Responding to men's sexual concerns: research and intervention in slum communities in Mumbai, India.

Much of the responsibility for the transmission of HIV/STD lies with men involved in sexually risky behavior. While there are many programs aimed at reducing men's risky behavior, insufficient attention has been paid to men's perspectives on sexual health and the cultural context within which men engage in risky behavior. This paper reports on a multi-year, multi-level research and intervention project to assess men's culturally based sexual health concerns and to utilize those concerns in the development of HIV/STD risk reduction and treatment programs in urban poor communities in Mumbai (Bombay), India. The intervention approach consists of community-level education, training of both public allopathic and private nonallopathic providers and a treatment modality that centers on syndromic diagnosis and management, behavioral change, and a therapeutic approach based on narrative and cognitive therapy termed the "narrative intervention model." The project's pre-post, control, and experimental design allows evaluation of impact at each intervention level.

Keywords: men, sexual problems, HIV, STD, culturally based intervention, risky sexual behavior

**********

Much of the literature with regard to men's involvement in reproductive health emphasizes men's reluctance to address their own health, the health of their sexual partners, and the health of their children. As a result, programs directed toward men and reproductive health have emphasized expansion of their health knowledge, a redefinition of their gender roles, a reduction of their risky behaviors, and an increased utilization of healthcare services. Intervention programs, however, must cope with current realities: Men have poor knowledge of their own health, let alone of the health of women and children: a significant number of men will not easily conform to calls for gender equity: in most locales men underutilize healthcare services: and men are more prone to engagement in such risky behaviors as smoking, alcohol and drug use, and extramarital sex that put themselves and their families at risk.

Although the challenges and obstacles have been apparent, the answers have not been so easily forthcoming. Though there is a commitment to change men's behavior, much of that change is based on concerns and concepts that have been exogenously generated, particularly when directed toward men who must also cope with a wide range of economic, environmental, and structural deficiencies that undermine attention to their own health and the health of their families. This paper suggests that before we move to the change mode, we need to carefully and systematically listen to and observe men within local communities to identify their unique concerns and utilize that knowledge for the development of change opportunities. One such opportunity emerged in the assessment of men's sexual health problems and development of prevention programs for HIV/STD risk reduction in slum communities in Mumbai, India.

The concern about men's sexual health and the health of their sexual partners is set in the context of the rapid spread of HIV/AIDS and increasing rates of STDs in India. It is now estimated that more than five million individuals are living with HIV/AIDS in India, a prevalence of 0.9% (National AIDS Control Organization, 2004; UNAIDS, 2004). Kumar (1999) has estimated the actual burden of HIV-infected people as 1.5% or 11.5 million individuals already infected with HIV, whereas Eberstat (2002) estimated 30-140 million new cases of HIV/AIDS in the period of 2000-2025. Although the actual and projected figures are in some dispute, it is generally agreed that AIDS will emerge as the single most important cause of adult mortality in India in the coming decade (UNAIDS, 2004).

The state of Maharashtra and the city of Mumbai have been severely impacted by the spread of STDs and HIV/AIDS. In Mumbai, surveillance data indicate a steady progression of HIV-positive individuals among patients attending STD clinics rising from a low of 1.6% in 1987 to 64.4% in 1999, with HIV prevalence increasing in the city from 1% in 1993 to 3% in 1999 (UNAIDS/WHO, 2000). A screening of female sex workers and their clients attending an STD clinic in Mumbai showed that 42% were seropositive for HIV, 72% for herpes simplex virus-2. 38% for syphilis, and 26% for gonorrhea. Findings also indicated that members of high-risk cohorts suffered from multiple STDs, which increases the risk of subsequent HIV infection (Das, Yemul, & Deshmuk, 1998; Hawkes & Hart, 2000).

The predominance of HIV/STD infected individuals in India are men: estimates in 1994 indicated a male to female ratio of 5:1, with female cases being mainly sex workers (Pais, 1996). More recent estimates indicate a 2.5:1 ratio (UNAIDS, 2002). Heterosexual contact with sex workers, both before and during marriage, has been considered the major source of infection in men. The increasing proportion of HIV-infected women is seen to result from men having risky sex and then having sex with their wives (Bentley et al., 1998; Jacob, John, George, Rao, & Babu, 1995; Jain, John, & Keusch, 1994). In Mumbai, 2-4% of pregnant women have tested positive for HIV in public hospitals (Maniar, 2000). Date from Pune in Maharasthra have shown a relatively high prevalence rate among presumably low-risk, married, monogamous women whose only risk factor was sexual contact with a husband who had experienced an STD (Gangakhedkar, Bentley, & Gadkari, 1997: Newman et al., 2001).

Multi-country studies have shown that men of all age groups have reproductive health concerns but tend to ignore minor illnesses and avoid seeking treatment for their conditions (Nataraj, 1994; Singh, Bloom, & Tsui, 1998). Many men do not realize that they have a problem needing treatment, whereas others are embarrassed and do not seek treatment until the problem reaches an advanced stage (Raina & Malhotra, 1998). For many men, reproductive health services are synonymous with maternal and child healthcare, and the structure of service delivery discourages them from seeking reproductive health treatment and other services (Ndong, Becker, Haws, & Wegner, 1999).

In recent years, there have been a number of pilot projects developed to increase male involvement and improve male-oriented services with the objective that if men are effectively brought into reproductive health services, there will be positive reproductive outcomes for both men and women (Raju & Leonard, 2000). These projects have developed a series of key principles for an effective male-oriented reproductive health service: (a) ability to communicate in culturally and socially appropriate terms about men's sexuality (Grenon & Tazeem, 1996): (b) provision of information, education, and counseling on a variety of health topics in a sensitive, direct, and honest manner without judgment (George, 1997: Helzner, 1996: Ndong et al., 1999; Raina & Malhotra, 1998: Raju & Leonard, 2000; Sachdev, 1997: Verma, Khaitan, & Singh, 1998); (c) promotion of communication, education, testing, and treatment for both partners in order for STD programs to be effective (Bloom, Tsui, Plotkin, & Bassett, 1999: Ndong et al., 1999; Singh et al., 1998: Wegner, 1998); (d) diagnosis, treatment, education, and partner notification in relation to sexually transmitted infections integrated into male-focused reproductive healthcare (Shelton 1999; UNAIDS/WHO, 2000); and (e) promotion of condom use for both family planning and prevention of disease transmission (Hawkes & Hart, 2000: Raju & Leonard, 2000). Although these pilot programs have shown selective effectiveness, many more community-level interventions need to be undertaken to fully understand and implement effective male-oriented reproductive health programs in India and other parts of the world. This paper describes formative research leading to an intervention focused on enhanced provider services as a means of addressing sexual disease transmission in slum communities in Mumbai.

