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UCHC Articles - Research University of Connecticut Health Center Research

5-2011

A Methodology for Building Culture and Gender

Norms Into Intervention: An Example From
Mumbai, India
Kristin M. Kostick,
University of Connecticut School of Medicine and Dentistry

Stephen L. Schensul
University of Connecticut School of Medicine and Dentistry

Pertti Pelto
University of Connecticut - Storrs

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Recommended Citation
Kostick,, Kristin M.; Schensul, Stephen L.; and Pelto, Pertti, "A Methodology for Building Culture and Gender Norms Into
Intervention: An Example From Mumbai, India" (2011). UCHC Articles - Research. 116.
https://opencommons.uconn.edu/uchcres_articles/116
 NIH Public Access
Author Manuscript
Soc Sci Med. Author manuscript; available in PMC 2012 May 1.
Published in final edited form as:
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Soc Sci Med. 2011 May ; 72(10): 1630–1638. doi:10.1016/j.socscimed.2011.03.029.

A methodology for building culture and gender norms into

intervention: An example from Mumbai, India
Kristin M. Kostick,
University of Connecticut School of Medicine, Farmington, CT, (478) 747-3514
Stephen L. Schensul,
University of Connecticut School of Medicine, Farmington, CT, (860) 679-1570
Rajendra Singh,
International Center for Research on Women, Mumbai, India, (011)+22+25505718/19
Pertti Pelto, and
University of Connecticut, Department of Anthropology, (860) 429-0434
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Niranjan Saggurti
Population Council, HIV/AIDS Program, New Delhi 91-9871211195
Kristin M. Kostick: [email protected]; Stephen L. Schensul: [email protected]; Rajendra Singh: [email protected];
Pertti Pelto: [email protected]; Niranjan Saggurti: [email protected]

Abstract
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
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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.

© 2011 Elsevier Ltd. All rights reserved.

Correspondence to: Kristin M. Kostick, [email protected].
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
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 Kostick et al. Page 2

Keywords
India; culturally-relevant intervention; cultural norms; multi-method intervention; HIV; gender;
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equity

Introduction
Adjusting and adapting interventions to a community’s cultural and social context is now a
well-recognized part of behavioral change and development programs (Lyles et al., 2006;
McKleroy et al., 2006). Most intervention programs are developed in the West (Europe and
the United States), and while nowadays they are not simply imposed without modification,
they more often than not aim for speedy implementation at the risk of overlooking critical
contextual factors. Anthropologists and other social scientists who explore culture as a key
variable have been critical of interventions for their oversimplification of the role of culture,
but have generally not provided guidelines that can suggest how to make interventions more
culturally-informed.

This paper seeks to implement a call for culturally-relevant intervention research and
implementation (UNAIDS, 2008) that can assist developers and interventionists to identify
existing community norms and resources available to disseminate and sustain intervention
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activities. We seek to present innovative approaches that can apply cultural insights into
intervention research and project implementation. These approaches include how to (1)
examine modal beliefs and norms, any patterned variation within the community and the
strength of cultural agreement or cohesion within and among community subgroups (2)
identify and assess variation in cultural beliefs and norms among different community
sectors (including community and religious leaders, community service sector, and the
general population); 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.

Results of an analysis of community norms, specifically attitudes toward gender equity, are
presented from a research and intervention project on HIV/STI prevention in a low-income
community in Mumbai, India. Prevention of HIV has been identified as a critical topic
requiring culturally-informed and evidence-based intervention approaches (NIMH, 2007),
particularly those addressing gender inequities and sexual double standards (Bermudez et
al., 2010; Jewkes, 2010).

The role of culture in sustainable behavioral change

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Interventions promoting behavioral change need to address relational and community-level

factors (e.g., marital, social, economic, political) contributing to behaviors that negatively
impact health (Becker et al., 2008; Peterson & DiClemente, 2000;). The limited long-term
efficacy of behavioral, individual skills-based and informational approaches to prevention
and intervention (Gillies, 1998) highlights the need to understand sociocultural contexts and
to develop “health-enabling communities” (Tawil et al., 1995) to support and sustain
behavioral change. Addressing community dynamics can lead to better absorption and
institutionalization of intervention activities and principles by implementing organizations,
increased capacity of community members and organizations to mobilize resources,
technical assistance, researcher involvement, and public support for existing or developing
programs (Jana et al 2004; Schensul, 2009). Programs that extend beyond the individual to
peer, family, and community involvement have proven effective in a number of
interventions, contributing to the reduction of cardiovascular risk (Weinehall et al., 2001),
reduction in childhood obesity (Beech, 2003; Janicke, 2008), greater adolescent

