Huwa Rog, Parhej, and Desi Dawai: Women's Perceptions of Postpartum Maternal Morbidity and Care in Rajasthan, India.

Although more maternal deaths occur in the postpartum period, this period receives far less attention from the program managers. To understand how the women and their families perceive postpartum health problems, the culturally derived restrictions, and precautions controlling diets and behavior patterns, we conducted a mixed-method study in Rajasthan, India. The study methods included free listing of maternal morbidity conditions, interviews with 81 recently delivered women, case interviews with eight cases of huwa rog (postpartum illness), and interviews with nine key informants. The study showed that huwa rog refers to a broad category of serious postpartum illness, thought to affect women a few weeks to several months after delivery. Prevention of the illness involves a system of precautions referred to as parhej, which includes a distinctive set of "medicinal dietary items" referred to as desi dawai, or "country medicine," and restrictions about mobility and work patterns of a postpartum woman. This cultural framework around the concept of huwa rog and peoples' beliefs about it are of central importance for planning postpartum health interventions, including place of contact and communication messages.

What is so new about mixed methods?

In this article, I dispute claims that mixed methods research emerged only recently in the social sciences. I argue that some anthropologists and sociologists (and others) have used mixed methods in fieldwork for at least 80 years, and there are studies from early in the 20th century that clearly fall within the definition of "mixed methods." I explore some of the history of the mixing of qualitative and quantitative data in earlier ethnographic works and show that in some sectors of social science research, the "emergence" and proliferation of mixed methods were particularly notable around the middle of the 20th century. Furthermore, concerning issues about "paradigms of research" in the social sciences, I identify some of the types of research in which the mixing of QUAL and QUAN approaches was more likely to occur. I suggest that some of the literature about research paradigms has involved a certain amount of "myth-making" in connection with descriptions of qualitative and quantitative research assumptions and styles.

A model for translating ethnography and theory into culturally constructed clinical practices.

This article describes the development of a dynamic culturally constructed clinical practice model for HIV/STI prevention, the Narrative Intervention Model (NIM), and illustrates its application in practice, within the context of a 6-year transdisciplinary research program in Mumbai, India. Theory and research from anthropology, psychology, and public health, and mixed-method ethnographic research with practitioners, patients, and community members, contributed to the articulation of the NIM for HIV/STI risk reduction and prevention among married men living in low-income communities. The NIM involves a process of negotiation of patient narratives regarding their sexual health problems and related risk factors to facilitate risk reduction. The goal of the NIM is to facilitate cognitive-behavioral change through a three-stage process of co-construction (eliciting patient narrative), deconstruction (articulating discrepancies between current and desired narrative), and reconstruction (proposing alternative narratives that facilitate risk reduction). The NIM process extends the traditional clinical approach through the integration of biological, psychological, interpersonal, and cultural factors as depicted in the patient narrative. Our work demonstrates the use of a recursive integration of research and practice to address limitations of current evidence-based intervention approaches that fail to address the diversity of cultural constructions across populations and contexts.

Intimate relationships of Devadasi sex workers in South India: An exploration of risks of HIV/STI transmission.

Global literature on female sex workers suggests that being in an intimate relationship is associated with barriers to practising safe sex behaviours. Condom use within intimate relationships is often seen as a sign of infidelity and fosters mistrust which could affect longevity, trust and intimacy within partnerships. Using qualitative data from Devadasi sex workers and their intimate male partners in Bagalkot District, Karnataka, India, we examined both partners' perspectives to understand the quality and dynamics of these relationships and the factors that influence condom use in intimate relationships. Our thematic analysis of individual interviews conducted in May 2011 with 20 couples suggests that many Devadasi sex workers and their intimate partners define their relationships as 'like marriage' which reduced their motivation to use condoms. Evidence from this study suggests that active participation in sex workers' collectives (sanghas) can increase condom use, education and family planning services, among other things, and could be helpful for both Devadasis and their intimate partners to better understand and accept safer sexual practices. Our work has direct implications for designing couple-based health interventions for traditional Devadasi sex workers and their intimate partners in India.

Community mobilisation programme for female sex workers in coastal Andhra Pradesh, India: processes and their effects.