PRELIMINARY DATA

Research conducted over the past decade in India has shown that men living in both urban and rural areas of India have widespread anxieties associated with sexual matters (Kulhara & Avasthi, 1995: Pelto, Joshi. & Verma, 1999: Verma et al., 2001, 2003). Men in India are dealing with many of the universal male sexual health problems including premature ejaculation, impotence, infertility, nocturnal emission (wet dreams), feelings of guilt associated with masturbation, and concerns about penis size (Verma et al., 1998). South Asian and Indian culture amplifies these concerns through the concept of gupt rog ("secret illness" in Hindi), which refers to culturally defined illnesses that belong to the secret parts of the body. What makes these issues even more problematic in India is that sex is often associated with matters of pollution and purity (Savara, 1993). Many of the sexual health problems reported by men in India are described in terms of semen impurity and are viewed as caused by excessive sexual intercourse, wrong types of food, excessive exercise, grief, and loveless sexual intercourse (Bhugra & de Silva, 1995). According to Indian tradition (writings in the Upanishids), semen is known as virya, derived from a Sanskrit word that means bravery, power, or greatness (Nag, 1996: Verma et al., 1998) and is considered the source of physical and spiritual strength. The loss of virya through sexual acts or imagery (including masturbation and nocturnal emission) is considered harmful both physically and spiritually. The focus on semen loss makes premature ejaculation, nocturnal emission, and masturbation special concerns among Indian men (Verma et al., 1998). Although nocturnal emission and masturbation are the main sources of sexual release in the years before marriage among the majority of males, they are also major causes of anxieties among unmarried young men in South Asia (Bhende+ 1994; Watsa, 1993). Closely related to concerns about masturbation are erectile deficiencies and early ejaculation (Jain et al., 1998). Reports of impotence resulting from old age, excessive semen loss due to jealousy and drunkenness, semen and penile conditions, fear, anger, and incompatibility with a sexual partner have been extensively reported by men in India (Bhugra & de Silva, 1995). Since the etiology and diagnosis of gupt rog problems are outside the allopathic tradition, they have generally been ignored, demeaned, and seen as a relic of the cultural past by cosmopolitan health services. As a result, when men seek treatment for these problems, they go to the traditional, nonallopathic doctors in their communities.

R.K. Verma and his research team at the international Institute for Population Sciences in Mumbai conducted a study (1995-2000, Ford Foundation) of men's sexual health in a slum community in Mumbai. The team conducted a survey of a random sample of 1,344 men: among many questions, respondents were asked about whether they had a sexual health problem in the past two months, and if so what was the nature of the problem. The resulting list of problems were divided into those that were primarily not a result of sexual contact (noncontact) including nocturnal emission, sexual weakness, white discharge, early ejaculation, masturbation, poor quality and quantity of semen and erection problems: and those STIs or STI-like symptoms that were seen to be a result of sexual transmission (contact). In all, 43.7% (458) reported at least one of the noncontact problems, and 4.8% reported at least one contact problem. Bivariate analysis showed that respondents who report a noncontact problem have a significantly greater frequency of contact problems ([chi-square] = 22.76, df = 1, p < .001). In addition both contact and noncontact problems were significantly related to men with a riskier life style ([chi-square] = 3.59, df = 1, p < .05) as defined by smoking, drinking, gambling, alcohol use, and visiting sex workers (Verma & Schensul, 2004). These survey results and additional qualitative data showed that men identified noncontact problems at 10 times the frequency of contact problems and that culturally defined, noncontact problems are a mechanism with which to address both contact problems and risky behavior. The results demonstrated that it would be highly inappropriate for any behavioral change-oriented program seeking to address sexually transmitted diseases in the community to ignore noncontact gupt rog problems.

THE RISHTA PROJECT

The interrelationship of noncontact and contact sexual health problems and risky lifestyle has been the basis of a five-year (2001-2006), NIMH-funded (RO1-MH64875) research and intervention project in three slum communities (including the community in which Dr. Verma and his team worked) in Mumbai. The collaborating partners for the project are the Center for International Community Health Studies at the University of Connecticut School of Medicine in Farmington, CT, the Institute for Community Research in Hartford, CT, and the International Institute for Population Sciences in Mumbai, the apex demographic institution in India. The project, and a supplement for women funded by the Office of AIDS Research of the National Institutes of Health, formed the basis for the IIPS program, "Research and Intervention in Sexual Health: Theory to Action (RISHTA, meaning "relationship" in Hindi and Urdu). The project team consists of an interdisciplinary mix of anthropologists, demographers, physicians and psychologists, and a field staff of community residents and those experienced in research and intervention in similar communities. The project objectives were to (a) test the proposition that noncontact problems predict higher rates of risky sex and STD: (b) determine the degree to which an intervention focused on culturally based sexual health concerns can attract men into HIV/STD education, sexual risk reduction, and early identification of HIV/STDs; and (c) develop and test a culturally based therapeutic approach to male sexual health problems that could result in positive social, psychological, and health outcomes for male sexual health problems. The project called for formative research, which would provide the empirical base for the development of the intervention, and evaluation of the effectiveness, integrity, and acceptability of the intervention among patients, providers, and the community as a whole, utilizing a pretest, post-test control group design and qualitative evaluation methods. This paper will focus on the formative research and the translation of those results into an innovative intervention for men in the experimental communities. With less than a year since the initiation of the intervention, sufficient outcome evaluation results are not yet available: however, we will present preliminary results of process evaluation to comment on the acceptability and integrity of the intervention to date.

FORMATIVE RESEARCH RESULTS

The primary aim of the formative research was to learn more about men in the three study communities, with particular emphasis on sexuality and sexual health problems and the providers who treat those problems. To achieve this objective the project team, in the period of February 2002-September 2003, conducted in-depth interviews with 52 men, carried out a rapid assessment of all private providers in the three communities, conducted in-depth interviews with 45 private allopathic and nonallopathic private providers, and conducted a baseline survey of 2,408 randomly selected men and STD testing with a sub-sample of 640 men.

THE COMMUNITY

The project is being conducted in three low-income, "slum" communities that have grown rapidly in the past two decades with a large number of illegal and unauthorized structures added by migrants coming from various parts of the country. The population is mixed Hindu and Muslim, with the majority coming from Uttar Pradesh and other poor states in northern India and rural Maharashtra and Tamil Nadu in the West and South. These communities are typical of overcrowded Mumbai slums with many lanes and by-lanes, unplanned and ad-hoc structures, and many "joints" such as tea and paan (betel nut) shops, beer bars, country liquor outlets, and illegal gambling establishments.

A stratified random sample of 2,408 married men ranging in age from 21 to 40 was drawn from the three study communities. The average age of men in the sample is 31 years, with a mean education at sixth standard (grade). The sample is 53% Muslim, 43% Hindu, and 4% other. Men's average income is Rs. 3272 ($70) per month. Participants are currently living in households with a mean of 5.6 people per household, with 1.2 rooms or approximately four people per room.

In the RISHTA project survey, the men in the survey sample were given a list of 33 symptoms and asked if they had ever experienced a problem, in the past three months and currently. Table 1 present men's self-reports for the leading symptoms over the previous three months.

Overall, 1272 (53%) of married men reported at least one sexual health problem in the last three months, with 40% reporting a noncontact problem and 36% a contact problem. Early ejaculation was the number-one sexual health problem in these communities, with itching on the genital organs, burning urination, "hot urine," loss of sexual desire, and nocturnal emission also of relatively high frequency.

SEXUAL HEALTH CONCERNS FROM THE MEN'S PERSPECTIVE

Four themes emerged from the men's discussion of their sexual health problems: (a) definition of symptoms, (b) concepts of masculinity; (c) the nature of the marital relationship; and (d) involvement in a risky lifestyle. Illustrations of each of these themes follow.

Definitions of Symptoms. In terms of the definition of symptoms of noncontact problems, one man said: "I suffered from the problem of bent penis, lack of desire for sex, erection difficulty, early ejaculation." Another interviewee described his problems as "loss of sexual desire, joint pain, black circles around eyes, and early ejaculation." "Those who are suffering wet dream and do excessive masturbation, their semen becomes weak and [are not able to do] intercourse. In this case, they should not marry." "Before marriage I used to masturbate ... by which I wasted semen to a great extent, for which I suffered the problem of bent penis, lack of desire for sex, erection problem, and early ejaculation." "Due to anxiety and hesitation, I ejaculated beforehand." "[During first sexual experience] I was scared to do sex with her: I was not getting a proper erection." Other men cited reasons related to perceived male and female roles (e.g., failure of man to be dominant), having sex too frequently (e.g., if sex daily, "there is no semen in the penis, how can I get erection?"), lack of physical strength, and external factors such as income and arranged marriages. Descriptions of contact problems are summarized in one man's description of STD-like problems, "I suffered from ... pus discharge, burning urination ... also the penis became red." Men viewed their sexual health problems as stemming from previous sexual experiences with partners they perceived as risky (older women, sex workers, eunuchs, multiple partners). "People say if we do sex with eunuchs then there is a chance of suffering from [STD-like symptoms]."