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psychosocial health (Williams et al., 2003), greater treatment efficacy for co-occuring
mental illness and substance abuse disorders (Holder, 2000), and reduction of sexual risk
factors among substance-users (Fleming, 2006).
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Addressing contextual factors is particularly important in the context of HIV/STI

prevention. Dworkin and Ehrhardt (2007) and others (Gupta, 2001; Exner et al., 2003) argue
that many commonly-used strategies to reduce HIV-risk among women (e.g. abstinence,
fidelity, condom use) are ineffective because they fail to address how “gendered contexts,”
including how cultural practices and institutions contribute to sexual double standards and
gender-discriminatory practices affecting women’s sexual risk and disempowerment.
Findings from a variety of cultural settings, including China, India, Peru, Russia and
Zimbabwe (NIMH, 2007; Becker et al., 2008; Hawe et al., 2004) suggest that to effectively
impact sexual risk reduction, it is necessary to address how gender power dynamics are
supported by cultural beliefs and norms. A number of studies from India (e.g. Bermudez et
al., 2010; Go et al., 2003; Jewkes, 2010; Maitra & Schensul, 2002) suggest that community
gender norms often sanction domestic violence and contribute to sexual double standards
that interfere with women’s ability to effectively adopt HIV-preventive behaviors. However,
programs designed to reduce HIV risk in this context have so far been challenged by a lack
of clear strategies and methodologies for changing behavioral norms and stigma associated
with safe sex practices (Latkin & Knowlton, 2005; Bhattacharya, 2004; Jana, 2004)
Furthermore, few HIV risk-related studies illustrate how to characterize contextual norms
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without resorting to stereotypes and how to apply information about cultural norms in
practice (Grassly, 2001).

Translating Knowledge about Cultural Norms

For the purposes of this paper, norms are defined here as any expectations and proscriptions
for behavior that are associated with cultural values and beliefs and have motivational
influence (D’Andrade, 1992). Because norms are likely to vary among individuals and
across segments of a population (Pelto & Pelto, 1975), a challenge for interventionists is to
identify not only the dominant cultural pattern(s) but also the degree and sources of intra-
community variation in order to most effectively target or seek support for messages and
activities. Identifying key individuals and segments of the population whose views are
congruent with planned intervention messages in addition to those whose views are
dissimilar helps interventionists to better understand the composition of the community and
to engage with these subgroups both as sources of potential support and opposition.

Analyzing variation in a community can entail a wide range of mixed-methods.

Ethnographic interviewing to explore community characteristics constitutes an important
first step in getting to know a community (Schensul et al., 1999). Ethnography can also
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provide a means for describing and tracking change both qualitatively and quantitatively
(Schensul, 2009) and for understanding cultural knowledge from an “emic” perspective
(LeCompte and Schensul, 1999). Various techniques, including ethnographic mapping
(Tripathi et al., 2010), in-depth interviewing and immersion in the daily lives of community-
members can provide insight into links between individuals, groups and institutions. For the
purposes of intervention, ethnography can help to identify social network and media-based
links (e.g. television, radio, and/or internet communications) that can be constructive for
dissemination of preventive messages (Buraway et al. 2000; Schensul & Trickett, 2009).
Participant observation and interviews with key informants can also help to assess potentials
for collaboration (Averill, 2003), particularly useful in formative stages of intervention
research.

Cultural analysis contributes to one of the fundamental goals of translational research, which
is the need for a better understanding of the factors affecting the reception of intervention

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programs and their continuity within the community (Green & Glasgow, 2006; Mendel et
al., 2008; Mercer et al., 2007). Successfully translating data about cultural norms into an
intervention requires a clear sense of how intra-cultural or community differences may be
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interpreted and acted upon by interventionists in order to match the needs, capacities,
interests, cultural perspectives and values of both implementers and recipients of the
program (Castro et al., 2004; Solomon et al., 2006). Cultural analysis forms part of a larger
pre-implementation or community “readiness” assessment (e.g. Plested et al., 1998; Miller
& Spilker, 2003) in order to predict challenges in the implementation process, anticipate
outcomes and strategize scaling up of interventions (Fuller et al., 2007; Panzano et al., 2006)

