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Journal of Health Communication: International Perspectives Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcm20
Evaluation of the “Let's Talk” Safer Sex Intervention in Nepal a
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Jennifer J. Harman , Michelle R. Kaufman & Deepti Khati Shrestha
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Department of Psychology , Colorado State University , Fort Collins , Colorado , USA b
Center for Communication Programs , Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA c
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Kathmandu , Nepal Published online: 28 Feb 2014.
To cite this article: Jennifer J. Harman , Michelle R. Kaufman & Deepti Khati Shrestha (2014) Evaluation of the “Let's Talk” Safer Sex Intervention in Nepal, Journal of Health Communication: International Perspectives, 19:8, 970-979, DOI: 10.1080/10810730.2013.864731 To link to this article: http://dx.doi.org/10.1080/10810730.2013.864731
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Journal of Health Communication, 19:970–979, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print=1087-0415 online DOI: 10.1080/10810730.2013.864731
Evaluation of the ‘‘Let’s Talk’’ Safer Sex Intervention in Nepal JENNIFER J. HARMAN
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Department of Psychology, Colorado State University, Fort Collins, Colorado, USA
MICHELLE R. KAUFMAN Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
DEEPTI KHATI SHRESTHA Kathmandu, Nepal This study is an evaluation of a pilot of the Let’s Talk Intervention for Nepali women for effectiveness in increasing sexual health communication between women and the men in their lives. The intervention included 88 women in Kathmandu and spanned three 2-hour group sessions. Baseline, posttest, and follow-up knowledge, attitude, and behavior surveys were completed. Results showed women at posttest and follow-up spoke with more women and men about sex than they had at baseline. Attitudes regarding gender norms about sex improved as a result of the intervention, and shame about sex and sexuality for women decreased after intervention. Women also reported greater comfort discussing sex after the intervention. HIV knowledge scores increased after intervention but dropped again at follow-up, likely because of time constraints in addressing this topic in sufficient detail. This is the first program in Nepal that addresses communication about sexual health while focusing on education and prevention for HIV=STIs for women.
Nepal is a country characterized by high levels of political instability, gender inequality, and poverty, all of which contribute to low literacy and poor health outcomes (World Bank, 2010). Although accurate prevalence data are difficult to obtain, infection rates of HIV are rising (Jha, Plummer, & Bowers, 2011) and pose serious social, economic, and health threats to the country (Family Health International, 2004). Recently, HIV infections have increased in the general population, primarily resulting from an increase in the number of migrant workers who have unprotected extramarital sex while traveling (National Centre for AIDS and STD Control, 2009). Every day, an estimated 1,300 Nepalis travel to other countries to find work (Sidner, 2012), a majority of them men. If these migrant workers use sex workers or engage in any sort of unprotected sex, they are likely putting their wives at risk when they return home. Heterosexual intercourse is the primary mode of transmission in Nepal, and if effective public health programs are not introduced in the country, it Address correspondence to Jennifer J. Harman, Department of Psychology, 219 Behavioral Sciences Building, Colorado State University, Fort Collins, CO 80523, USA. E-mail: jjharman@ colostate.edu
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is estimated that AIDS may become the leading cause of death among 15–49-year-olds within the next 10 years (Family Health International, 2007). Despite Nepal being a very diverse society (e.g., region, religion, caste, ethnicity), Hinduism has greatly influenced the traditional norms of the culture (Acharya & Alpass, 2004). Nepalese families are strongly patriarchal (Gautam, Saito, Houde, & Kai, 2011), and women have little choice in the selection of their marital partners or decisions about their reproductive health (Puri, Shah, & Tamang, 2010). Because early marriage is the norm, women know very little about sexual health before or after their sexual debut (usually at marriage), further compromising their ability to negotiate sex with their partners (Santhya & Shireen, 2005). Women are also shy and introverted about sex (Kaufman, Harman, & Khati, 2012), and sex is a taboo topic of discussion in schools, which further limits exposure to sexual health education for women (Puri et al., 2010). Being poorly informed about sexual health matters puts women at heightened risk for a number of negative outcomes, such as relationship violence (Puri et al., 2010) and HIV=STI exposure (Kaufman et al., 2012). Nepal is also challenged with rapid urbanization, and this has resulted in losses of traditional kinship patterns (Patel & Burke, 2009), and drastic changes in norms about sexual practices as a result of exposure to developed-world media formats (e.g., TV and Internet; Dahal, 2008; Regmi, van Teijlingen, Simkhad, & Acharya, 2011). Unfortunately, the loss of kinship patterns in more urban contexts has not adequately been replaced by societal