Concepts of Masculinity. Concepts of masculinity and self-perceptions of manliness showed a clear link to their concerns about sexual health problems, emphasizing the importance of cultural-specific role definitions. "A real man or manliness is [one] who can satisfy his wife and should be ready for sex whenever his wife asks for sex. If he has relation with more than one woman, he should be able to [satisfy] all...." "He can produce a male child, also females should be attracted to him." "Man should be able to control himself till her orgasm." "A real man should have control on masturbation." "[A real man should be] able to do sex for a longer period, at least for 30 minutes." "The sign of manliness is the size and thickness of penis." Presence of sexual health problems was seen as contrary to manliness: "[A real man] is not suffering from such problems like early ejaculation and loss of semen." "In case the wife initiates [sex], that means her husband is a eunuch." "Wife should never take initiative in sex; rather she should feel scared about sex. She should always be satisfied during sex." "When I need sex it takes place: no need to give any special indication." "I also don't ask her about satisfaction. As it is penetrative sex, she gets the semen inside her vagina, by which I know that she is satisfied." Men also associated masculinity with forced sex: "Unless the man forces his wife [for sex], he will not be called a real man: in other words forceful sex is a sign of manliness." "A real man is he who can do sex till his wife cries in pain." Men's definitions of masculinity, and thus their self-perceptions, were closely tied to sexual health. This link is critical in the treatment of men's sexual health problems.

Nature of Marital Relationship. Relationship with spouse was closely linked to male sexual health concerns. Men spoke primarily about the actual or potential impact of their sexual health problems on their marital relationships or wife's health. "From a health point of view, there should not be any sexual health problems. So he [husband] will be able to satisfy the sexual urges of his wife, and in turn marital relations will be good." Men also expressed concerns about the failure to satisfy their wives, "If my wife is not satisfied, she will get attracted to other males." The men also talked about the negative reactions of their wives to sexual difficulties. For example, "[in response to early ejaculation], she becomes annoyed and teases me for this:" or "she sleeps with anger and doesn't talk to me." The potential impact on the wife's health is exemplified in the following quote: "She also has pimples around her genital organs. She also has the problems I suffer from ... complains about pain in her abdomen, burning urination, white discharge: she looks like a TB patient."

The men spoke of forced sex as typical in their own marriages, "She always says no to sex. But I always force her." "As per my knowledge everyone does forceful sex in the first night [of marriage], so I also did forcefully." "But this is my right to have sex forcefully, which I do frequently." "Friends also told me in the first night ... the bride would feel shy and hesitate ... forcefully I had sex for two times.... But the second night she completely refused for intercourse and told me she is getting severe pain in vagina due to forceful sex at first night. I shared the experience with my friends ... they told me nothing is wrong in this, every women search some excuses to avoid sex ... when women are getting pain, they enjoy more." The interviews revealed the presence of conflict and physical violence in men's marriages, "I beat her furiously." "I got angry and slapped her." "Sometimes, due to alcohol, I use to beat her." "Last night I drank a bit: when I went near her she said I am stinking, so I should stay away. Then I got angry and slapped her." "So always my wife fights with me for the luxurious amenities, which I can't provide her. Once I became very upset and slapped her." The men's narratives clearly indicate that domestic violence is an issue that warrants attention and may be part of a pattern of marital dissatisfaction that includes sexual dissatisfaction.

Involvement in Risky Lifestyle. Risky lifestyle of the respondents was evident in their comments about extramarital sex, sex with commercial sex workers, perceived norms about acceptable sexual activity of men, and attitudes toward condoms. The men spoke about engaging in sex with commercial sex workers before and during marriage. There were many references to having sex with sex workers. The men provided several reasons for engaging in extramarital relationships, particularly with sex workers. They cited sexual dissatisfaction in their marriages: "CSWs are prepared to do sex in different ways, as we saw in blue films, which we can't do with our wives. So I went to the CSW;" "with CSW I can enjoy as I wish within Rs. 50/." They spoke also of general marital dissatisfaction: "I am fed up of my family. Nowadays I am involved with a Nepali girl. First time I met her is at a beer bar." They also cited perceived norms that support premarital and extramarital sex, "Who is a saint these days? Everybody experiences sex before marriage.... Everybody gets bored with their wives. If one wants true enjoyment, then he should go out and keep someone for that, no matter he has to spend money for that." "I experienced it [first sexual experience] with a CSW, when I was around 20 years." And "I had extramarital relation [with sex workers]." "We enjoy sex together rather than one by one. She [CSW] does masturbation to all. I prefer to do intercourse, so I used to have intercourse first; after that my friends enjoy with her in different ways as shown in blue films."

A number of studies have indicated that men are more concerned about performance issues related to semen loss than they are about sexually transmitted infections (Pelto et al., 1999). Strongly held cultural beliefs cause the vulnerable individual to develop concerns about sexual performance, thereby leading to anxiety that may then act as a mediator for the genesis and perpetuation of problems (Bhugra & de Silva, 1995: Shah, 1998; Verma et al., 1998). The role of women and the prevalence of arranged marriages bringing together strangers on the wedding night may also contribute to sexual dysfunction (Bhugra & de Silva 1993: Verma et al., 1998). A study in Pune reported that young men had sex with sex workers only a few days before marriage, either due to peer pressure or performance anxiety (Raju & Leonard 2000). Concerns about sexual performance are a primary reason for non-marital sexual experience in India (Pelto, 1999; Savara & Sridhar, 1992; Singh et al., 1998: Verma et al., 1998). One of the motives for seeking out compliant sexual partners and being involved in risky sexual contacts (with sex workers or with multiple partners) is to avoid the perceived dangers and debilitating effects of excessive semen loss believed to result from masturbation: there is a widespread belief among Indian men that the loss of semen during sex with partners is less and therefore not as dangerous as the loss of semen in masturbation (Deepak Charitable Trust, 2000).

THE PROVIDERS

Healthcare services available to residents in the study communities include public hospitals located near the community, with inpatient and outpatient facilities, government-run urban health centers located in the community and conducted jointly between the Mumbai Municipal Corporation and medical colleges, government-run health posts: and private practitioners located on almost every lane in the three study communities. Men are reluctant due to tear, stigma, and embarrassment to bring their contact problems to the STD clinics in the area. A significant number of men (46%) report on the survey that they obtain antibiotics from chemist shops in the communities for contact symptoms. Since noncontact problems are seen in a negative light by the allopathic system, they are almost never brought to the governmental facilities, which see few men anyway since they primarily provide maternal and child health services. As a result, when men want to see a provider for a gupt tog problem, they go to either private nonallopathic providers or allopaths (MBBS) in their communities.

In the current terminology of the Ministry of Health in India, nonallopathic doctors are now called AYUSH (an acronym meaning "life") and include Ayurveda, Yoga and Naturopathy, Unani, Sidha, and Homeopthy. The Rapid Assessment of Providers (RAP) identified 245 practitioners in the three study communities that could be categorized into the four disciplines: ayurveda (79, 32.2%); homeopathy (73, 29.8%): unani (67, 27.3%), and allopathy [MBBS] (26, 10.6%). The average age of the nonallopathic providers is 36.6, with a reported 17.6 years of education and training. Of the 245 providers, 22 (8.9%) are women. In general, the AYUSH providers are an established group; they have an average of 9.3 years of practice and an average of 7.2 years of practice in one of the study communities. More than 60% have never practiced in another location, and almost 90% of their patients come from the same community where they have their practice. The nonallopathic providers see an average of 28 patients per day, and the allopaths see an average of 42 patients per day. The overall breakdown of patients, as reported by the private providers, is 44.2% adult men, 34.8% adult women, and 21% children. It is notable that men, who generally underutilize healthcare services in most locales, are the highest consumers of community-based private practitioners.