Methods
The data on which this paper is based are drawn from an Indo-US, NIMH funded project
(2007–2012) involving collaboration of the University of Connecticut School of Medicine,
the Institute for Community Research, Tulane University, the Asia Regional Office of the
International Center for Research on Women, the Tata Institute for Social Sciences, the
Population Council and the National Institute for Medical Statistics of the Indian Council for
Medical Research (ICMR). Permissions to conduct this study were obtained from the
Institutional Review Boards (IRBs) at all of the above institutions. The project is a part of
RISHTA (Research and Intervention in Sexual Health: Theory to Action and meaning
“relationship” in Hindi and Urdu) and focuses on the reduction of HIV/STI transmission risk
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and gender-based inequities among married women in a low-income community in Mumbai,

India. The project involves a multi-level intervention (community, health care system,
marital dyads and individual women) that includes a randomized controlled trial (RCT) at an
urban health center in the study community. Participants in the RCT are randomly assigned
to receive individual counseling, group couples’ (wives and husbands) counseling, both
interventions and a control group receiving standard care Individual and couples receive
counseling on topics related to risky sexual behaviors, sexual relationships and intimacy,
and problem-solving skills to improve negotiation, communication and trust. These sessions
introduce alternative culturally-rooted views and risk-reduction narratives through
negotiation and dialogue. The individual and couples’ interventions are facilitated by the
development of a Women’s Health Clinic (WHC) within the urban primary care center,
which provides services exclusively for women with gynecological problems.

The RCT and the WHC are situated within a larger community-level intervention to help
reduce sexual risk through the dissemination of educational messages and activities aimed at
increasing marital communication, raising the priority of women’s health, reducing intimate
partner violence, creating positive changes in gender norms and decreasing sexual risk
behavior. The analyses that are described are specifically designed to help strategize and
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monitor the community-level intervention. This wider community-level intervention is

conducted in collaboration with the service sector and the religious sector. The goal of the
community-level intervention is to develop and disseminate intervention messages
concerning gender equity and sexual risk reduction that help to create a supportive context
for the improvement of women’s social and health status.

The Study Community

The study community consists of approximately 500,000 people living in dwellings varying
in type, with the majority being pucca (permanent structures constructed of concrete,
including floor, walls, and roofs) or semi-pucca (partly concrete, but supplemented with
“found materials” such as corrugated metal sheets or wood, sometimes with a dirt floor).
Almost 90% of the dwellings consist of one room with a small portion of the space for
cooking and bathing. The poorest residents in the community live in houses of entirely
found materials (katccha) close to dumps and bogs. About two-thirds of the people are

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migrants to Mumbai, particularly from impoverished northern Indian states. Most men are
daily wage workers, small shopkeepers, vegetable/fruit vendors, tailors, hawkers, auto
rickshaw (3-wheel taxi) drivers, truck drivers and low-level civil servants. Average income
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has remained stable over the past five years at about Rs. 3500 (US$80) per month. An
increasing number of women (28% as opposed to a previous survey in 2006 of 4%) are
involved in generating cash income from work at home and/or outside the home. They
receive minimal wages for tasks such as embroidering, sewing, cooking or selling
vegetables and fruit. The population is primarily Muslim (80%), Hindu (16%) and a small
percentage of Christians and Buddhists. The Islamic religious institutions include over 40
mosques (masjid) with large congregations ranging up to 2500. A number of mosques have
madrassas where students are taught the Koran as well as secular subjects, and some have
schools for Imams and Aalimas, (male and female religious scholars, respectively) who
provide religious instruction to members of the community. Within the community-service
sectors, five NGOs work to address issues related to health care, awareness and prevention
of HIV/AIDS/STIs, family counseling, primary health care, prevention of tuberculosis,
women’s empowerment, and adolescent sexual health. In addition, a number of community
health volunteers (CHVs) and female anganwadi workers help women in the community by
providing advice and services related to reproductive health issues and day care services
(balwadis).

Constructing a Culturally-Grounded Measure of Gender Norms—We conducted

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research on community norms in the domain of gender equity because of its centrality to
sexual risk within marriage and its relevancy to the project interventions. An iterative
process was utilized for measurement in which a quantitative instrument was gradually
derived from information learned through successive analyses of qualitative ethnographic
data. In the first step, in-depth interviews were conducted with married women 18–40
(n=40), married men, 21–40; (n=32), marital couples (n=21 dyads), key informants (17),
community-based organization (CBO) members (n=18), Imams (n=16), and health service
providers (n=31). All qualitative interviews were one-on-one, open-ended interviews and
centered on women’s health issues, life situations, and marital/family dynamics affecting
sexual and reproductive health and empowerment. These questions were designed to elicit
open-ended personal narratives that could provide a composite picture about women’s roles
and expectations in relation to husband and family, and to discover more general community
expectations about gender through a comparison of narratives across numerous respondents.
Women were interviewed in their homes by female interviewers when husband and children
were not present over three to four visits lasting about 1–1.5 hours for each visit. When
privacy could not be maintained, a subsequent visit was scheduled. Interviews with men
were conducted by male interviewers in either private or public settings (with privacy) in the
community in one or two visits lasting from 1–1.5 hours each, with the more focused aim of
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identifying knowledge of and involvement in women’s health issues. Interviews with