programs or policies (legal, governmental, nongovernmental organizations) that can foster greater quality of life, such as improved health or protection from domestic violence (Patel & Burke, 2009; Puri et al., 2010). Public policies still reflect traditional values and are only slowly adjusting to these cultural shifts (Simkhada, van Teijlingen, Regmi, & Bhatta, 2010). Despite the adoption of a national policy for AIDS prevention in 1995, few prevention activities were actually implemented in Nepal until 2001, and what programs were implemented at that point understandably targeted populations at highest risk of infection and transmission (e.g., individuals who inject drugs, sex workers; Family Health International, 2007). To date, most sexual health prevention efforts with heterosexual intimate relationship partners in Nepal have examined spousal communication as it relates to contraceptive use (e.g., greater use associated with greater communication; Sharan & Valente, 2002). Unfortunately, prevailing patriarchal norms make such communication less likely for a large number of women, particularly in very traditional regions of the country (Yue, O’Donnell, & Sparks, 2010). Even on topics such as maternal health (e.g., purchasing a safe delivery kit), husbands and wives disagree considerably, which is likely because of cultural barriers for communication between marital partners in this context (Mullany, 2010). Most health information in Nepal is transmitted informally between women through kinship channels, such as between a mother and a daughter, or between a wife and her mother-in-law. However, as urban areas become more developed and modernized, women are turning more towards their female friends and media for knowledge and advice, particularly about sexual health. It is not normative for Nepalese women and men to discuss sexual health, even with their own spouse. Bingham and colleagues (2011) found that approximately half of Nepali women in their sample reported trusting a female friend or family member with discussions about their sexual health (e.g., family planning methods, pregnancy concerns) compared with 15–16% reporting this trust level with their own spouse, which may be due to the fact that most Nepali marriages are arranged, and a companionate relationship does not develop between spouses until later in their relationship. Without female
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kinship support in urban settings, women become isolated, particularly after marriage; this further restricts their ability to make decisions about their sexual health (Fikree & Pasha, 2004). While increased media access in urban areas has afforded greater exposure to information about HIV=AIDS, obtaining information about sexual risk or prevention strategies is comparatively more difficult (Ministry of Health and Population, 2007). The purpose of the present study is to evaluate the effectiveness through a pilot testing of the Let’s Talk Intervention among a sample of urban Nepalese women between February and May of 2008. This intervention was designed to increase communication about sexual health with other women and in mother– daughter relationships, as well as with men in their lives (male friends, brothers, intimate partners=spouses). We hypothesized that the intervention, which also aimed to change normative attitudes about sexual health, would elicit positive effects aligned with these aims. The intervention also contained an education element in order to target myths and inform participants about HIV and STIs, so an additional, although not central hypothesis was that HIV knowledge would also improve as a result of participation.
Method The intervention involved three 2-hour group sessions held 1 week apart to allow participants to have time to talk with other women in between sessions, but not have too much time elapse in order to ensure greater retention. The formative research that led to the intervention development, recruitment plan, implementation strategies and barriers, as well as the content of the intervention have been described in thorough detail elsewhere (Kaufman et al., 2012). In summary, a group format was used to have an open discussion about sexual communication and answer questions (Session 1), provide information about STIs and HIV, proper condom use, and further facilitate discussions on the topics (Session 2), and role-playing activities were used to discuss sex with female peers and one’s sexual partner (Session 3). Six waves of the intervention were implemented over 4 months in urban Kathmandu. Recruitment for these interventions was conducted primarily using word of mouth referrals from community agencies and personal contacts of the second and third author. Enrollment varied between 10–22 women per wave of the intervention, and the inclusion criteria were that the women had to be fluent in English and older than 18 years of age. Attendance for all three 2-hour sessions was near 100% (N ¼ 88); only 1 woman missed one of three sessions. Participants completed paper-and-pencil surveys at baseline (just before participating in the first session and after obtaining informed consent), immediately at posttest (after finishing the final intervention session), and at a 1-month follow-up, which was completed either at the intervention site or during an in-person visit with the respondent. The follow-up survey was completed by 85% of the participants (N ¼ 75). Because this was a pilot test of the intervention, there was not a control or comparison group.