Based on the provider reports of utilization given on the RAP, it is estimated that the 245 private practitioners see more than 6,800 patients daily in the three study communities. Furthermore, the private practitioners see more men (an estimated 3,000 per month) than any other sector of the healthcare system in Mumbai. Based on RAP results, providers see a monthly average of more than 2,400 male patients with sexual health problems and an estimated 1,350 individuals with STD-like problems. These data suggest that the private practice providers, of which the AYUSH practitioners represent more than 90%, are a major resource for addressing the general health of communities and are an important resource for men, particularly for men with sexual health problems.

THE INTERVENTION

The application of current empirically supported models of HIV/STD prevention to male cultural and national realities represents a challenge for the development of appropriate interventions. Most men in India have a very clear culturally derived sense of sexual-problem priority (e.g., performance over disease), etiology (inappropriate semen loss), consequences (threats to masculinity), and treatment approach (self-medication or treatment by a nonallopathic provider). At a time of increasing incidence of STD/AIDS. these cultural concepts, beliefs, and actions strongly contrast with the usual intervention focus on disease prevention, risky-behavior reduction. early allopathic treatment, and accurate sexual health information. The RISHTA project takes the perspective that these concepts are not simply barriers to proper action but can be a gift to the interventionist who is willing to be open to the realities of the healthcare system and to men's narratives as a base for behavior change.

Current intervention models are based in psychological theories, with a particular focus on cognition and behavior of the individual (e.g., Azjen & Fishbein, 1980; Fisher & Fisher. 1993: Kelly, 1995). These interventions are directed toward providing information, fostering attitudes, influencing motivations, and teaching skills that support engagement in health-promoting (or risk-reducing) behavior. Despite the documented effectiveness of these approaches, there are several limitations. First, they have been developed and tested primarily within the U.S. (O'Reilly & Piot, 1996). Second, these approaches focus on individual change and do not typically include community-oriented components to address the environmental factors (e.g., economic, political) that support risky behavior. Current approaches have typically neglected the sociocultural aspects of illness and health--in particular, how culture influences patients' and health providers' interpretations of physical illness and psychological distress (Kleinman, 1986).

To facilitate a broader understanding of sexual health problems in India and the development of culture-specific interventions for prevention and risk-reduction of HIV/STDs. the RISHTA project has utilized an interdisciplinary approach that is consistent with recent thinking about health promotion (Leviton, 1996) and our earlier work on sexual risk in South Asia (Nastasi et al., 1998-99; Silva et al., 1997). The RISHTA project is based on a culture-specific intervention for HIV/STD risk reduction and prevention--Narrative Intervention Model (NIM). This approach integrates principles and strategies from narrative therapy (Eron & Lund, 1996: Howard, 1991: McNamee, 1997: McNamee & Gergen, 1992: Sarbin, 1986), cognitive therapy (Beck, 1976; Ellis, 1962), and cognitive-behavioral approaches to sexual risk prevention and risk reduction (Azjen & Fishbein, 1980: Fisher & Fisher, 1993; Kelly, 1995). The theoretical underpinnings of NIM reflect social construction (Berger & Luckman, 1966: Nastasi et al., 1999; Vygotsky, 1978: Wertsch, 1991). bioecological (Bronfenbrenner, 1989, 1999), anthropological (Kleinman, 1986; Pelto & Pelto, 1997: Wallace, 1961) and social-psychological perspectives (Abrams & Niaura, 1987: Azjen & Fishbein, 1980: Bandura, 1986; Jemmott & Jones, 1983; Miller et al., 1993: Fisher & Fisher, 1993). The RISHTA model posits that human behavior (specifically, behavior related to sexual health) is influenced by the interaction of biological, psychological, and sociocultural factors. Behavior is influenced by cognitions (ideas, attitudes, beliefs) that are developed or transmitted primarily through social (interpersonal) interactions. Through these interpersonal interactions, culture (ideas, beliefs, values, norms) is transmitted and influences the development of cognitions and behavior patterns. Culturally transmitted cognitions influence not only behavioral responses but also the interpretation of internal responses (e.g., emotions, perceptions, bodily processes) and external contextual (physical and social environment) experiences. Through repeated experiences, individuals develop narratives or scripts that guide their behavior. Among Indian men these narratives intimately link performance issues, masculinity, and risky sex and complicate primary relationships with wives or other sex partners.

Any approach to issues of behavioral change requires knowledge of the individual's sociocultural history and a sense of how to structure interpersonal interactions (e.g., between provider and client) that can lead to reconstruction of the relevant personal narratives. Through the use of focused interpersonal interactions, trained practitioners can help individuals to (a) identify the narrative related to the presenting problem (construct the narrative), (b) critically examine the psychological and sociocultural 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/STDs prevention and treatment.

Consistent with cognitive-behavioral intervention models (e.g., Fisher & Fisher, 1993), we emphasize the role of cognition in guiding behavior and assume that changes in thinking (e.g., ideas, beliefs, values) are critical to behavior change. The importance of culture in guiding human behavior reflects our anthropological focus and is consistent with bioecological perspectives in psychology. Narrative therapy, based in social constructionist thinking, is focused on the use of clients' stories (narratives) to assess the affective, cognitive, behavioral, and sociocultural elements of the presenting problem and to facilitate change in these elements through a systematic deconstruction and co-construction of the narrative. 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.

With this theoretical base and the empirical results generated by the formative research, a multi-level intervention plan was generated that would reflect the NIM at three levels: the community, the provider, and the patient. All three of the study communities received community-level health education. Two communities were selected for experimental interventions, with the third community as the control. In the first experimental community, all nonallopathic providers were provided training to upgrade their skills in dealing with sexual health problems. In the second community, an allopathic intervention was established in which a male health clinic was organized in the community's urban health center in conjunction with a Mumbai-based medical college. The male health clinic, one of the first to be organized in India, provides services to men with all problems three days per week at times that are convenient to working men and do not overlap with the use of the health center by women. Community-Level Intervention. The objectives of the community-level intervention are to (a) create, on the part of the community at large, a revised narrative that links noncontact sexual problems to issues of masculinity, lifestyle, and primary sexual relationships and supports the development of health-promoting and risk-reducing behaviors related to HIV/STD prevention and treatment; and (b) create awareness on the part of the experimental communities of the presence and accessibility of RISHTA project-trained providers who will address their sexual health problems with respect, comprehensiveness, and efficacy. The components of the community level intervention include:

* Street dramas depicting the linkages of hypermasculinity, poor marital relationships, and a risky lifestyle to gupt rog. Street dramas are presented in each section of the three communities on a rotating basis. To date, more than 60 street dramas have been presented involving three rotating scripts.

* Follow-up meetings are conducted on the day after a street drama is held and approximately a week thereafter. RISHTA staff holds the first meeting to debrief men concerning the content and messages of the street dramas. A second meeting is held to answer men's questions concerning sexual health and prevention of disease. To date, the RISHTA program has held 45 sets of follow-up meetings.

* Community meetings involve systematic coverage of leaders of community-based organizations (CBOs) including parush mandals (men's organizations) and service organizations. Eventually the RISHTA staff will work with these organizations to address the sustainability of its community and provider interventions.

* Community events include health camps, educational sessions, festivals, and religious holidays in which RISHTA program staff set up a booth and supply sexual health information. To date, a single event has been held in each of the three communities.