healthcare providers took place within their own private or public clinics in the community,
over one visit lasting about 1–1.5 hours in between or over the course of meeting patients.
These interviews were designed to elicit providers’ diagnostic and treatment practices, as
well as their explanatory models of common illnesses faced by women in the community.
Interviews with husbands and providers were also intended to triangulate information about
gender norms and expectations within the community. Interviewees were debriefed about
the purpose of the research and written informed consent was obtained.

In the second step, transcripts from in-depth interviews were analyzed inductively, using a
grounded approach involving the progressive abstraction of themes from raw data (Strauss
& Corbin, 1990). Interview notes were transcribed by interviewers into English from notes
written in Hindi. These translated notes were then entered into the Atlas.ti qualitative data
analysis software program (Muhr, 2004). The data were coded independently and cross-

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checked by the authors and other collaborators. The goal of this analysis, from the
perspective of instrument development, was to identify expectations related to gender
embedded in women’s personal narratives and life histories. For example, women’s
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accounts of having an argument with her husband over making a trip to the clinic without
seeking permission generated the statement: “A woman should seek permission from her
husband before seeking treatment for a health problem.”

A list of 150 proscriptive statements about gender norms was generated from all interviews,
structured around the phrase: “A woman or man should (or should not)…” Statements
covered issues related to marital communication, women’s and men’s roles and expectations
regarding sex, health and health-access issues related to beliefs about sex, gender
expectations governing women’s mobility and decision-making about personal and family
concerns, gender issues in food acquisition and distribution, expectations about women’s
work within and outside the home, and beliefs about and experiences of spousal violence.
The list of statements was reduced by eliminating redundant statements, resulting in 81
proscriptive items that were pilot tested with 101 respondents in the community who
reported their agreement with each statement on a four-point Likert scale. The data were
analyzed using SPSS v. 18.0 (SPSS, Inc, 2010).

Results from the pilot survey were used to further reduce the questionnaire by eliminating
items with little variation across respondents, items with a significant positive skew (thereby
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leaving no room for positive change), items contributing to lower scale reliability using
Cronbach’s alpha analysis, and also those items that interviewers in the field reported were
confusing to respondents. The resulting 29-items of the Gender Equity Scale (GES) are
listed in Appendix 1. All in-depth interviews and the Gender Equity survey were conducted
in Hindi by RISHTA field staff.

The instrument was then administered to a stratified random sample of men and women
(n=946, aged 21–60), with 795 from the study community and 151 from a nearby control
community. This sample was gathered by selecting every fifth household within
geographical sub-areas of the community, taking into account population density and greater
or lesser coverage by CBO/NGOs and mosques. In addition, individuals from the
community service and religious sectors were selected because of their potential to
contribute to intracultural variation. From the service sector, we included members of
CBOs/NGOs in the study communities (n=35), community health volunteers (CHVs; n=24),
Anganwadi workers (n=42); and from the religious sector, Imams (n=48) and Aalimas
(n=19).

Cultural Consensus and Intra-cultural Variation Analysis—A consensus analysis

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(Romney, Weller, and Batchelder, 1986) of the Gender Equity Scale data was conducted to
assess the extent to which respondents have similar views regarding gender norms, roles and
responsibilities. In this analysis, individuals in the community (between and across
subgroups) are correlated with other individuals based on their responses to the GES items,
resulting in a respondent-by-respondent correlation matrix. Cultural consensus analysis
(CCA) not only identifies variation within a community but also has the unique feature of
gauging and comparing cohesion within and among segments of a community with regard to
beliefs and norms. CCA performs an ordinary least-squares (OLS) factor analysis of the
matrix to look for patterns of agreement, or shared knowledge, among the respondent
sample. Rather than examining correlations between and among question items (as do
traditional Item Response Theory models), CCA examines correlations between and among
individuals. The resulting underlying “construct” is assumed to be the most prominent
cultural model upon which a majority of individuals in the sample agree. To ensure a more
conservative analysis of the data, we adapted CCA to perform a varimax (rather than OLS)