Measures Participants had the option of completing the surveys in English or Nepali, and 80% (70 of 88 women at baseline and posttest, and 50 of 75 at follow-up) at each time point chose the English language version. Means and standard deviations of the measures across all time points are presented in Table 1.
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Table 1. Means and standard deviations of measures at baseline, posttest, and follow-up
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Baseline (n ¼ 88)
Posttest (n ¼ 88)
Follow-up (n ¼ 75)
Measure
M
SD
M
SD
M
SD
Talk to other women about sex Talk to men about sex Female gender norms and sex Shame about sex Comfort discussing sex Sexual education as empowerment HIV knowledge
2.00 0.43 1.49 1.56 1.87 3.69
1.16 0.77 0.50 0.52 0.53 0.65
2.57 0.21 1.38 1.44 1.47 3.85
1.29 0.95 0.40 0.45 0.42 0.36
2.68 0.69 1.35 1.38 1.48 3.81
1.48 0.77 0.42 0.06 0.44 0.60
10.60
1.86
12.04
1.13
10.56
4.15
Note. Difference between baseline and posttest: p < .05. p < .001. All follow-up means did not differ significantly from posttest scores, except HIV knowledge and talking to men about sex ( p < .01).
Communication about Sex Participants were provided with a check-list of social roles (e.g., mother, daughter, aunt, sister, female friend, brother, spouse=intimate partner), and asked to indicate whether they had spoken to any of these people about sex. The total number of check marks was calculated for each female participant for male and female roles. Attitudes Attitudes concerning communicating about and expressing sexual behaviors were also assessed using a 14-item measure. In an initial analysis of the baseline data (Kaufman et al., 2012), four attitude subscales were identified that assessed female gender norms about sex (four items, e.g., ‘‘Women are not supposed to talk about sex with anyone,’’ a ¼ .67), sexual shame (two items, e.g., ‘‘When a woman talks about sex, it makes her look like a ‘bad’ woman,’’ r ¼ .28), comfort discussing sex (two items, e.g., ‘‘I feel comfortable talking about sex,’’ r ¼ .34), and beliefs that sex education is empowering (one item, ‘‘Knowing about sex helps a woman to take care of her sexual health’’). Each of the items on the attitude measure used a 4-point semantic differential scale ranging from 1 (strongly disagree) and 4 (strongly agree). HIV Knowledge Participants completed an HIV knowledge questionnaire created by the second author for this study, and it contained 15 true=false=I don’t know items about transmission. One point was given for each correct answer (I don’t know was scored as incorrect). The reliability of this scale was good, a ¼ .87.
Results Participants Of the 88 women who participated in the intervention, all lived in Kathmandu and were fluent in English. They ranged in age from 18 to 61 years, with an average of 26.86 years (SD ¼ 8.78). More than 60% of participants were unmarried (60.2%),
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with the remainder identifying as being in a marital relationship, 21.6% of which were arranged (1 woman did not report her marital status). Twenty-five women reported having children (28.4%). Women reported belonging to more than 15 separate castes, but the largest number of participants were members of the Brahmin caste (46.8%). Only 26 (29.5%) of the women reported current employment, and their education level was high for this population: þ2 (n ¼ 28, 31.8%); bachelors (n ¼ 31, 35.2%); master’s (n ¼ 18, 20.5%). Demographic characteristics are presented in Table 2. We conducted repeated-measures analyses of variance, with variables from baseline, posttest, and follow-up entered as within-person factors. Talking to Other Women and Men about Sex Our primary hypothesis was that participants would start talking more openly with other women and men about their sexual health as a result of the intervention. As predicted, a significant effect was found, F(2, 51) ¼ 10.51, p < .001. Women at posttest and follow-up reported speaking with more women about sex than they had at baseline. The difference between posttest and follow-up was not significant, but because of the way the construct was measured, we could not calculate the total number of friends, aunts, daughters, and so forth that women had spoken to, only numbers of women in these social roles in relation to the participant. Similarly, we found effects for increased communication with men, F(2, 51) ¼ 5.65, p < .01. Women at posttest and follow-up reported speaking with more Table 2. Demographic characteristics of the intervention participants (N ¼ 88)
Characteristic Marital status Single Married Type of marriage Love marriage Arranged marriage Employed Educational level High school or less þ2 Bachelor’s or equivalent Master’s or equivalent Caste Wearers of the sacred thread (Brahmin, Chettri, Newar) Matwali ‘‘alcohol drinkers’’ (Gurung, Magar, Rai, Limbu, Newari) Other (e.g., Dalit, Moktan, Saki, Sunwar, Thakur) Religion Hindu Buddhist Other
n (%) 53 (60.2) 34 (38.6) 14 (15.9) 19 (21.6) 26 (29.5) 5 28 31 18
(5.7) (31.8) (35.2) (20.5)
60 (67.3) 11 (12.4) 17 (19.3) 76 (86.4) 4 (4.5) 3 (3.6)
Note: Data were missing for some participants when total number does not equal 88. Caste categorizations taken from Bennett, Dahal, and Govindasamy (2008).