BACKGROUND: This paper describes the process of setting up community-based organisations (CBOs) of sex workers during the 5-year community mobilisation initiative of the Swagati project, an HIV prevention programme in nine coastal districts of Andhra Pradesh. METHOD: The Swagati project facilitated the formation of 11 CBOs through partnerships with local non-governmental organisations and meetings with groups of sex workers. Activities included peer-led outreach, information campaigns, institution building through community committees and capacity building for organisational development. RESULTS: In 2010, a Community Ownership and Preparedness Index tool assessed the CBOs in terms of leadership, democratic governance, decision making and others qualities. All except two CBOs scored in the 'promising' category. One of these CBOs moved to promising stage by the year 2011 indicating good progress, considering how recently they were established. The Community Ownership and Preparedness Index assessments of organisational strengths showed wide variations among the CBOs, despite the essentially similar organisational steps taken by the Swagati programme. A Behavioural Tracking Survey (2010) of individual CBO members also showed district-level differences in sex workers' expressions of confidence in collective action, participation in organisational activities and other indicators. CONCLUSION: Mobilising marginalised populations such as sex workers to form CBOs is a complex process and can be affected by many influences, including the qualities of CBO leadership. Although the CBOs have not yet reached full 'maturity', they have made significant improvements in terms of collectivisation and its translation into collective action as reported by individual sex workers.

A methodology for building culture and gender norms into intervention: an example from Mumbai, India.

This paper responds to the call for culturally-relevant intervention research by introducing a methodology for identifying community norms and resources in order to more effectively implement sustainable interventions strategies. Results of an analysis of community norms, specifically attitudes toward gender equity, are presented from an HIV/STI research and intervention project in a low-income community in Mumbai, India (2008-2012). Community gender norms were explored because of their relevance to sexual risk in settings characterized by high levels of gender inequity. This paper recommends approaches that interventionists and social scientists can take to incorporate cultural insights into formative assessments and project implementation These approaches include how to (1) examine modal beliefs and norms and any patterned variation within the community; (2) identify and assess variation in cultural beliefs and norms among community members (including leaders, social workers, members of civil society and the religious sector); and (3) identify differential needs among sectors of the community and key types of individuals best suited to help formulate and disseminate culturally-relevant intervention messages. Using a multi-method approach that includes the progressive translation of qualitative interviews into a quantitative survey of cultural norms, along with an analysis of community consensus, we outline a means for measuring variation in cultural expectations and beliefs about gender relations in an urban community in Mumbai. Results illustrate how intervention strategies and implementation can benefit from an organic (versus a priori and/or stereotypical) approach to cultural characteristics and analysis of community resources and vulnerabilities.

The evolution of alcohol use in India.

This paper traces the role of alcohol production and use in the daily lives of people in India, from ancient times to the present day. Alcohol use has been an issue of great ambivalence throughout the rich and long history of the Indian subcontinent. The behaviors and attitudes about alcohol use in India are very complex, contradictory and convoluted because of the many different influences in that history. The evolution of alcohol use patterns in India can be divided into four broad historical periods (time of written records), beginning with the Vedic era (ca. 1500-700 BCE). From 700 BCE to 1100 CE, ("Reinterpretation and Synthesis") is the time of emergence of Buddhism and Jainism, with some new anti-alcohol doctrines, as well as post-Vedic developments in the Hindu traditions and scholarly writing. The writings of the renowned medical practitioners, Charaka and Susruta, added new lines of thought, including arguments for "moderate alcohol use." The Period of Islamic Influence (1100-1800 CE), including the Mughal era from the 1520s to 1800, exhibited a complex interplay of widespread alcohol use, competing with the clear Quranic opposition to alcohol consumption. The fourth period (1800 to the present) includes the deep influence of British colonial rule and the recent half century of Indian independence, beginning in 1947. The contradictions and ambiguities-with widespread alcohol use in some sectors of society, including the high status caste of warriors/rulers (Kshatriyas), versus prohibitions and condemnation of alcohol use, especially for the Brahmin (scholar-priest) caste, have produced alcohol use patterns that include frequent high-risk, heavy and hazardous drinking. The recent increases in alcohol consumption in many sectors of the general Indian population, coupled with the strong evidence of the role of alcohol in the spread of HIV/STI infections and other health risks, point to the need for detailed understanding of the complex cross-currents emerging from the past history of alcohol use and abuse in India.