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rotated factor analysis. The resulting eigenvalues show whether one or more cultural
model(s) exist between and/or across subgroups, with the strength of agreement measured in
the ratio between eigenvalues assigned to each factor. Though levels of “agreement”
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(cultural consensus) are best represented along a continuum, significant cultural sharing is
traditionally represented by a first-to-second eigenvalue ratio of at least 3:1, and all positive,
high factor loadings on the first factor. Two or more cultural models may be present if the
second-to-third or third-to-fourth eigenvalue ratios are at least 3:1. Agreement was assessed
and respondents were ordered both within and between groups on the basis of Gender
Equity Scale scores, representing community members holding beliefs along a continuum
from “equitable” to “inequitable” with regard to gender norms. Within-group individual
variation was examined using mean scores and distribution.

Results
The distribution of Gender Equity scores across all respondent groups (Figure 1) reflects a
skew (.88) toward less equitable views about gender, with a mean score of 2.01 (n=1114;
sd=.49) on a 4-point Likert scale (higher scores indicate more equitable views). For
example, in response to the five statements concerning mobility, an average of 58% of the
respondent sample agree that women’s mobility should be restricted (primarily by husband)
in comparison to men’s mobility. With regard to women’s work (measured by 5 statements),
an average of 77% of respondents agree that women should be discouraged from pursuing
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work outside the home and that managing the household and preserving family honor are
centrally defining features of womanhood. In response to four statements regarding
women’s health and treatment-seeking, almost three-fourths (71%) of respondents endorse
the view that women’s health is secondary to her husband’s and children’s, and that women
are not free to discuss or seek treatment for their health problems without their husband’s
permission. With regard to women’s communication with men (two statements), over half
(55%) of all respondents report that women’s communication with men should be restricted
to her husband, and that topics of conversation should be limited to household and childcare
issues. In response to six statements related to women’s submission to men (particularly
husband), 69% of respondents support the view that women should be obedient and
subservient to men, that a woman’s husband should be her primary source of pride, and that
a woman’s needs are secondary to those of her husband and family. An average of 65% of
respondents hold the view that women should be ready whenever their husbands desire sex
and that women should engage in sex primarily for men’s satisfaction. Finally, responses to
four statements related to spousal violence indicate that almost three-fourths (70%) of
respondents believe that men have a right to beat their wives in response to perceived
transgressions and that women should not respond to violence by reporting it to others or by
fighting back.
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Cultural Consensus and Intra-cultural Variation Analysis

The results of the Consensus Analysis reveal significant intra-cultural variation within the
community. The ratio of the first-to-second factor eigenvalues was found to be 2.8:1 and
does not meet the 3:1 ratio criteria suggested by Romney, Weller and Batchelder (1986) for
a single, highly-shared cultural model among community members. This finding
demonstrates a substantial amount of intra-cultural variation. Consensus was greater within
groups than between groups split by gender, with ratio of first-to-second eigenvalues of
4.1:1 for men and 4.3:1 for women indicating a substantial difference between men and
women with regard to views about gender norms. An independent samples t-test confirmed
that men have significant less equitable views about gender than women (t=−4.32, df=595,
p<.001).

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While a single cultural model of gender norms did not emerge among the total sample, a
further analysis allowed us to explore which individuals are representative of the most
commonly held views in the community. Individual respondents were also ordered on the
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basis of their “cultural representativeness,” using their factor loadings on the first factor
derived from a factor analysis across community subgroups. Drawing from basic principles
of factor analysis, factor 1 represents the cultural construct or model that accounts for the
greatest degree of variance in the total respondent sample. Thus, individuals with the highest
loadings on factor 1 are most representative of those beliefs about gender expectations
within the community that are the most prevalent (relatively great gender inequity).
Likewise, individuals with the lowest factor loadings can be said to be in the minority with
regard to their beliefs in the measured domain. Factor 1 loadings are referred to here as
“cultural representativeness” scores, ranging from −1 to 1, with scores representing the
degree of each respondent’s correlation with the most prevalent cultural belief model
(represented by the first factor accounting for the greatest variance). In this case, the most
culturally representative model represents more inequitable views about gender.

Using linear regression, the most significant predictor of cultural representativeness (see
Table 1) was found to be individuals with Lower Education, followed by being male and
being of Muslim faith. Other demographic factors, such as age, income and marital status
were not significant predictors of cultural representativeness. This analysis of cultural
representativeness led us to further explore sources of variation in the community with
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regard to gender equity. A separate multiple linear regression analysis showed that the same
demographic variables that predict cultural representativeness were also found to be
significant predictors of gender equity, as measured by the GES (see Table 1). While
cultural representativeness can be best conceptualized as a measure of how much an
individual correlates with the cultural “average,” gender equity is instead a more direct
measure of where an individual’s views toward gender and women’s empowerment fall on a
continuum from more to less equitable. The distinguishing feature between the two
dependent variables is that the former is a measure of similarity to other cultural members
while the latter is an attitudinal measure regarding gender norms.