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men in their lives about sex than they had at baseline. In addition, there was a marginally significant difference between posttest and follow-up, with women speaking to more men (e.g., friend, sibling) about sex at follow-up than at immediate posttest, t(53) ¼ 1.97, p ¼ .06. As with the female roles, we again could calculate only total numbers of roles—not individuals—because of the way the construct was measured. We also wanted to explore whether communication increased significantly between the female participants and their intimate partners. Thirty-six participants reported being married or having a boyfriend, and these women were significantly more likely to talk with their intimate partner about sex after participating in the intervention compared with baseline, F(2, 70) ¼ 4.48, p ¼ .02, partial g2 ¼ .11. The increase was evident at immediate posttest, t(35) ¼ 3.16, p < .01, with 13 women reporting speaking to their husbands or boyfriends about sex compared with only 5 at baseline. There was no significant change from posttest to follow-up, p > .05. Female Gender Norms As predicted, attitudes about female gender norms around sex improved as a result of the intervention. A significant effect was found, F(2, 150) ¼ 3.53, p ¼ .03, and a post hoc comparison of paired means indicated the largest difference was between baseline and posttest, t(83) ¼ 1.94, p ¼ .05. Although the differences between posttest and follow-up means were not significant (p > .05), the mean was slightly more positive at follow-up, indicating the attitude held stable since the end of the intervention. Shame about Sex Shame about sex and sexuality decreased after the intervention for participants, F(2, 152) ¼ 3.54, p ¼ .03. A post hoc comparison indicated baseline scores were significantly higher than posttest, t(85) ¼ 1.98, p ¼ .05; and follow-up, t(77) ¼ 1.98, p ¼ .05. However, differences between posttest and follow-up were not significant (p > .05). Comfort Discussing Sex As predicted, women reported greater comfort discussing sex after participating in the intervention, F(2, 150) ¼ 28.09, p < .001. The posttest showed significant improvements in comfort level from baseline, t(86) ¼ 5.90, p < .001, and this attitude remained stable from posttest to follow-up due to there being no significant differences between the means (p > .05). We conducted an analysis of variance to determine whether comfort discussing sex as rated at posttest would be positively related to the number of women participants reported talking to about sex at the follow-up survey, controlling for the number of women that were reported at posttest. The results of this analysis were marginally significant, F(4, 49) ¼ 2.66, p ¼ .06, indicating the increased comfort to discuss sex obtained as a result of being in the intervention was related to discussing sex with more female friends and family members over time. Sex Education as Empowerment Although we predicted women would feel sexual education is important for their sexual health, and hence be empowering, we did not find significant differences across
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time points on this item, F(2, 154) ¼ 2.09, p ¼ .13. There was a slight trend, as indicated by the means presented in Table 2, towards endorsing this item more strongly after the intervention.
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HIV Knowledge Our repeated measures analysis was found to be significant for HIV knowledge, F(1.30, 112.93) ¼ 11.38, p < .001. This effect was, however, quadratic, F(1, 87) ¼ 37.00, p < .001. A post hoc analysis using paired t tests indicated that correct HIV scores were significantly higher at follow-up than baseline, t(88) ¼ –7.89, p < .001, but dropped significantly again at posttest, t(88) ¼ 6.61, p ¼ .001, to baseline levels. It is important to note the standard deviation of the mean at follow-up was quite large (4.15) compared with the baseline survey (1.86), so the drop in HIV knowledge scores was not as strong for some participants compared with others.
