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Health Promotion International, Vol. 20 No. 4
doi:10.1093/heapro/dai012
Advance access publication 17 June 2005
© The Author 2005. Published by Oxford University Press. All rights reserved.
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Sexual health promotion in Chennai, India: key role
of communication among social networks
SUDHA SIVARAM1, SETHULAKSHMI JOHNSON2, MARGARET
E. BENTLEY3, VIVIAN F. GO1, CARL LATKIN1, A. K. SRIKRISHNAN2,
DAVID D. CELENTANO1 and SUNITI SOLOMON2
1
Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health,
Baltimore, MD 21205 USA, 2YRG Center for AIDS Research and Education, Voluntary Health
Services, Taramani, Chennai, India and 3School of Public Health, University of North Carolina,
Chapel Hill, NC 27516, USA
SUMMARY
Communication about sex and sexual health is an important
facilitator in gaining accurate knowledge about prevention
of sexually transmitted diseases (STDs) and promotion of
sexual health. Understanding how and with whom communication about sex occurs and the nature of the
information exchanged is valuable in designing sexual risk
prevention interventions. In this study of low-income
communities residents in Chennai, India, our aim was to
understand the composition of personal communication
networks, the nature of information related to sex and sexual
health that is exchanged in these networks and the value of
communication among members of these networks. We
conducted in-depth open-ended interviews using a
structured interview guide with 43 individuals. We also
conducted 12 focus group discussions. Individuals were
selected using snowball sampling. Our results indicate that
information about sex and sexual health is exchanged within
and between four groups: married women, married men,
unmarried men and unmarried women. Communication
leads to an expansion of sexual networks among unmarried
men and treatment seeking behaviour for STDs in all
groups. Unmarried men offer immense potential for
intervention given the range of topics related to sex and
sexual health that are discussed and the risky sexual
behaviours practiced. Spousal communication about sexual
behaviour or sexual health is minimal and shifting norms
for prevention would be difficult. Interventions identifying
communication networks and influencing the natural
communication patterns in these networks may be a viable
HIV prevention strategy in the study area.
Key words: HIV communication; India; social networks
INTRODUCTION
Community-based health promotion programs
in part rely on the communication of one or
more messages that help inform and empower
individuals to take control of their health. Communication is broadly defined as the exchange
of information between people (Rogers and
Kincaid, 1981). Communication networks are
comprised of individuals linked to each other by
virtue of the information they exchange. While
an individual may simultaneously belong to
several networks, the nature of information
exchanged in a network is often specific to the
interests of network members.
In HIV/STD (sexually transmitted disease)
prevention programs, we are interested in communication about sexual health. Communication
about sexual health can be defined as the
exchange of information between individuals
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S. Sivaram et al.
that can potentially promote behaviour change
and reduce the risk of STDs and AIDS (Gupta
et al., 1996). For instance, sexual partners may
talk about safe sex (Moore et al., 1999),
encourage mutual testing for HIV and STDs
(Hutchinson, 1998) and discuss test outcomes
(Potterat, 2003). In addition to communication
between partners, communication can also take
place between members of a network. Health
promotion interventions such as those to promote family planning (Kincaid, 2001) and HIV
prevention (Latkin, 1998) have used peer social
networks as an important starting point to
change behaviour. Peers have influenced HIV
risk behaviours through exchange of information, modeling and reinforcement and facilitating
acquisition of new sexual and drug use partners
(Fisher, 1988).
In this paper, we report on research conducted
in the city of Chennai (formerly Madras) in
southern India to understand the composition
and content of interpersonal sexual communication among networks. India has 5 million
adult HIV infections (UNAIDS, 2004). Sex and
sexuality have long been considered a sensitive
subject here and policy makers perceiving sociocultural constraints to discuss this issue are
cautious to introduce such discussions in the
public realm (Nag, 1998). With the spread of
HIV in India, it is important to understand the
extent to which sexuality and sexual health are
discussed in order to inform design of HIV
prevention interventions.
Our study data were collected as part of the
ethnographic phase of the US National Institute
of Mental Health (NIMH) HIV/STD collaborative prevention trial. This trial is a randomized
controlled trial to test the efficacy of HIV
prevention messages disseminated through community popular opinion leaders (CPOLs).