The primary messages of these community education activities focus on positive masculinity, reduction of intimate partner violence, the negative effects of excessive alcohol use, communication and negotiation between spouses, the dangers of extramarital sex, condom use as means of prevention of disease, and the need for appropriate treatment by trained providers for both noncontact and contact sexual health problems. Based on previous research with the target population and specifically men's narratives about their sexual health concerns, we have identified several themes that constitute the content of community messages as well as provider and patient interventions (see Table 2).

Provider-Level Intervention. Provider training involved a participatory consultation approach based on our previous work in South Asia (Nastasi, Varjas, Bernstein, & Jayasena, 2000; Nastasi, Varjas, Schensul, et al., 2000). In this approach practitioners received skills-development training in workshop format preceding the intervention implementation (initial training) with follow-up training and consultation throughout implementation on both a scheduled and ad hoc basis (ongoing consultation). Training activities included lecture, demonstration, practice, and feedback. Ongoing consultation involved periodic visits by the project's intervention coordinator and monthly training/discussion sessions to address challenges in implementation. In addition, evaluation staff visited doctors weekly to monitor implementation and gather information about challenges presented by NIM.

Both the allopathic staff of the male health clinic in the first experimental community and the 23 AYUSH providers who chose to be involved in the second experimental community participated in a 12-hour initial training workshop conducted by RISHTA over four consecutive days in October 2003. The curriculum of the program focused on the following elements:

1. an introduction to the RISHTA project:

2. increasing the knowledge on the part of the allopathic providers concerning types and prevalence of gupt rog symptoms as reported by the men in both the qualitative and quantitative interviews;

3. examination of the link between contact and noncontact problems;

4. increasing the knowledge about the factors that contribute to, co-occur with, and result from gupt tog;

5. expansion of the treatment of contact and noncontact problems, through the use of the Narrative Intervention Model (NIM), to include attention to factors reflected in Table 2 including:

a. biological, psychological, and sociocultural factors;

b. links among biological, psychological, and sociocultural factors as influences on etiology, treatment seeking, treatment, and prevention of gupt rog;

c. education and counseling for prevention of sexual risks;

d. appropriate testing and treatment of STDs;

e. referrals for medical, psychological, and social services as needed:

6. creation of a support system for providers in implementing the NIM, consisting of RISHTA intervention staff:

8. information about RISHTA evaluation procedures and providers' role in evaluation.

After the initial training, formal three-hour refresher training sessions were provided quarterly. The sessions conducted to date have focused on enhancing provider knowledge of syndromic management of STIs (presentation by national Indian experts), addressing sexual dysfunction (presentation by local psychiatrist and sexologist), and implementing the assessment and intervention phases of NIM (conducted by RISHTA team). In response to provider requests, monthly training meetings began in October 2004. These meetings are conducted by local RISHTA staff and focus on challenges that the providers face in implementing NIM. RISHTA field staff visit each provider on a weekly basis to identify informational needs and to assess the integration of the NIM into patient treatment.

Patient-Level Intervention. The treatment objectives of the staff of the male health clinic and the nonallopathic providers in the experimental communities are to foster knowledge, attitudes/beliefs, and behavioral changes in the individual clients that lead to appropriate culture-specific care-seeking behaviors and STD/HIV risk-reduction behaviors. The one to two sessions, brief intervention (fitting into the standard provider-patient contacts) combines assessment, education, counseling, and treatment to (a) address the medical/physical (symptoms), psychological (self-esteem, masculinity, assessment as a husband), and social relationship (gender equity, gender violence, extended family conflicts) issues related to male sexual health concerns (contact and noncontact); (b) provide accurate information about STDs, particularly HIV/STD transmission, risk reduction, and prevention: (c) determine the presence of STD symptoms and make referrals for STD testing and treatment as warranted; and (d) determine the need for social services related to economic, family, and individual psychological concerns and make referrals as warranted.

The Narrative Intervention Model (NIM) for HIV/STDs prevention and risk reduction provides a culture-specific program of healthcare and risk reduction that addresses medical, sociocultural, and psychological components of male sexual health problems and STD/HIV risk. The unique feature of the intervention is the use of personal narrative (story) to facilitate the assessment-intervention process and to insure that the intervention session(s) address emotional, cognitive, and behavioral components that are both individually and culturally relevant to the experiences of clients. The focus of the intervention is primarily affective and cognitive. The assumption, based on formative research, is that the primary barriers to risk reduction and prevention are found in the personal, community, and culturally based beliefs that guide the men's behavior. The brief nature of the intervention and provider capacity precluded the provision of specific skills training beyond the encouragement and refinement of existing skills or treatment of psychological or marital problems. For this reason, the project called for the development of a referral network for clients who need additional skills training, psychological counseling for individual or marital problems, or more intensive medical treatment for STIs.

The steps in the model involve assessment, support, reframing, retelling, and referral in the context of the client's individual story about sexual health concerns. Although presented in a sequential manner, the specific steps are recursive. That is, the health provider revisits earlier steps during the course of the session. In addition, the sequence of the steps may vary across provider and client. The key criterion is that all the steps are covered in the context of the client's narrative.

Step 1. Assessment is focused on (a) eliciting the narrative that includes client's current knowledge, attitudes, beliefs, emotions, and behaviors relevant to sexual health, sexual health problems, and HIV/STDs; and (b) testing for HIV/STDs.

Step 2. Support is designed to provide (a) emotional support to allay anxiety and foster optimism: and (b) instrumental support with suggestions for seeking related services.

Step 3. Reframing is focused on facilitating (a) acquisition of accurate information about sexual health, sexual health problems, and HIV/STDs; (b) awareness of the links between sexual health and psychological, interpersonal, and sociocultural factors: (c) awareness of the links between emotions, cognitions (attitudes, beliefs), and behaviors: (d) reframing of attitudes and beliefs consistent with health promotion and risk reduction: and (e) a minimal level of behavioral skills training related to anxiety reduction, health promotion, and risk reduction.

Step 4. Retelling facilitates narration of the reconstructed story incorporating changes in knowledge, attitudes, and behavioral intentions consistent with health promotion and risk reduction.

Step 5. Referral involves referring clients to relevant community agencies for additional services related to medical, psychological, or social concerns that are beyond the scope of the intervention.

Acknowledging the challenges of introducing NIM into the daily medical practice, we proposed to work closely with the providers on adapting the model to meet time limitations and providing ongoing support and training to facilitate modification of their approach to treatment. The modification of provider practice became an important component of the intervention. Our ongoing consultation with the providers alerted us to specific gaps in knowledge and challenges in modifying practice.

We have worked with the providers in training sessions to identify ways to integrate the five steps outlined above into their preexisting approach to history taking. diagnosis, and treatment. Step 1 (assessment) has been reframed as an extension of history taking and diagnosis to include gathering information about the patient's attitudes, beliefs, feelings, and behaviors that may influence sexual risk and integrating that information into their "diagnosis" of the problem. Over the course of the first year of implementation, the providers have reported success in using the NIM to achieve a more extensive history taking of the psychological and sociocultural factors related to patients' sexual health concerns and sexual risk. Step 2 (support) is consistent with current provider practices and has presented minimal challenges. At present, we are working closely with the providers on more effectively integrating Steps 3 and 4 (reframing and retelling) into the treatment phase of their treatment. Implementing Step 5 represents a major challenge for our project staff, primarily because of the lack of adequate resources in the target communities. For example, individual and marital counseling services are nonexistent in the study communities and are not easily accessed in the metropolitan area of Mumbai because of financial and transportation restrictions. It has been necessary to build these services into the capabilities of local community-based organizations rather than seek these referrals in the wider city.

Issues related to hypermasculinity, gender equity, and the marital relationship are particularly challenging to the intervention team at community, provider, and patient levels. Changing deeply rooted cultural beliefs about masculinity and gender require intensive, consistent, long-term intervention. Efforts to challenge and modify these beliefs are targeted at all three intervention levels. As we have worked with men and providers, the need for work with women, marital couples, and youth has become clear, and we are currently in the process of extending our work to these sectors.