Individuals holding less equitable views about gender were found to be nearly four times
more likely to be less educated, two and a half times more likely to be men, and almost two
times more likely to be Muslim. These combined regression analyses suggest that the more
culturally representative members of the community are also those who hold more
patriarchical views about gender norms.

Analysis of Variation in Gender Equity Scores among Community Sectors

Intracultural variation in Gender Equity was also explored among community residents,
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including those in the community-service (community-based organizations and health

volunteers, anganwadi workers) and in the religious sectors (Imams and Aalimas), because
of the key role of these sectors in health and change programs and as partners with RISHTA
in disseminating intervention messages at the community level. An analysis of variance
(ANOVA) in average GES scores revealed significant similarities and differences across
community subgroups (see Table 2). A Student-Newman-Keuls analysis was performed in
order to explore whether any of the identified subgroups in particular account for significant
differences among groups discovered by the ANOVA. A general distinction among
subgroups was found on the basis of equitable versus inequitable views about gender, with
community staff of NGOs community based organizations, community health volunteers
(CHVs), and anganwadi workers (involved in conducting day care or balwadis) forming a
set of subgroups with more equitable views about gender, and Imams, Aalimas, general
community members forming another set of subgroups with less equitable views about
gender. These results indicate that the majority of members from the general community,

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hold views similar to leaders in the religious sector; and members of the community-service
sector form another distinct subset with more equitable views.
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This analysis revealed higher levels of cultural consensus within the special subgroups than
across the total sample (see Figure 2). Members of the religious sector (i.e. Imams and
Aalimas) demonstrated the highest levels of within-group agreement (ratio of 1:2
eigenvalues = 6.6 and 6.8, respectively), reaching twice the criteria for a shared belief model
that accounts for over half of the variance. Lower levels of within-group agreement were
found among members of the general community (1:2 ratio = 3.3) and among women
participants in the intervention (1:2 ratio = 3.4). The lowest levels of agreement were found
among members of the community service sector, including CBO/NGOs (1:2 ratio = 4.1),
anganwadi workers (1:2 ratio = 3.4), and Community Health Volunteers (1:2 ratio = 3.3).
Greater average loadings on the first factor and smaller standard deviations provide
convergent evidence for these levels of agreement found within and across groups. Overall,
levels of cultural consensus are higher within subgroups than across the total community
sample.

Identification of Key Community Members

A further analysis of individual variation was conducted in order to better involve specific
individuals within the community with the resources and influence to help with
dissemination. While a majority of individuals in the community hold beliefs similar to
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those of the Islamic religious leaders, a substantial number of community members hold
alternative and more equitable views about gender. Even subgroups with highly inequitable
views on average (e.g. Imams) include individuals with more equitable views, contributing
to a significant degree of heterogeneity both within and across all community subgroups.
For example, although the Imams as a group have a high degree of cultural consensus, and
represent what we are labeling “inequitable” views regarding gender roles and relations,
there is nonetheless a range of variation, and two of these Muslim leaders have scores (2.69;
2.45) more closely resembling some of the more equitable members of the community
service sector. Examination of individual scores within special subgroups allowed us to
identify individuals who are more likely to be supportive or less supportive of gender equity
messages that RISHTA partners disseminated in the community. We found that Imams with
greater GES scores were more likely to attend community meetings and gatherings to
discuss women’s social and health issues and found more time in their schedules to help
disseminate information and handbills to members of their congregations. While all Imams
were exposed to community messages, it was helpful to recognize those Imams who could
provide leadership for gender equity issues and those with lower scores who required
additional discussion by RISHTA interventionists. Our ability to identify these key
individuals using both quantitative and qualitative methods contributed directly to
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intervention goals.

Discussion
This paper describes a methodology to characterize gender norms relevant to the
implementation and sustainability of health interventions. Specifically we sought to
demonstrate how examining intracultural variation and cohesion with regard to gender
norms helps to identify the range of variation in the community and in the special sectors,
identifying both individuals and groups that can help to facilitate the dissemination of
intervention messages. Using a multi-method approach that included the progressive
translation of qualitative interviews into a quantitative survey, we were able to assess the
range of variation in cultural expectations and beliefs about gender relations across
community sectors, and to use this understanding of variation as basis for planning and
targeting messages to those sectors demonstrating greater need of intervention.