Discussion The Let’s Talk Intervention appears to be not only feasible to implement in Nepal (Kaufman et al., 2012), but also effective at promoting communication between women and men about sex, improving attitudes about being knowledgeable about sex, and changing gender norms around sexual health. This intervention was culturally sensitive to the way communication about sexual health occurs in Nepal because it aimed to develop and enhance channels of communication between women and the individuals in their lives about sex, and because there are few formal educational or societal resources in the Nepalese environment to substitute for these. Although this program is not the first dialogue-based interpersonal communication intervention demonstrated to change behaviors in Nepal (e.g., Dialogues for Life; Bingham et al., 2011), it is the first that we are aware of that addresses communication about sexual health generally, and also addresses education and prevention for HIV and STIs. Recent qualitative interviews in Nepal with dating young adults in urban settings have cited a need for formal and informal discussion groups around sexual health (Regmi et al., 2011), so formal implementation of this intervention with women in Nepal could address this need. Unfortunately, in the present study, we measured only whether women spoke to other women and men in certain social roles (e.g., aunt) rather than total numbers of individuals at each time point. Therefore, it is highly likely the intervention was even more effective than reported here, as there were ceiling effects for each social role category. For example, a woman may have reported speaking with one aunt or sister at pretest, and she may have spoken to multiple sisters and aunts over the course of the intervention. On the basis of the response options provided, this variability would not have been captured. The fact that significant changes were found even across social roles is important, and future assessments evaluating this intervention should measure total numbers of individuals in each category to determine the strength of this change. Because it is stigmatizing for women to be knowledgeable about sex in Nepal, another aim of the intervention was to alter gender norms about sex, because this could help increase communication about sex as well. We learned through formative research (described in Kaufman et al., 2012) that Nepali women support women and girls in their communities being more knowledgeable about sexual health issues, being able to have more control over their sexual experiences, and
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the idea of increasing communication in families and communities (particularly among women) about sexual health issues. We therefore thought this aim would be appropriate, despite the fact that sex is a male domain in Nepal, because it would benefit the sexual health of women. We found greater positivity towards this factor in our analysis as a result of participating in the intervention, and this improved attitude held constant at posttest. It is important to acknowledge that the reliability of the gender norm subscale was minimally adequate (George & Mallery, 2010), but it is common for one or more scales in a measure to have lower alphas in the .60 to .69 range, especially if there are only a few items in the scale (which was the case here; Leech, Barrett, & Morgan, 2005). Formal implementation of this intervention should include additional items in the evaluation assessment aimed to improve this reliability. Feeling shame about sex and female sexuality also decreased as a result of the intervention, and this effect held over time as well. Women also reported feeling more comfortable communicating about sex after participating in the intervention and this effect held constant over time. This comfort was marginally predictive of talking with greater numbers of women about sex over time. As mentioned earlier, this effect may have been even greater had the measure used for this construct been more sensitive. There was also a slight trend for women to report sex education as being empowering; however, the sensitivity of this item was not strong given it was measured using only one question on the survey. A more sensitive measure containing additional survey items should be used in future evaluations. The primary purpose of this pilot intervention was to determine whether increases in communication between women and men about sexual health could be increased and whether norms about communication could be changed. In addition, we wanted to examine whether the intervention itself could improve knowledge about HIV=STIs. Although there were immediate improvements at the end of the intervention, there appeared to be a decay effect, as the improvement disappeared as soon as 30 days after completion. Intervention effects may have been impacted by the small sample size, as there might have been statistically significant improvements for some demographic groups and not others. Given this was a pilot intervention and significant effects were found for several of the outcome variables targeted, the sample size for this initial test was deemed adequate for these purposes. However, the sample size should be increased for future tests of the intervention in order to provide greater statistical power to assess other outcomes such as HIV=STI knowledge and communication with spouses or boyfriends. English-speaking women were targeted for this intervention because this was a pilot study led primarily by the second author. English-speaking women, while more common in Kathmandu, is not the norm. However, we were most concerned with feasibility and acceptability for this testing, so decided to do the sessions primarily in English so that the primary investigator (second author) could monitor the comfort level and potential topics of confusion of the participants, because such taboo and sensitive topics were discussed. Naturally, a requirement for English-speaking participants led to a highly educated sample. This is an obvious limitation of this study that would have to be addressed in a randomized controlled trial of the intervention, which would be better implemented in the local language. For the purposes of this study, an English delivery was acceptable. We do not believe the English language requirement affected our results because despite the sample being highly educated, HIV scores were quite low at baseline, and many women reported wishing there had been more time or intervention sessions to thoroughly discuss more of the material (Kaufman et al., 2012). Given the fact that much of the intervention was dedicated to dispelling myths and educating about topics such as basic anatomy, teaching about HIV
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and STI transmission was challenging to fit into the time frame allotted for the topic. Past surveys have found that 24.2% of women in Nepali urban settings believe condoms cannot protect someone from HIV infection (Gill & Stewart, 2011), so the amount of time dedicated to addressing basic deficits in information is not surprising in retrospect. A formal implementation of the intervention would likely benefit from including a pretest to assess HIV knowledge before the education sessions, and then tailoring the educational components of the intervention to work from the knowledge level of the group. Furthermore, an additional HIV= AIDS information component would likely be more effective, as would a booster session to reinforce learned material.