CPOLs have facilitated health promotive
behaviors in diverse settings in the USA (Kelly,
2004) and the goal of this trial is to determine if
this model of prevention can work in international settings. In the trial, we aim to identify and
train CPOLs to disseminate HIV prevention
messages to members of their network. Our
ethnographic phase had three specific aims. The
first was to understand the composition of
personal networks and to identify the characteristics of opinion leaders. The second was to
examine the content of communication about sex
and sexual health in these networks. Finally, we
looked at how this communication influences
two preventive behaviours—unprotected sex and
seeking care for STDs. These research aims were
guided by the theory of diffusion of innovations
(Rogers, 1995). This theory posits that new ideas
spread through a community via interpersonal
communication, and analyzing the flow of information among social networks (Rogers and
Kincaid, 1981) is a key method of understanding
how communication takes place. We present the
methodology, outline results, following which we
discuss how study findings can inform HIV
prevention and sexual health promotion interventions in similar settings.
METHODOLOGY
Participants in our study were either clients of the
government STD center or lived in low-income
public housing communities known locally as
‘slums’. A typical slum has an area of a couple of
city blocks and may be inhabited by as many as 500
families living in horizontally spread tenements.
Forty-three in-depth interviews were conducted with residents of slums and STD clinic
clients. Twenty-four STD clinic clients (11 women
and 13 men) and 19 (seven men and 12 women)
individuals selected from the slums were
interviewed. We also conducted 12 focus group
discussions with slum residents (seven with men
and five with women). Overall, 30 women and
39 men participated in the focus group discussions. Slum residents were contacted through ‘key
informants’—leaders and prominent citizens of
the slums. Participants in clinics were recruited by
interviewers after they sought care. Recruitment
involved administration of informed consent and
the once the participant agreed, the interview was
conducted in a pre-arranged venue in the slum or
private space in the clinic, respectively. All
participants were between 18 and 40 years in age.
Of the STD clinic interviews (n = 24), all women
were married while eight of the 13 men were
unmarried. Of the community interviews, more
men (four of the seven) were married while all
women were married. We conducted one focus
group discussion with unmarried women.
Recruiting these young women was difficult
because they were not permitted to participate by
their families. The majority of participants in the
other focus groups were married women and
unmarried men. Participants shared information
without inhibition after the study goals and
objectives were clarified. Often, there were
Sexual health communication in India
questions and interactions after the close of an
interview or discussion.
In the focus groups, trained interviewers asked
questions to understand the composition of social
and communication networks. In in-depth
interviews, we explored the patterns of communication about sex and sexual health and sexual
behaviour at the individual level. Using both
methods, we gathered information on the characteristics of CPOLs who influenced sexual communication. All interviews and discussions were
tape-recorded in the local language, translated
and transcribed in English. Transcripts were
analyzed using Atlas.ti (Muhr, 1998), a textual
analysis software program. The data were
reviewed for three main themes or codes as they
were called in the software program: composition
and characteristics of social networks, the content
of communication in these networks and the association of communication with sexual behaviour.
Text that matched these codes were retrieved and
reviewed. Matrices were developed for each code
to enable the organization of the data and to
understand similarities and contrasts across
related themes. This study was initiated after
ethical review and approval from the institutional
review boards of YRG Center for AIDS
Research and Education in Chennai, India and
the Johns Hopkins University Bloomberg School
of Public Health in Baltimore, MD.
RESULTS
Network composition and opinion leader
characteristics
Information was exchanged among peers in four
categories: married women, married men,
unmarried men and unmarried women. Married
women’s networks consisted of women in the
general neighborhood, immediate neighbors and
women engaging in specific activities, such as
standing in line for daily water supply or playing
games in the evenings. Women typically met in
groups of three or four people. Women often
came together for social support and attempted
to offer verbal and physical assistance. One
married woman urged a younger woman to talk
to about her experience with spousal abuse and
reported:
Since she is from a different place, she does not have
anybody to help her. So we go and talk to her husband
(to prevent abuse). (Married woman aged 30.)
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Within networks of married women were
natural ‘opinion leaders’—married older women
who were more vocal than others, bold and
prominent in their demeanor and behaviour.
Women referred to them as ‘akka’ or older sister.
These women were more likely to discuss issues
of sex and sexual health openly.
While married women formed networks based
on location and personal experience, married
men did so based on common interests.
Neighborhood-based networks consisted of
those who may come together to have casual
conversation after lunch or dinner. There were
usually three to four men of the same age range
within a group. Married men formed work place
friendships, formal group memberships and often
met with friends in bars. Informal groups of four
to five men also gathered on a regular basis at a
designated spot in the community to play dice.
Opinion leaders among married men were
usually older, respected and credible. One
desired characteristic of married male opinion
leaders was that they should themselves display
safe sexual behavior and not have any vices. Men
reported that if this was not the case, people
would say ‘correct yourself before you preach!’.