EVALUATION

The major hypotheses of the intervention study include the following:

* All communities will show an improvement in a reduction in the prevalence of STDs, in men's sexual risk behavior, and in knowledge and attitudes with regard to sexually transmitted diseases as a result of community education.

* The experimental communities will show a significantly greater improvement than the control community.

* The trained providers will integrate the NIM into their practices.

* Patients provided treatment by the trained (AYUSH and allopathic) providers will show a greater reduction in risky sexual behavior than patients seen by untrained providers.

* It is difficult to predict whether the AYUSH-focused community and the patients treated by the AYUSH providers will show greater improvement than the allopathic-focused community and patients treated by the male health clinic. We have proposed that, given the traditional involvement of AYUSH providers in men's sexual health issues, their outcomes may be superior to those of the allopathic providers.

The methods utilized for evaluation are designed to assess the intervention from the perspective of the community, the provider, and the patient. Community-level impact is assessed through a baseline (already completed) and end-line survey (2 1/2 years after initiation of the intervention) of 2,400 men in the two experimental (intervention) communities and one control community. Provider-level impact, acceptability, and integrity are assessed through in-depth interviews with patients and providers, and collection and analysis of patient case records. Patient-level impact is assessed through pre-treatment, immediate post-treatment, and six-month follow-up for a random sample of 640 patients visiting the male health clinic and the trained AYUSH providers in the experimental community and untrained allopathic and nonallopathic providers in the control community. The pre-treatment, post-treatment, and follow-up instruments assess patient sociodemographics, presenting problems and perceived causes and consequences, the prior relationship with the doctor, activities with friends, substance use, exposure to pornographic materials, self-assessment as a husband and sexual partner, administration of a masculinity scale (hypermasculinity to positive masculinity), global life assessment, quality of the marital relationship, the nature of marital sex, spousal abuse, involvement in extramarital sex, and STD knowledge.

Preliminary results of trained provider capacities indicate that the intervention model at both the community and provider levels is being well implemented. The data from the patient records of the male health clinic show a steady flow of male patients into what has been an almost exclusive female health clinic since its opening in December 2003. The clinic is opened from 4:40 p.m. to 8:30 p.m. on two weeknights and from 10 a.m. to 1 p.m. on Sundays. From December to May, 68 clinic sessions were held, involving 834 patient visits representing 373 new cases for an average of 14 patients for each clinic session. Of 373 patients, 210 people (56.3%) presented with sexual health problems, of which 27 (12.9%) presented with syndromically defined contact problems. Out of the 210 patients who presented with sexual health problems, the specific presenting complaints mirror those in the baseline survey: 40.5% (85) had premature ejaculation; 21.9% (46) had issues with the quality and quantity of semen; 18.1% (38) impotency: and 15.2% (32) nocturnal emission. Of those with sexual health problems, 57.9% (216) of the patients are in the 21-40 age group, and 74.0% (276) are married. The six-month results indicate that a male health clinic in a government urban health clinic is capable of attracting men, of which a significant percentage will present a sexual health problem.

Reports from the AYUSH providers indicate that the training was very positively received, as evidenced by pre-post evaluation and by calls for monthly refresher training. An interim assessment of the impact of the training on the AYUSH providers indicated that there was a significant increase in the number of men being seen for sexual health problems, the willingness of men to discuss their sexual health problems, and referrals by AYUSH providers to other services within the healthcare system. AYUSH providers also reported that the frequent trainings provided them with an opportunity to network among their fellow providers and to seek out assistance from them after the training. Prior to the intervention, AYUSH providers served in the role of "family doctor," dealing with common complaints that included cold, fever, and diarrhea. After the training the AYUSH providers reported that they felt more comfortable dealing with their patients with sexual health problems and that their patients felt more comfortable in raising these problems. Further, AYUSH providers reported that men presented sexual health problems at shorter intervals after onset (a mean of five months) rather than delaying treatment (a mean of 20 months) as was the case prior to intervention.

At the community level, the RISHTA program and its field staff have become well known in the three study communities. Team members are now regularly contacted by men in the community for advice on their sexual health problems; community-based organizations request education sessions; and official and unofficial community leaders provide advice and input into programmatic decisions.

CONCLUSION

The major theoretical frameworks and AIDS behavior change models provide important guidance in developing interventions on the ground in the local study communities. This study shows that it is essential, however, to generate concepts and methodologies that emerge from the local context, which can provide the structural and cultural links for these exogenously derived intervention approaches. The delineation of the concepts and beliefs surrounding gupt rog, the identification of the role of AYUSH providers in treating these problems, and the opportunities provided by the urban health center to implement a male health clinic represent an ethnographically generated approach to ground-up planning and implementation of intervention. Further, these ground-up intervention approaches increase the sustainability of the interventions. The male health clinic is being implemented at a low cost and can be continued by the Mumbai Municipal Corporation, should the data show it to be a successful intervention. Further, periodic training of the nonallopathic providers also represents a low-cost approach to the upgrading of the key resource for men seeking treatment for their sexual problems. Finally, the strength of the RISHTA program lies in its capacity to have a multi-level impact on the community, the provider, and the individual male resident/patient with a message that sexual health problems are linked to all aspects of men's lives. This ecological approach is consistent with Indian cultural and healing traditions and is central to the intervention being implemented in the study communities. In the next two years, the RISHTA program will have the data to fully test the impact of this intervention model on the community, provider, and patient levels. In its first year, the model shows promise of reaching and involving men in a comprehensive and responsible approach to their sexual health and the health of their families.

Table 1
Self-Reported Sexual Health Problems and Treatment Seeking
in the Previous Three Months by Men Living in Three Slum
Communities in Mumbai (n =2408)

                                                       Sought
Sexual Health Problem             Experienced       Treatment (a)

                                  %       (#)       %       (#)

Early ejaculation                 16.1    (388)     19.6     (76)
Itching on genital organs         13.9    (335)     79.9    (263)
Burning urination                 11.5    (276)     37.8    (104)
Nocturnal emission                10.5    (178)      5.3      (9)
Pain in lower abdomen              9.6    (125)     53.3     (65)
Hot urine                          9.2    (221)     18.6     (39)
Loss of sexual desire              7.7    (185)     15.2     (28)
Thinning of semen                  4.3    (104)     16.2     (17)
Masturbation                       3.9     (37)      2.6      (1)
White discharge                    3.2     (78)     33.8     (26)
Quantity of semen                  2.7     (64)     12.3      (8)
Pimples on the genital organs      2.3     (55)     56.4     (31)
Small penis                        2.2     (52)      3.9      (2)
Bent penis                         2.1     (50)      2.0      (1)
Loss of erection                   2.0     (27)     17.0      (8)

(a) Percentage of those reporting the respective problem

Table 2
Key Themes Related to Male Sexual Health Problems Derived from
Formative Research and Their Link to RISHTA Intervention Program

Theme                                Intervention Focus

Noncontact sexual health problem     Culturally appropriate treatment
(early ejaculation, weakness,        (e.g., benign herbal preparation
erection difficulty, bent penis,     consistent with homeopathic,
loss of desire, pain, wet dream,     unani, or ayurvedic practice)
semen quality/quantity)
                                     Alternative techniques to treat
                                     sexual health problem

                                     Treatment or referral for related
                                     health concerns

Contact sexual health problem        Provide information about possible
(pus discharge, itching,             link to HIV/STDs
"pimples;" inflammation,
STD-like symptoms)                   Testing and/or referral for
                                     HIV/STDs treatment as warranted

Perceived etiology gf sexual         Disconfirm "misperceptions" about
health problems (masturbation,       etiology
wet dreams, sex with older woman,
CSW, eunuch, multiple partners,      Confirm risk factors for HIV/STDs
heat and dirt, anxiety or fear,
frequency of sex, economic, grief,   Discuss male-female roles in
physical strength, male-female       sexual performance/satisfaction
roles, blame others)
                                     Anxiety reduction techniques