Community street theatre as a tool for interventions on alcohol use and other behaviors related to HIV risks.

This paper presents data on the role and implementation of street theatre as a communications technique for HIV behavioral interventions in low income slum communities in Mumbai. Second, we situate the uses of street theatre as a social intervention strategy within a long history of outdoor drama as entertainment and social action in India. Street theatre with accompanying activities was a central element of the RISHTA project's communications strategy in communities in Mumbai, designed to deliver tailored risk reduction messages to married men who were involved in extramarital relationships. The paper presents examples of the contents and delivery of alcohol risk reduction messages through street plays that were developed and performed by actors from low income communities. The paper situates street plays as part of the domain of prevention strategies, which can be effective in reducing HIV risks, including those related to alcohol use.

The psychological and social contexts of complaints of abnormal vaginal discharge: a study of illness narratives in India.

OBJECTIVE: Epidemiological studies have reported strong associations between psychosocial adversity and complaints of abnormal vaginal discharge (AVD) in South Asia. We aimed to explore the mechanism of these associations through qualitative research. METHOD: We carried out serial in-depth interviews with 42 married women with the complaint of AVD who were purposively selected from a sample of 2494 women recruited into a population-based cohort study in Goa, India. The interviews elicited illness narratives of their complaint, focusing on causal attributions and help-seeking behaviors. RESULTS: Women explicitly link their personal experiences of social adversity and stress (such as marital problems and heavy workloads) with their complaints of AVD. The complaint of tiredness, a core feature of depressive and somatoform disorders, and complaint of "tension" were commonly associated with AVD through bidirectional causal interpretations. Reproductive events, particularly related to the menstrual cycle and contraception, comprise another set of causal attributions. Many women hold multiple causal attributions. Most women sought health care, both biomedical and traditional, and their narratives indicate reinforcement of their causal attributions by health care providers. However, treatments were often discontinued or changed due to lack of symptomatic relief, side effects, or costs. CONCLUSIONS: Reproductive health policy and practice must explicitly acknowledge and integrate research findings on psychosocial associations of AVD to promote a holistic and evidence-based approach for this common complaint in women in South Asia.

The explanatory models of depression in low income countries: listening to women in India.

INTRODUCTION: Women, and persons facing social and economic disadvantage, are at greater risk for depressive disorders. Our objective was to describe the explanatory models of illness in depressed women, in particular, their idioms of distress, and their views of their social circumstances and how this related to their illness. METHOD: We carried out a qualitative investigation nested in a population based cohort study of women's mental and reproductive health in Goa, India. We purposively sampled women who were ever-married and who had been found to be suffering from a depressive disorder on the basis of a structured diagnostic interview. In-depth interviews were carried out about six months apart exploring stressors in women's lives, a typical day in their recent lives, and their illness narratives (idioms of distress, causal models, impact of illness, help-seeking). RESULTS: 35 women consented to participate in the study, 28 completing both interviews. Women gave expression to their problems primarily through somatic complaints, typically a variety of body aches, autonomic symptoms, gynecological symptoms and sleep problems. There was frequent mention of overall "weakness" and tiredness. Economic difficulties and difficulties with interpersonal relationships (particularly related to marital relationships) were the most common causal models. However, women rarely considered biomedical concepts, for example, the notion that they may suffer from an illness or that their complaints were due to a biochemical disturbance in the brain. Despite the lack of a biomedical concept, most of the participants had sought medical help, typically for reproductive and somatic complaints. CONCLUSIONS: We recommend the use of somatic idioms as the defining clinical features, and a broader, psychosocial model for understanding the aetiology and conceptualization of the clinical syndrome of depression for public health interventions and mental health promotion in the Indian context.

Medical abortion in rural Tamil Nadu, South India: a quiet transformation.