The communication networks of unmarried
men and women varied widely relative to their
married counterparts. Unmarried women were
closely guarded in their communities. Their
networks were restricted to their friends and
their immediate family members. Respondents
reported that they did not perceive a need to
discuss sex, as it did not affect their lives.
Unmarried male networks were unrestricted to
residential location or age. Common activities
included playing sports, drinking together and
visiting venues where sexual services were
available. Friendship groups ranged from eight to
20 members and included younger married men.
In addition to these informal groups, formal
groups such as local cricket clubs were a venue for
socialization. Unmarried men looked up to peers
who are popular and sexually experienced. They
looked to opinion leaders who were aware of
issues relating to sexual experiences and sexual
health. As with married men, unmarried men
often looked up to older men and preferred
individuals who did not have any vices. There was
also substantial overlap among these networks.
For instance, young unmarried men would play
cricket with married men but a few unmarried
men from the cricket playing group would also
belong to a group that goes drinking.
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S. Sivaram et al.
We note here that among all networks
reported here, opinion leaders were always part
of a network and were referred by men
and women simply as ‘friends’ (the English word
was used).
Inter-network communication
In addition to communicating between members
of these networks, individuals communicated
between networks. The first involved sexual
communication between married women and
unmarried men. This involved sexually suggestive talk and teasing, and typically resulted in
sexual intercourse. Such communication about
information on the location and nature of sex
workers was facilitated by personal networks of
unmarried men. This is illustrated in the quote
below. In this quote, the sex worker is an
‘auntie’—the local term for a married woman
who is offering sexual services.
I used to ask her ‘enna avan sappitu porran, ennakku
illyaa’ (how come he comes to eat at your house, but
nothing for me?). So she said—‘nee venna vandhittu
po’ (if you want, you can come too). So I went one day
to experience this. (Unmarried male, age 25.)
The second communication pattern across
networks was between men (married and
unmarried) and unmarried women. This communication was initiated either during the course
of normal social contact between strangers or
between family members. For instance, a married
vegetable vendor reported befriending an
unmarried customer, and a tea vendor flirted
with a young girl passing by on her way to school.
In both these instances in our data, communication was followed by sex with no significant
courtship period. When family was involved, we
found references to male cousins or other
relatives who engaged in sex or sought sex from
a sex worker.
Content of communication
While a variety of topics were discussed within
networks, sex and sexual health were prominent.
Married women’s discussions can be classified
under the following broad categories: teasing
(‘did you play the cat and mouse game last night?’
to ask if a woman has sex with her husband),
openly discussing sexual lives and sexual health.
Married men’s communication was generally
limited to close friends, spouses and sexual
partners. They rarely discussed their sexual needs
or sexual health with their wives or anybody
else. The following married STD clinic client
justified keeping silent about sexual health as
follows:
Because I thought people will look at me with a
different perspective. That is why I chose to keep
quiet. (Married male, age 27.)
Most of the data in our study about communication within marriage comes from women,
not men. Women reported that they were shy to
discuss their sexual needs verbally with their
spouses. One married woman said,
When I get ‘unnarchi’ (sexual desire) and if my hand
comes in contact with him sometimes, he will say his
body is aching and he is not interested. At that time I
used to wonder why he is not satisfying me. But what
can I do?
Women reported acquiescing to the sexual
demands of their husband, even though they
were uninterested or unwilling:
He will ask me to come and sleep, began a married
woman, but I will tell him no. But even then he will not
allow and he will hit me. (Married woman, age 29.)
Unmarried men engaged in extensive
conversations about sex and sexual health. They
used a large repertoire of phrases and words to
refer to sexual intercourse and parts of the
human anatomy, e.g. kai (raw fruit) to refer to
breasts; saaman (property) to refer to penis. They
also used terms to describe sexual feelings and
sexual behavior: verri—a violent sexual urge,
how they set up a super figure (figure is a term
used to refer to a sex worker). Unmarried men
also advised peers about sex and sexual
opportunities:
I told my friend about how my girlfriend was not
objecting to my being physically intimate. So he
suggested that I try having sex with her ‘matter
pannudaa’ (finish the ‘matter’). I went ahead and had
sex. (‘Unmarried male’ age 16.)
Sexual intercourse was not always consensual.
Unmarried men joked about touching girls and
women in public places such as in a crowded bus.
Such non-verbal gestures were seen as a step
towards gaining sexual experience. In addition to
communication about sexual experiences, men
Sexual health communication in India
reported being aware of STDs and AIDS. As one
respondent remarked:
You must have a single partner to prevent AIDS, it
spreads if you go to many women. (Unmarried man,
age 23.)