                                     Discuss the relationship between
                                     anxiety and performance

                                     Referral for economic, marital,
                                     psychological concerns as
                                     warranted

Definition of manliness/             Question sources of perceptions
masculinity (causes pain,
initiate/perform sex on demand,      Redefine "manliness"
control masturbation/ejaculation,
male children, satisfy many women,   Redefine male-female roles and
raise children well, last long in    responsibilities
sex, penis size, force wife to
have sex, dominate wife, value of    Reexamine and redefine sense of
semen)                               personal worth

                                     Explore perceptions of the link
                                     between concerns about masculinity
                                     and sexual health problems;
                                     challenge misperceptions

Impact of sexual health problems     Referral for wife's sexual health
(marital problems, wife's sexual     problems as warranted
dissatisfaction, wife has sexual
health problems, forcible sex)       Strategies for addressing sexual
                                     relationship difficulties

                                     Referral for marital counseling
                                     as warranted

Marital relationship (husband/wife   Explore links of marital beliefs,
rights and responsibilities,         attitudes, emotions, behaviors to
privacy, sexual satisfaction,        sexual health problems
expectations about sex, "wedding
night" scenario, sexual patterns/    Reframe attitudes and beliefs
practices)                           toward promotion of sexual and
                                     psychological health and
                                     satisfactory marital relations

                                     Referral to appropriate social
                                     service agencies as warranted

Forcible sex in marriage (man's      Explore links of forced sex to
right, normative, alcohol-related)   "manliness" and sexual problems

                                     Question sources of perceptions

                                     Strategies for improving sexual
                                     relationship

                                     Referral for marital counseling
                                     as warranted

Marital [domestic] conflict and      Explore links between violence
violence (expectations not met,      and sexual difficulties,
alcohol-related, mutual abuse,       "manliness," and personal
dissatisfaction with sex,            difficulties/frustrations
dominance)
                                     Alternative strategies for
                                     conflict resolution

                                     Referral for psychological/marital
                                     counseling as warranted

HIV/STDs (sex with CSW; condom       Confirm and extend knowledge about
protection)                          HIV/STD transmission/prevention

Emotions related to sexual health    Link emotions to sexual
problems (guilt, anger, worry,       difficulties
anxiety, tension)
                                     Emotional support for
                                     "disturbance" about
                                     sexual health problems

                                     Anxiety-reduction or alternative
                                     strategies

                                     Referral for psychological
                                     services as warranted

Risky lifestyle (extramarital sex,   Link beliefs, attitudes. emotions,
perceived norms, sex with CSWs,      behaviors to sexual health problem
condom attitudes)
                                     Question sources of perceptions
                                     and attitudes

                                     Reframe attitudes and beliefs
                                     about sexual/psychological health

                                     Alternative strategies for
                                     personal and interpersonal
                                     problems

                                     Referral for psychological
                                     concerns as warranted

                                     Referral or treatment for
                                     HIV/STDs as warranted

REFERENCES

Azjen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

Beck, A.T. (1976). Cognitive therapy and emotional disorders. New York: International Universities Press.

Bentley, M.E., Spratt, K., Shepher, M.E., Gangakhedkar, R.R., Thilikavathi, S., Bollinger, R.C., et al. (1998). HIV testing and counseling among men attending sexually transmitted disease clinics in Pune, India: Changes in condom use and sexual behavior over time. AIDS, 12, 1869-1877.

Berger, P.L., & Luckman, T. (1966). The social construction of reality: A treatise in the sociology of knowledge. Garden City, NJ: Doubleday.

Bhende, A.A. (1994). A study of sexuality of adolescent girls and boys in underprivileged groups in Bombay. The Indian Journal of Social Work, 55(4), 557-571.

Bhugra, D., & de Silva, P. (1995). Sexual dysfunction and sex therapy: An historical perspective. International Review of Psychiatry, 7(2), 159-167.

Bloom, S.S., Tsui, A.O., Plotkin, M., & Bassett, S. (1999). What husbands in northern India know about reproductive health: Correlates of knowledge about pregnancy and maternal and sexual health. Journal of Biosocial Science, 32(2), 237-251.

Bronfenbrenner, U. (1989). Ecological systems theory. In R. Vasta (Ed.), Annals of child development (Vol. 6, pp. 187-249). Greenwich. CT: JAI Press.

Bronfenbrenner, U. (1999). Environments in developmental perspectives: Theoretical and operational models. In S.L. Friedman & T.D. Wachs (Eds.), Measuring environment across the life span: Emerging methods and concepts (pp. 3-28). Washington, DC: American Psychological Association.

Das, S., Yemul, V., & Deshmukh, R. (1998). Incidence and association of HIV and other STDs in 200 persons belonging to a high risk group in central Mumbai. Venereology, 11(1), 19-23.

Deepak Charitable Trust. (2000). Male semen loss concerns. Baroda, India: Deepak Charitable Trust.

Eberstadt, N. (2002). The future of AIDS. Foreign Affairs, November/December, 81(6), 22-45.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Eron, J.B., & Lurid, T.W. (1996). Narrative solutions in brief therapy. New York: Guilford.

Fisher, W.A., & Fisher. J.D. (1993). A general social psychological model for changing AIDS risk behavior. In J.B. Pryor & G.D. Reeder (Eds.), The social psychology of HIV infection. Hillsdale, NJ: Erlbaum.

Gangakhedkar, R.R., Bentley, M.E., & Gadkari. D.A. (1997). Spread of HIV infection in married monogamous women in India. Journal of the American Medical Association, 278, 2090-2092.

George, A. (1997). Sexual behavior and sexual negotiation among poor women and men in Mumbai: An exploratory study. Baroda. India: SAHAJ Society for Health Alternatives.

Grenon, M.C., & Tazeem, M. (1997). Men's perceptions o1 illnesses of the nether areas. Unpublished manuscript. Sarathi Gujarat, India.

Hawkes, S., & Hart, G. (2000). Men's sexual health matters: Promoting reproductive health in an international context. Tropical Medicine & International Health, 5(7), A37-A44.

Helzner, J.F. (1996). Men's involvement in family planning. Reproductive Health Matters, 7, 146-154.

Howard, G.S. (1991). Culture tales: A narrative approach to thinking, cross-cultural psychology, and psychotherapy. American Psychologist, 46, 187-197.

Jacob, M., John, T.J., George, S., Rao, P.S., & Babu, P.G. (1995). Increasing prevalence of human immunodeficiency virus infection among patients attending a clinic for sexually transmitted diseases. Indian Journal of Medical Research, 101, 6-9.

Jain, M.K., John, T.J., & Keusch, G.T. (1994). A review of human immunodeficiency virus infection in India. Journal of Acquired Immune Deficiency Syndrome, 7(11), 1185-1194.

Jemmott, J.B., & Jones, J.M. (1993). Social psychology and AIDS among ethnic minority individuals: Risk behaviors and strategies for changing them. In J.B. Pryor & G.D. Reeder (Eds.). The social psychology of HIV infection (pp. 183-224). Hillsdale, NJ: Erlbaum.

Kelly, J.A. (1995). Changing HIV risk behavior: Practical strategies. New York: Guilford.

Kleinman, A. (1986). Social origins o/distress and disease. New Haven, CT: Yale University Press.

Kulhara, P., & Avasthi, A. (1995). Sexual dysfunction on the Indian subcontinent. International Review of Psychiatry, 7(2), 231-240.

Kumar, S. (1999). India has the largest number of people infected with HIV. The Lancet, 353(9146). 48.

Leviton, L.C. (1996). Integrating psychology and public health: Challenges and opportunities. American Psychologist, 51, 42-51.