Conclusions In summary, the Let’s Talk Intervention showed demonstrated improvements in increased communication with men and women about sex, and also changed gender norms to be more positive about being knowledgeable about sex, which is stigmatized in Nepalese culture. Given recent increases in HIV infections and societal changes occurring in Nepal, such as increased property ownership for women (Pandey, 2010) and greater political participation (UNdata, 2011), now is an opportune time to more fully implement intervention efforts addressing gender inequality issues around sexual health.
Funding This research was funded by a Fulbright Research Fellowship to Michelle Kaufman.
Acknowledgments Many thanks to Dr. Mary Crawford, Beena Mahat and the Family Planning Association of Nepal, and the USEF Office in Kathmandu.
References Acharya, P. P., & Alpass, F. (2004). Birth outcomes across ethnic groups of women in Nepal. Health Care for Women International, 25, 40–54. Bennett, L., Dahal, D. R., & Govindasamy, P. (2008). Caste, ethnic and regional identity in Nepal: Further analysis of the 2006 Nepal Demographic and Health Survey. Calverton, MD: Macro International, Inc. Bingham, A., Drake, J. K., Goodyear, L., Gopinath, C. Y., Kaufman, A., & Bhattari, S. (2011). The role of interpersonal communication in preventing unsafe abortion in communities: The dialogues for life project in Nepal. Journal of Health Communication, 16, 245–263. Dahal, G. P. (2008). Sexual and contraceptive behaviour among men in Nepal: The need for male- friendly reproductive health policies and services. Lewiston, NY: Mellen Press. Family Health International. (2004). National estimates of adult HIV infections 2003. HMG, Nepal: National Center for AIDS and STD Control. Retrieved from http://www.fhi.org Family Health International. (2007). IMPACT=Nepal Final Report: May 2001–March 2007 for USAID’s Implementing AIDS Prevention and Care (IMPACT) Project. Durham, NC: FHI. Retrieved from http://www.fhi360.org/NR/rdonlyres/e2kggmqeu6eu22 ttfobjzvyvu3eno2c3a7xhkrc63cw6fjpgnlchnishqri5oqad2pxf5qb3vzk7bh/IMPACTFinal ReportNepalHV.pdf
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Fikree, F. F., & Pasha, O. (2004). Role of gender in health disparity: The South Asian context. British Medical Journal, 328, 823–826. Gautam, R., Saito, T., Houde, S. C., & Kai, I. (2011). Social interactions and depressive symptoms among a community of older adults in Nepal: A synergic effect model. Archives of Gerontology and Geriatrics, 53, 24–30. George, D., & Mallery, P. (2010). SPSS for Windows: Step by step (10th ed.). Boston, MA: Allyn & Bacon. Gill, R., & Stewart, D. E. (2011). Relevance of gender-sensitive policies and general health indicators to compare the status of south Asian women’s health. Women’s Health Issues, 21, 12–18. Jha, C. K., Plummer, D., & Bowers, R. (2011). Coping with HIV and dealing with the threat of impending death in Nepal. Mortality, 16, 20–34. Kaufman, M. R., Harman, J. J., & Khati, D. (2012). Let’s talk about sex: Development of a sexual health program for Nepali Women. AIDS Education and Prevention, 24, 327–338. Leech, N. L., Barrett, K. C., & Morgan, G. A. (2005). SPSS for intermediate statistics: Use and interpretation (2nd ed.). Mahwah, NJ: Erlbaum. Ministry of Health, & Population. (2007). New ERA and Macro International Inc. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: Author. Mullany, B. C. (2010). Spousal agreement on maternal health practices in Kathmandu, Nepal. Journal of Biosocial Science, 42, 689–693. National Centre for AIDS, & STD Control. (2009). Cumulative HIV=AIDS situation in Nepal. Kathmandu, Nepal: Author. Retrieved from http://www.ncasc.gov.np Pandey, S. (2010). Rising property ownership among women in Kathmandu, Nepal: An exploration of causes and consequences. International Journal of Social Welfare, 19, 281–292. Patel, R. B., & Burke, T. F. (2009). Global health urbanization—An emerging humanitarian disaster. New England Journal of Medicine, 361, 741–743. Puri, M., Shah, I., & Tamang, J. (2010). Exploring the nature and reasons for sexual violence within marriage among young women in Nepal. Journal of Interpersonal Violence, 25, 