Another distinguished between HIV and other
STDs:
AIDS is basically a disease that cannot be treated and
it results in quick death, whereas a person with STD
can be cured. I know people get various diseases like
that especially if they go to different women; but there
are medicines to treat them. (Unmarried man, age 28.)
Awareness about condom use was also high:
‘I will not have sex without a condom’, responded
one man who reported multiple partners.
Another said that condom education was
‘everywhere’ referring to news and print media
and reported using condoms with sex worker.
However, despite condom awareness and use by
some men, others revealed several factors
outweighing its use. One factor was peer pressure
as reflect in this quote by a young man, who
recalled his experience with a girl he liked when
they were on a college field trip:
It (sex) happened not because I forced my self on her,
not because I was having the ‘kama veri’ (lust for sex)
but my friends will say that you should have sex
whenever you have ‘tension’ (erection) and that sex
will never happen when you want to be sincere in our
approach to the girl. So I thought when I got the
opportunity I should make use of it. (Unmarried man,
age 19.)
Another factor is the need to ‘get value for
money’ with a sex worker, as this quote reflects:
Sometimes when we find a woman who is not willing to
have sex without using the condom. We will say, ‘we are
paying you and you cannot give us the rules, there are
better figures (sex workers) than you in this area’. When
we say that they will comply. (Unmarried man, age 21.)
While unmarried men discussed sex openly,
unmarried women do not. One woman said that
‘it is enough for the men to know about all this
(sex)’ and that they would wait to find out about
this when they get married. Older female
relatives communicated expectations of unmarried women on their wedding night using dictates
such as ‘He will do everything’, or ‘listen to what
your husband says’. Men who courted unmarried
331
women also used non-specific language such as
‘you will see what I do’, to address queries
from women who wondered about the interest
in them.
Communication and sexual risk behaviour
Our findings show that communication about
sexual risk behaviors was different for married
and unmarried individuals. Married couples
talked about condom use and health care seeking
behaviors resulting from sexual risk behaviors.
Unmarried individuals talked about sexual risk
in general and less about health seeking
behaviors. Among married couples, sexual risk
behaviour (multiple partners, extra marital
affairs) was typically inferred by women who
reported initiating conversation with their
husbands about the behavior itself or talking
about condom use. As in this quoted from a
married woman, discussing condom use with a
husband (a long distance truck driver) who she
suspects having multiple partners was futile:
He has been traveling and could have been with other
women, I am scared of what could happen. So I ask
him to wear a condom and he will retort saying that he
would slipper me if I suspect him of cheating on me.
So I will trust him and we have sex without any
protection. (Married woman, age 24.)
In those cases where marital communication
did lead to care seeking for a sexual health
symptom, care was incomplete and unresolved.
A married woman reported that both she and her
husband had an STD and upon the urging of his
doctor, he took her along to seek care:
The doctors talked to us about condoms. They gave us
condoms and said that until we are fully cured, we
should use condoms during sex. They also said if we do
not use a condom, this disease may not be cured from
our bodies. When we went home, I used to ask him to
bring ‘that’—condom. He used to react saying that he
is clean and they are just like that saying and nothing is
wrong with him. He said that I am unnecessarily
trusting the doctors. He will not bring the condom and
when I insist, he used to abuse me verbally and hit me.
(Married woman, age 28.)
Unmarried men’s discussion about risk
behavior did not focus on condom use but on
sexual risk. The following statements between
friends on risk behavior illustrate this:
Having unprotected sex once will not cause any
problems (STDs). (Unmarried man, age 25.)
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S. Sivaram et al.
I did not use condom because she looks nice and she has
sex only with their husband. (Unmarried man, age 18)
In another instance, a man reported ‘Since
talking to him, I always use condoms’ recalling
a discussion with an STD-infected friend who
urged him to have safe sex.
DISCUSSION
Our findings suggest that despite perceived
taboos to sex communication, a wide range of
issues related to sex and sexual health are in fact
discussed within and between networks in the
slum communities in Chennai. That such topics
are discussed freely and in-depth both within
networks and shared freely with researchers is a
starting point for interventions that focus on HIV
prevention and sexual health promotion. Our
findings suggest two main areas of focus for
planners of health promotion programs. First is
the pattern of communication within social
networks, which can inform program design, and
second is the content of this communication,
which can inform program participation and
content.