McNamee, S. (1996). Psychotherapy as a social construction. In H. Rosen & K. Kuehlwein (Eds.), Constructing realities: Meaning-making perspectives for psychotherapists (pp. 115-137). San Francisco: Jossey-Bass.

McNamee, S., & Gergen, K.J. (1992). Therapy as a social construction. New Park, CA: Sage.

Miller, L.C., Bettencourt, B.A., DeBro, S.C., & Hoffman, V. (1993). Negotiating safer sex: Interpersonal dynamics. In J.B. Pryor & G.D. Reeder (Eds.), The social psychology of HIV injection (pp. 85-123). Hillsdale, NJ: Erlbaum.

Nag, M. (1996). Sexual behavior and AIDS in India. New Delhi, India: Vikas Publishing House.

Nastasi, B.K. (1998). A model for mental health programming in schools and communities. School Psychology Review, 27(2), 165-174.

Nastasi, B.K., Schensul, J.J., deSilva, M.W.A., Varjas, K., Silva, K.T., Ratnayake, P., et al. (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.

Nastasi, B.K., Varjas, K., Bernstein, R., & Jayasena, A. (2000). Conducting participatory culture-specific consultation: A global perspective on multicultural consultation. School Psychology Quarterly, 29(3), 401-413.

Nastasi, B.K., Varjas, K., Schensul, S.L., Silva, K.T., Schensul, J.J., & Ratnayake, P. (2000). The participatory intervention model: A framework for conceptualizing and promoting intervention acceptability. School Psychology Quarterly. 15, 207-232.

Nataraj, S. (1994). Waiting for a connection. Populi, 21(10), 6-11.

National AIDS Control Organization. (2004). HIV estimates in India (based on HIV Sentinel surveillance). Retrieved January 10, 2005, from http://www.naco.nic.in /indianscene/esthiv.htm.

Ndong, I., Becker, R.M., Haws, J.M., & Wegner, M.N. (1999). Men's reproductive health: Defining, designing and delivering service. International Family Planning Perspectives, 25(Supplement), S53-S55.

Newmann, S., Sarin, P., Kumarasamy, N., Amalraj, E., Rogers, M., Madhivanan, P., et al. (2000). Marriage, monogamy and HIV: A profile of HIV-infected women in South India. International Journal of STD & AIDS, 11(4), 250-253.

O'Reilly, K.R., & Piot, P. (1996). International perspectives on individual and community approaches to the prevention of sexually transmitted disease and human immunodeficiency virus infection. The Journal of Infectious Disease, 174, 214-222.

Pais, P. (1996). HIV and India: Looking into the abyss. Tropical Medicine and International Health, 1(3), 295-304.

Pelto, P.J. (1999). Sexuality and sexual behavior in India: The current discourse. In S. Pacbauri (Ed.), Implementing a reproductive health agenda in India: The beginning (pp. 551-599). New Delhi, India: Population Council.

Pelto, P.J., Joshi, A., & Verma, R. (1999). The development of Indian male sexuality. New Delhi, India: Population Council, South and Southeast Asian Regional Office.

Raina, N., & Malhotra, V. (1998). Understanding men's reproductive health behavior. Haryana, India: Survival for Women and Children Foundation (SWACH).

Raju, S., & Leonard, A. (2000). Men as supportive partners in reproductive health: Moving from rhetoric to reality. New Delhi, India: Population Council.

Sachdev, P. (1997). University students in Delhi, India: Their sexual knowledge, attitudes and behavior. Journal of Family Welfare, 43(1), 1-12.

Sarbin, T. (1986). Narrative psychology: The storied nature of human conduct. New York: Praeger.

Savara, M., & Sridhar, C.R. (1992). Sexual behavior of urban, educated Indian men: Results of a survey. Journal of Family Welfare, 38(1), 30-43.

Shah, R. (1998, April 27). Impotency: Growing malaise, India Today, 61-69.

Shelton, J.D. (1999). Prevention first: A three-pronged strategy to integrate family planning program efforts against HIV and Sexually Transmitted Infections. International Family Planning Perspectives, 25(3), 147-152.

Silva. K.T., Schensul, S.L., Schensul, J.J., Nastasi, B.K., de Silva, M.W.A., Sivayoganathan, C., et al. (1997). Youth and sexual risk in Sri Lanka. Women and AIDS research program phase 11. Research report Series No. 3. Washington, DC: International Center for Research on Women.

Singh, K.K., Bloom, S.S., & Tsui, A.O. (1998). Husbands' reproductive health knowledge, attitudes, and behavior in Uttar Pradesh, India. Studies in Family Planning. 29(4), 388-399.

Swanson, J.M., & Forrest, K.A. (1987). Men's reproductive health. New York: Springer Publishing Co.

UNAIDS. (2004). Report on the global AIDS epidemic: Executive summary. Geneva: UNAIDS.

UNAIDS/WHO. (2000). Epidemiology fact sheet on HIV/AIDS and sexually transmitted infections: India. Geneva: UNAIDS/WHO Working Group on HIV/AIDS and STI Surveillance.

Verma, R.K., Khaitan, B.K., & Singh, O.P. (1998). The frequency of sexual dysfunctions in patients attending a sex therapy clinic in North India. Archives of Sexual Behavior, 27(3), 309-313.

Verma, R.K., & Schensul, S.L. (2004). Male sexual health problems in Mumbai: Cultural constructs that present opportunities for HIV/AIDS risk education. In R.K. Verma, P.J. Pelto, S.L. Schensul, & A. Joshi (Eds.), Sexuality in the time of AIDS: Contemporary perspectives from communities in India (pp. 243-261). New Delhi, India: Sage Publications.

Verma, R.K., Rangaiyan, K.G., Singh, R. Sharma, S., Pelto, P.J. (2001). A study of male sexual health problems in a Mumbai slum population. Culture, Health & Sexuality, 3(3), 339-352.

Verma, R.K., Sharma, S., Rangaiyan, K.G., Singh, R. Pelto, P.J. (2003). Beliefs concerning male sexual health problems and treatment seeking among men in Mumbai slums. Culture, Health and Sexuality, 3, 165-173.

Vygotsky, L.S. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.

Watsa, M. (1993). Premarital sexual behavior of urban educated youth in India. Paper presented at the workshop on sexual aspects of AIDS/STD prevention in India, Tara Institute of Social Sciences, Mumbai. India.

Wegner, M.N. (1998). Men as partners in reproductive health: From issues to action. International Family Planning Perspectives, 24(1), 38-42.

Wertsch, J.V. (1991). Voices of the mind: A sociocultural approach to mediated action. Cambridge, MA: Harvard University Press.

Data presented in this paper were collected as a part of a National Institute of Mental Health Grant (RO1-MH64875, S. Shensul, P.I.). Key faculty and staff involved in the project from the International Institute for Population Sciences include Prof. G. Rama Rao, site Pl: Dr. Saggurti Niranjan, co-PI: Dr. Sharad S. Narvekar, India project coordinator: Dr. Sumitra Sharma and Mr. Rajendra Singh, senior research officers: and the field research and intervention staff. Key staff at the University of Connecticut School of Medicine involved in the project include Dr. Abdelwahed Mekki-Berrada, U.S. Project Coordinator, and Ms. Carmen Manuela Pinto, research assistant.

Correspondence concerning this article should be sent to Stephen L. Schensul, Department of Community Medicine, University of Connecticut School of Medicine, 263 Farmington Avenue. Farmington, CT 06030-6325. Electronic mail: [e-mail].

STEPHEN L. SCHENSUL

Department of Community Medicine

University of Connecticut School of Medicine

RAVI K. VERMA

Population Council

New Delhi, India

BONNIE K. NASTASI

Institute for Community Research, Hartford, CT