The medical abortion drugs mifepristone and misoprostol are now widely available in rural Tamil Nadu, India, and the practice of abortion is being transformed. This paper reports on current attitudes and practices concerning medical abortion among qualified abortion providers in a rural area of Tamil Nadu. Interviews were carried out with a purposive sample of 40 doctors, 15 informants at chemist shops, 10 village health nurses and 23 women who had recently had an abortion. Twelve of the 37 private doctors who were providing abortions, were providing medical abortion to 70-80% of their patients and 12 others to a selected minority. Eleven had largely rejected it and still used D&C, two had never heard of it. A number of doctors were using misoprostol for cervical dilatation prior to D&C. Some doctors and women who were concerned about incomplete abortion and heavy bleeding did not have a clear idea of what normal bleeding with medical abortion was. Incorrect regimens with second trimester medical abortions might have been responsible for cases of excessive bleeding. Most chemist shops said they were selling the tablets only on prescription, but doctors reported widespread over-the-counter sales. Medical abortion appeared to be quite acceptable to most women, and women were increasingly requesting it. Mechanisms are needed for sharing information about medical abortion among professionals, community health workers and rural families. The state government should develop a comprehensive plan for incorporating medical abortion into the public health system.

Coping with a nutrient deficiency: cultural models of vitamin A deficiency in northern Niger.

Cultural explanations and management strategies for specific signs and symptoms of vitamin A deficiency are explored in a Hausa-speaking community in northern Niger. Their interpretations of the etiology of nightblindness in young children and pregnant women focus on food-related causes, in which "lack of good food" is central. In parallel with the significance of food in the etiology of nightblindness, the recommended treatments are home food remedies, primarily involving liver, meat, or green leaves. The locally attributed etiology for the more severe manifestation of vitamin A deficiency, xerophthalmia, stands in sharp contrast to this. People believe the primary cause is "heat" produced by acute infectious disease (particularly measles). A trip to the medical dispensary or a reliance upon home remedies are the preferred treatment options for this condition. We explore the striking correspondence between local interpretations of nightblindness and contemporary medical knowledge and treatment in relation to the very different explanations and curative measures offered for more serious manifestations of vitamin A deficiency.

Abortion providers and safety of abortion: a community-based study in a rural district of Tamil Nadu, India.

This paper reports on a community-based study in 2001-02 in a rural district of Tamil Nadu, India, among 97 women who had had recent abortions, to examine their decision-making processes, the types of facility they attended and the extent of post-abortion complications they experienced. The 36 facilities they attended, both government and private, were ranked by 18 village health nurses, acting as key informants, as regards safety and quality of care. Three categories qualified and safe, intermediate or unqualified and unsafe - were identified. Most of the providers were medically trained, and 75 of the 97 women went to facilities that were ranked as high or intermediate in quality. Government abortion services were mostly ranked intermediate in quality, and criticised by both women and village health nurses. There has been a substantial decrease in the numbers of traditional and unqualified providers. However, about 30% of the women experienced moderate to serious post-abortion complications, including women who went to facilities ranked high. We recommend that government facilities, both the district hospital and primary health centres, should improve their quality of care, that unqualified providers should be stopped from practising, and that all providers should be using the safer methods of vacuum aspiration and medical methods to reduce post-abortion complications.

The role of village health nurses in mediating abortions in rural Tamil Nadu, India.

This paper reports on qualitative research on abortion services in the Coimbatore district of Tamil Nadu in south India, and the role of government village health nurses (VHNs) in assisting women to obtain abortions. The aim of the research, carried out in 1997, was to document the process married women go through to obtain abortions in both the public and private sectors, particularly women in rural areas, and why they preferred private clinics. The research consisted of direct observation of "sterilization/medical termination of pregnancy camps" at rural primary health centres and in hospital settings, plus informal and in-depth, open-ended interviews with medical officers, gynaecologists, government medical administrators, VHNs and other health care personnel. It found that VHNs were not only helping their clients to obtain abortions in government facilities but also and more often with qualified private providers. Unmarried girls were excluded from this process by the need for secrecy, however, and were perceived to still be going to unqualified providers. Government records show that there were clear reductions in the availability of public abortion services in the rural areas throughout the 1990s. The widespread perception that private services were safer and treated women better, the increased availability of qualified private abortion providers and the help of VHNs to access private services all encouraged married women to use the private sector.