Communication patterns are based on
networks that individuals belong to. We found
that among each network seen—married women,
married men, unmarried men and unmarried
women—opinion leaders who are integral
members of a network were identified. These
individuals were considered credible sources of
information about HIV/STDs prevention, social
support related to STDs (married women,
married men and unmarried men), information
on sex, sexual partners and disease prevention
(married and unmarried men). Based on earlier
successes with opinion leader-led interventions
(Sikkema et al., 2000; Kelly, 2004), this finding
suggests that in Chennai, health promotion
programs may train opinion leaders to discuss
AIDS prevention with members of their network.
Analysis of health communication content
shows that stark gender and marital status differences. Men enjoy unrestricted expression of
their emotions before marriage and while unsafe
behaviors continue after marriage, there is very
little communication about this. Married women
commiserate on marital problems and stressors
such as domestic violence. Unmarried women do
not think that sexual matters affect their lives
and are guided by more experienced persons.
One can speculate that marriage marks a turning
point in communication within and between
genders. In a culture that expects female virginity at marriage and given the spread of HIV to
monogamous married women whose only risk is
being married to a promiscuous husband
(Gangakhedkar et al., 1997), there is a need to
address prevention messages to unmarried
women. Successes in mobilizing young women to
talk about sex and sexual health, albeit few
(Shedde, 2002), are encouraging and more HIV
prevention efforts targeted at unmarried women
are needed.
However, we find that amongst all networks,
communication does not include significant
discussion of health promotive behaviors. Rather,
encouraging non-consensual sex, sharing inaccurate risk perceptions (among unmarried men),
or unsuccessfully communicating with spouses
about safe sexual behavior and care seeking
(among married men and women) are examples
of behaviours that might increase HIV and STD
risk. Perhaps this reflects a lack of accurate
information about HIV and STDs. Studies have
also suggested gender differentials (Gupta, 2002)
and male sexual preferences (Roth et al., 2001)
may fuel these behaviors. Our findings suggest
that men’s safe sexual behaviors were preceded
by communication with peers who were affected
by HIV/STD or exposure to media. Thus, while
empowering young unmarried women with
knowledge of reproductive health, we also need
to focus intervention efforts to involve men,
unmarried men in particular.
With men, HIV interventions need to focus on
developing communication skills. Using the
network approach to intervention design,
interventions may begin by identifying male
opinion leaders and training them to communicate prevention messages that reflect scientific
facts and dispel myths about transmission.
Developing message delivery strategies that take
into account social context of conversation,
modeling conversations that reflect natural
communication patterns and framing appropriate
message delivery strategies are some ways to
involve male opinion leaders and help them be
change agents in their networks (Kelly, 2004).
Based on our study, we can see that men and
women referred to ‘opinion leaders’ simply as
‘friends’. This lack of hierarchy facilitates communication. In order to influence inter-network
communication (which typically leads to sexual
behavior), we can facilitate inter-network opinion
Sexual health communication in India
leader training sessions where prevention
messages could be tailored to those who cross
network lines to facilitate diffusion. We further
note that provision of accurate information about
prevention is only one factor that influences
safe behaviour. Other factors such as network
relationships (Latkin, 1998), and contextual
factors such as condom availability and barriers to
use (Roth et al., 2001) need be studied further and
incorporated into a network-based intervention.
In addition to opinion leaders, health promotion
programs can work with providers of STD
services who can make a valuable impact on their
patient’s behavior by talking to them about
prevention and partner notification.
In conclusion, we would like to outline some
limitations of the study. The study reports from a
small sample of individuals and findings may not
be generalizable. However, we feel that using
focus group discussions and in-depth interviews
helped collect very descriptive and detailed
information on sensitive issues. Our methodology allowed participants to share personal
experiences without inhibition more than they
might have with structured interviews (O’Brien,
1993). We also did not interview CPOLs or ‘egos’
(Rogers and Kincaid, 1981) to elicit information
on their own beliefs and behaviours relating to
HIV prevention and to examine the extent of
their influence in their networks. Although the
focus of this paper was to get information on
content of communication and to characterize
opinion leaders, information on a network’s ego
would help better understand the dynamics of
and factors influencing network communication
such as social pressure, network relationships
and network norms. These factors need to be
better understood in the Chennai context.
ACKNOWLEDGEMENTS
This research was funded by the US National
Institute of Mental Health (NIMH) under grant
number U10 MH61543.
Address for correspondence:
Sudha Sivaram
Department of Epidemiology
Johns Hopkins University Bloomberg School of
Public Health
615 North Wolfe Street, Suite E-6610
Baltimore, MD 21205
USA
E-mail: [email protected]
333
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