1873–1892. Regmi, P. R., van Teijlingen, E. R., Simkhada, P., & Acharya, D. R. (2011). Dating and sex among emerging adults in Nepal. Journal of Adolescent Research, 26, 675–700. Santhya, K. G., & Shireen, J. (2005). Young women’s experiences of forced sex within marriage: Evidence from India. In S. Jejeebhoy, I. Shah & S. Thapa (Eds.), Sex with consent: Young people in developing countries (pp. 59–73). New York, NY: Zed Books. Sharan, M., & Valente, T. W. (2002). Spousal communication and family planning adoption: Effects of a radio drama serial in Nepal. International Family Planning Perspectives, 28, 16–25. Sidner, S. (2012, May 13). Nepalese dying to work. Retrieved from http://thecnnfreedom project.blogs.cnn.com/2012/05/13/nepalese-dying-to-work/?hpt=hp_c3 Simkhada, P., van Teijlingen, E. R., Regmi, P. R., & Bhatta, P. (2010). Sexual health knowledge, sexual relationships and condom use among male trekking guides in Nepal: A qualitative study. Culture, Health & Sexuality, 12, 45–58. UNdata. (2011, August). Seats held by women in national parliament, percentage. New York, NY: Millennium Development Goals Database, United Nations Statistics Division. Retrieved from http://data.un.org/Data.aspx?q=nepal&d=MDG&f=seriesRowID%3A557%3BcountryID%3A524 World Bank. (2010). HIV=AIDS in Nepal. Washington, DC: Author. Retrieved from http:// siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-1192413140459/4281 804-1231540815570/5730961-1235157256443/5849910-1278963700621/NepalHIVJuly 2010.pdf Yue, K., O’Donnell, C. O., & Sparks, P. L. (2010). The effect of spousal communication on contraceptive use in Central Terai, Nepal. Patient Education and Counseling, 81, 402–408.
Journal of Health Communication: International Perspectives Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcm20
Evaluation of the “Let's Talk” Safer Sex Intervention in Nepal a
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Jennifer J. Harman , Michelle R. Kaufman & Deepti Khati Shrestha
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Department of Psychology , Colorado State University , Fort Collins , Colorado , USA b
Center for Communication Programs , Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA c
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Kathmandu , Nepal Published online: 28 Feb 2014.
To cite this article: Jennifer J. Harman , Michelle R. Kaufman & Deepti Khati Shrestha (2014) Evaluation of the “Let's Talk” Safer Sex Intervention in Nepal, Journal of Health Communication: International Perspectives, 19:8, 970-979, DOI: 10.1080/10810730.2013.864731 To link to this article: http://dx.doi.org/10.1080/10810730.2013.864731
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Journal of Health Communication, 19:970–979, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print=1087-0415 online DOI: 10.1080/10810730.2013.864731
Evaluation of the ‘‘Let’s Talk’’ Safer Sex Intervention in Nepal JENNIFER J. HARMAN
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Department of Psychology, Colorado State University, Fort Collins, Colorado, USA
MICHELLE R. KAUFMAN Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
DEEPTI KHATI SHRESTHA Kathmandu, Nepal This study is an evaluation of a pilot of the Let’s Talk Intervention for Nepali women for effectiveness in increasing sexual health communication between women and the men in their lives. The intervention included 88 women in Kathmandu and spanned three 2-hour group sessions. Baseline, posttest, and follow-up knowledge, attitude, and behavior surveys were completed. Results showed women at posttest and follow-up spoke with more women and men about sex than they had at baseline. Attitudes regarding gender norms about sex improved as a result of the intervention, and shame about sex and sexuality for women decreased after intervention. Women also reported greater comfort discussing sex after the intervention. HIV knowledge scores increased after intervention but dropped again at follow-up, likely because of time constraints in addressing this topic in sufficient detail. This is the first program in Nepal that addresses communication about sexual health while focusing on education and prevention for HIV=STIs for women.