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Applying Findings from Community Norms Analysis

We found that the mean (or stereotypical) members of the study community hold generally
inequitable views about gender roles and relations. However, we also found significant
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intra-cultural variation among individuals and sectors with regard to gender expectations.
Demographically, one subgroup characterized as being male, Muslim and having relatively
lower education is significantly more likely to have less equitable beliefs about gender.
Further, the consistency of beliefs within certain sectors of the population introduced an
additional degree of complexity, as some subgroups have more or less internal consensus
than others. These levels of consensus within sectors, along with their degree of influence
and exposure, affect the strength of their respective “voices” within the community. Imams
and Aalimas within the religious sector, in particular, were found to have the highest levels
of internal agreement in less equitable norms, and may thus send a strong and more
consistent signal to others in the community. Religious leaders are highly influential within
this community and likely contribute to greater endorsement of inequitable gender roles. On
the other end of the spectrum, we found that individuals working within community-service
entities (many of which promote women’s well-being) have much more equitable views, but
within these groups there is a significant range of variation in their beliefs about gender
norms. While the central tendency among those in the community-service sector is to have
significantly more equitable views about gender than do members of the religious sector,
they have lower overall levels of internal group agreement, and thus the content of their
messages and activities within the community are likely to be more variable and less
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consistent in relation to their stated goals of women’s development. Members of the general
community were found to exhibit cultural expectations more closely resembling the
religious leaders than individuals in the community-service sector, indicating an overall
skew in the community towards less equitable views about gender.

Equipped with a clearer understanding of community variation, we were better able to focus
intervention activities and capacity-building by utilizing strengths in the community (in this
case, existing sectors of the community with more equitable views about gender) and
expanding capacities for dissemination of positive messages related to gender equity,
particularly among community-based organizations and among key leaders in the religious
community who demonstrated greater endorsement of gender equity. We initially
approached community service workers to assess their interest and capacity to collaborate
with the RISHTA program. We then invited them to participate in RISHTA training sessions
and meetings designed to develop joint messages surrounding gender equity, and to provide
educational workshops focusing on issues of marital communication, health and sexuality,
prevention of STIs, sexual risk and violence. An important aspect of these meetings was to
identify aims, agendas and preferences of both the community service and religious sectors
for delivering messages to the community through their own habitual interactions with
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community members. Information from these meetings was used to develop educational
messages which were pre-tested and then disseminated through posters, street-performances,
and other activities organized in the community, including assisted lectures, speeches and
other public and religious events. Handbills describing the aims and available services were
provided by the community and religious sectors to members of the general community and
to key leaders for further dissemination. Banners containing gender equitable messages and
information about services offered at the WHC were also put at the entry of mosques, inside
of NGO offices and in day care centers where women drop off and pick up their children.
Messages developed jointly by members of the religious sector and RISHTA staff have in
turn been integrated into teachings (takreer) delivered by Imams at religious assemblies,
including the largest assembly, the Friday prayer (Jumma namaz) and daily during
Ramadan, and also among female-only religious gatherings led by Aalimas.

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These collaborative educational planning meetings with different sectors helped to ensure
that our community-level intervention was relevant to common community interests while
also creating opportunities to mobilize positive changes in existing norms. Messages
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disseminated through our collaborations with key community sectors also sought to convey
to the general population that the responsibilities associated with societal norm change need
to be the result of cooperation and shared effort by husbands and wives and the community
at large.

Evaluation of Community-Level Intervention

In addition to being a useful tool for understanding variation in existing perspectives, a
measure of community norms also provides an important means for monitoring the overall
efficacy of an intervention over time and at multiple levels. RISHTA is now in the process
of conducting its first annual follow-up GES administration and will continue the annual
follow-up throughout the course of the project. The GES is also being used as one measure
of the impact of RCT individual and couples’ intervention so that it also becomes a useful
tool in monitoring change among individuals and marital couples. In this way, the GES –
and any other questionnaire constructed according to the principles of Cultural Consensus
Analysis – can provide a mechanism for exploration and assessment of shared beliefs and
norms, as well as a structured tool for evaluation pre- and post-intervention. The
methodology outlined in this paper can be replicated to tailor assessments of a diverse
number of topics in different cultural settings.
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The success of intervention projects depends not only on their ability to mobilize change at
the individual level but also to affect broader contextual factors. If individual behavioral
change is expected to be acceptable and sustainable, prevention/intervention strategies must
be responsive to and impact on existing modal cultural norms. This paper provides an
example of how HIV-related and other interventions can enhance their cultural relevance
and effectiveness by first assessing normative variation and collaborating with key sectors of
community influence to generate education to the general community. Our assessment of
intracultural variation in gender norms in what is stereotypically seen as a male-dominant
community suggests that while modal norms may be generally at odds with intervention
messages, communities are likely to contain sub-groups that support the norms and
behaviors advocated by the intervention. Collaboration with these subgroups will be
important in implementing intervention strategies that affect not only individuals but larger
cultural and community dynamics. A better understanding of the scope of community
beliefs, and available infrastructure provides a basis for adapting and translating
interventions from short-term provisional solutions into self-sustaining and durable
community innovations.
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Figure 1.
Distribution of Gender Equity Scores
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Figure 2.
Distribution of Gender Equity Scores by Group
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Table 1

