategiesare
  needed for married, monogamous Indian women
  whose self-perception of HIV risk may be low, but
  whose risk is inextricably linked to the behavior
  of their husbands (Newman et al., 2001)
• Few programs have been ready to take on the
  challenge of recognizing that marital sex is a
  dyadic event
• Reduction of marital sexual risk involves
  intervention with both individuals and the dyad
• Intervention needs to be directed toward the
  difficult issues of reducing husbands (and less
  frequently, but significantly) wives
  extramarital risky sex, husbands violence and
  coercive sex, and promotion of mutual monogamy,
  increased sexual communication, and HIV/STD
  notification.

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Goals and objectives

• Describe sexual risk from the perspective of both
  married women and men in slum communities in
  Mumbai
• Assess the risk of HIV/STD for married,
  monogamous women
• Delineate the dynamics of the marital
  relationship that increase or reduce risk for
  HIV/STD transmission
• Assess the potential of the husband-wife dyad as
  a unit for intervention for sexual risk reduction
  through a pilot intervention
• Conduct community health education focused on
  risk reduction for the marital dyad
• Determine the feasibility of developing a marital
  intervention resource network.

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Target Population

• 21-40 year old married males and females in three
  slum communities
• Primarily migrants to Mumbai from rural areas
• Great majority of arranged v. love marriages
• A marriage of virtual strangers
• Negative first night experiences
• Husband goes (or returns) to Mumbai for work and
  lives with relatives or other males
• Wives stay in the village with husbands family
• Husband can be involved in sexually risky
  behavior in Mumbai
• Husband returns periodically to the village
• When the husband feels sufficiently established,
  the wife comes to Mumbai (1-5 years)
• Couple and children may be sharing 1-2 rooms with
  husbands brothers family or parents, leaving
  little privacy.
• Wife has limited knowledge of Mumbai and limited
  access to community resources

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Approach

• The project is nested within the larger research
  and intervention of the RISHTA program
• Describing the marriage formation process and
  current marital relationships for couples living
  in the three targeted slum communities
• Assessing the knowledge, attitudes and behaviors
  of both husband and wife
• Establishing the STD status of both husband and
  wife
• Examining the factors that contribute to
  concordant and discordant STD status
• Implementing a couples intervention program
• Utilizing community-based resources to support
  couples behavioral risk reduction

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Activities undertaken

• In-depth interviews with a purposive sample of 52
  men and 66 unrelated women
• Administration of a survey instrument to 2400
  randomly selected men in the three communities
• Random selection of a subset of 640 men for STD
  testing (syphilis, gonorrhea, HSV-2, Chlamydia)
• Selection of 207 wives for administration of a
  survey instrument, gynecological exam and STD
  testing
• Interviews with a random selection of 50 of the
  207 couples couples, conducted jointly by male
  and female interviewers
• Selection of 25 couples for pilot risk reduction
  counseling for both husband and wife and as a
  couple
• Establishment of a marital resource referral
  network
• Community-based reproductive health education
  directed at the marital dyad

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Indicators Contextual Variables

• Living space/degree of privacy
• Children (emphasis on production of male
  children, issues of birth control)
• Joint v. nuclear family
• Relationship with in-laws
• Availability of health services
• Micro- and immediate environment (water, toilet,
  safety, support)

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Husband characteristics

• Pre-marital sexual experience
• Gender concepts
• Satisfaction with the marital relationship
• Household income
• Substance use
• Activities with friends
• Involvement with blue films
• Marital sexual satisfaction
• Desire for particular sexual behaviors
• Perception of interest/satisfaction of wife
• Visits to CSW/extramarital affairs
• Male sexual dysfunctions (gupt rog)

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Wife characteristics

• Age at marriage
• Education
• Work outside home
• Level of sexual interest
• Ability to initiate/refuse sex
• Empowerment (economic, social, mobility)
• Peer networks
• Participation in community-based organizations
• Quality of the marital relationship
• Sexual satisfaction
• Reproductive history and health with emphasis on
  safed pani (white discharge), vaginal problems
  and kamjori (weakness)

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Dyadic variables

• Balance of power (gender roles)
• Economic decisions/control of money
• Children
• Mobility
• Communication (sex, economics, children)
• Age and status (social, economic, educational)
  differences
• Love v. arranged marriage
• Spousal violence
• The nature of sex
• Initiative and refusal
• Interest and satisfaction
• Frequency of sex
• Sexual sequence
• Coercive sex

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Monitoring

• Changes in the knowledge, attitudes and risk
  behaviors of the individuals in the dyad
• Changes in the interaction of husband and wife in
  terms of sex, communication, and violence
• STD status of the couple
• Womens non-STD, gynecological morbidity and
  mens sexual performance issues
• Availability and access to community resources
• Gender-based norms about the marital relationship

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Stakeholders

• The National AIDS Control Organization (NACO)
• The Ministry of Health and Family Welfare
• The Mumbai Municipal Corporation, Health Division
• Nair Medical College
• Mahila mandals (womens CBOs) and male youth
  mandals in the targeted communities
• Community-based providers of health services
  including governmental health centers and Indian
  Systems of Medicine (ayurvedic, unani and
  homeopathic)
• Agencies and programs directed toward marital
  therpay, domestic violence, mental health
  services

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Obstacles

• The difficulty of interviewing Indian women about
  sex, violence and marital communication
• The link between a womans monogamy and her lack
  of perceived risk for HIV/STD
• The frequent failure of men to link their risk
  behavior to their wives gynecological morbidity
• The lack of precedent (in India and elsewhere)
  for a couples approach to behavioral risk
  reduction
• The need to develop a methodology for
  intervention with couples

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Opportunities

• The HIV positive male to female ratio is reducing
  rapidly in India, with marriage being identified
  as the major risk factor for women
• Of 66 men interviewed in the course of STD
  testing in one of the study communities, 65
  indicated that they would be positive about their
  wives being tested for STDs
• Male gender norms that center on protection and
  support of the family provide a base for
  intervention to reduce couples risk
• Identification of a significant number of couples
  with greater communication, gender equity, no
  reported extramarital risk behavior and positive
  sexual relationships

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Lessons Learned

• There is great variation in in the nature,
  quality and roles of men and women in marital
  relationships in these study communities
• The marital relationship in all its sexual and
  non-sexual manifestations has a significant
  impact on the reproductive health of women and
  men
• A great deal more work to do to identify the key
  factors that contribute to reproductive and
  sexual risk for both wives and husbands
• It is necessary to build a set of intervention
  experiences involving both individuals and the
  marital dyad
• The lack of involvement of both husbands and
  wives significantly hampers risk reduction
  programs
• Even in the poorest communities, couples
  intervention can be a viable approach to risk
  reduction