Predictors of Cultural Representativeness and Gender Conservatism*

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Beta** (with t in parentheses)

PREDICTORS: GENDER CONSERVATISM CULTURAL REPRESENTATIVENESS Sig.

Less Education .379 (9.822) .302 (7.559) <.001

Male Gender .214 (5.816) .162 (4.245) <.001
Muslim Religion .186 (4.857) .218 (5.515) <.001
(Constant for unstandardized coeff.) 1.058 (13.748) .696 (11.097)

*
For Model Predicting Cultural Representativeness: R = .44; Adj. R2= .19; S.E. = .34, p<.001

For Model Predicting Gender Conservativism: R = .52; Adj. R2= .26; S.E. = .42, p<.001
**
Standardized Regressions Coefficients (Beta) are presented
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Table 2
Group Similarities and Differences in Gender Equity Scores

Student-Newman-Keulsa,b
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Subset for alpha = 0.05 95% Confidence Interval for Mean

MEANS
Subgroup N 1 2 3 Std. Deviation Skewness Lower Bound Upper Bound

Community Sample 601 1.8770 .486 .642 1.8380 1.9160

Imams 48 1.9472 .284 .510 1.8645 2.0298
Women Participants in Intervention 345 1.9549 .505 .284 1.9014 2.0084
Aalimas 19 1.9964 .253 .072 1.8743 2.1185
Community-based Organiz. Members 35 3.0325 .284 −.680 1.8645 2.0298
Anganwadi Workers 42 3.2545 .339 −.475 3.1485 3.3604
Community Health Volunteers 24 3.4389 .256 −3.280 3.3304 3.5474

Sig. .663 1.000 .078

TOTAL 1114 2.0281 .485 .768 1.9794 2.0503

a
Uses Harmonic Mean Sample Size = 40.680.
b
sum of squares between: 162.143; sum of squares within: 245.882; F=121.66; df=6; p<.001

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Appendix 1
Gender Equity Scale
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+ Less Equitable
Norm Statement
− More Equitable

1. A wife should eat after her husband and children have had their food. +

2. A woman should always be ready whenever her husband wants to have sex. +

3. A woman should obtain permission to seek medical treatment from her husband for any kind of health problems. +

4. A wife should manage the household with whatever money the husband gives. +

5. A woman is responsible for her own poor health. +

6. A man should have control over his wife. +

7. A woman should work only with other women outside of the house. +
8. If a wife disobeys her husband, she should be sent to her maternal home (as punishment). +

9. A woman can beat/hit her husband whenever her husband beats her. −

10. Only a man is responsible for household finances. +

11. A woman can get spoiled if she goes out of her home too often. +

12. A wife should take permission from the husband when she goes any where out of house. +
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13. A wife should think about her husband and children’s health before her own. +

14. Women engage in sex only for men’s satisfaction. +

15. The status of women is lower than that of men. +

16. If a husband is angry he can yell at his wife. +

17. A wife should feel free to criticize husband’s bad behavior. −

18. A woman should talk about her health problems only with other women. +

19. A woman should always cover their head/wear burkha/dupatta before stepping out of the house. +

20. A husband should only talk about household work and childcare issues with his wife. +

21. If a husband beats his wife, she should not share it with anyone. +

22. Only the wife is responsible for all household work. +

23. A man can spend any amount of time with his friends, as he wishes. +

24. A woman should finish all the household work before taking rest. +

25. A husband is a woman’s primary sense of self pride. +

26. A woman is responsible for the reputation, honor and respect of the family. +
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27. A woman can participate in community activity as per her wish. −

28. A woman can talk to men other than her husband −

29. A wife can be beaten up if she does not listen to (obey) her husband. +

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