Nepal is a country characterized by high levels of political instability, gender inequality, and poverty, all of which contribute to low literacy and poor health outcomes (World Bank, 2010). Although accurate prevalence data are difficult to obtain, infection rates of HIV are rising (Jha, Plummer, & Bowers, 2011) and pose serious social, economic, and health threats to the country (Family Health International, 2004). Recently, HIV infections have increased in the general population, primarily resulting from an increase in the number of migrant workers who have unprotected extramarital sex while traveling (National Centre for AIDS and STD Control, 2009). Every day, an estimated 1,300 Nepalis travel to other countries to find work (Sidner, 2012), a majority of them men. If these migrant workers use sex workers or engage in any sort of unprotected sex, they are likely putting their wives at risk when they return home. Heterosexual intercourse is the primary mode of transmission in Nepal, and if effective public health programs are not introduced in the country, it Address correspondence to Jennifer J. Harman, Department of Psychology, 219 Behavioral Sciences Building, Colorado State University, Fort Collins, CO 80523, USA. E-mail: jjharman@ colostate.edu
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is estimated that AIDS may become the leading cause of death among 15–49-year-olds within the next 10 years (Family Health International, 2007). Despite Nepal being a very diverse society (e.g., region, religion, caste, ethnicity), Hinduism has greatly influenced the traditional norms of the culture (Acharya & Alpass, 2004). Nepalese families are strongly patriarchal (Gautam, Saito, Houde, & Kai, 2011), and women have little choice in the selection of their marital partners or decisions about their reproductive health (Puri, Shah, & Tamang, 2010). Because early marriage is the norm, women know very little about sexual health before or after their sexual debut (usually at marriage), further compromising their ability to negotiate sex with their partners (Santhya & Shireen, 2005). Women are also shy and introverted about sex (Kaufman, Harman, & Khati, 2012), and sex is a taboo topic of discussion in schools, which further limits exposure to sexual health education for women (Puri et al., 2010). Being poorly informed about sexual health matters puts women at heightened risk for a number of negative outcomes, such as relationship violence (Puri et al., 2010) and HIV=STI exposure (Kaufman et al., 2012). Nepal is also challenged with rapid urbanization, and this has resulted in losses of traditional kinship patterns (Patel & Burke, 2009), and drastic changes in norms about sexual practices as a result of exposure to developed-world media formats (e.g., TV and Internet; Dahal, 2008; Regmi, van Teijlingen, Simkhad, & Acharya, 2011). Unfortunately, the loss of kinship patterns in more urban contexts has not adequately been replaced by societal programs or policies (legal, governmental, nongovernmental organizations) that can foster greater quality of life, such as improved health or protection from domestic violence (Patel & Burke, 2009; Puri et al., 2010). Public policies still reflect traditional values and are only slowly adjusting to these cultural shifts (Simkhada, van Teijlingen, Regmi, & Bhatta, 2010). Despite the adoption of a national policy for AIDS prevention in 1995, few prevention activities were actually implemented in Nepal until 2001, and what programs were implemented at that point understandably targeted populations at highest risk of infection and transmission (e.g., individuals who inject drugs, sex workers; Family Health International, 2007). To date, most sexual health prevention efforts with heterosexual intimate relationship partners in Nepal have examined spousal communication as it relates to contraceptive use (e.g., greater use associated with greater communication; Sharan & Valente, 2002). Unfortunately, prevailing patriarchal norms make such communication less likely for a large number of women, particularly in very traditional regions of the country (Yue, O’Donnell, & Sparks, 2010). Even on topics such as maternal health (e.g., purchasing a safe delivery kit), husbands and wives disagree considerably, which is likely because of cultural barriers for communication between marital partners in this context (Mullany, 2010). Most health information in Nepal is transmitted informally between women through kinship channels, such as between a mother and a daughter, or between a wife and her mother-in-law. However, as urban areas become more developed and modernized, women are turning more towards their female friends and media for knowledge and advice, particularly about sexual health. It is not normative for Nepalese women and men to discuss sexual health, even with their own spouse. Bingham and colleagues (2011) found that approximately half of Nepali women in their sample reported trusting a female friend or family member with discussions about their sexual health (e.g., family planning methods, pregnancy concerns) compared with 15–16% reporting this trust level with their own spouse, which may be due to the fact that most Nepali marriages are arranged, and a companionate relationship does not develop between spouses until later in their relationship. Without female
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kinship support in urban settings, women become isolated, particularly after marriage; this further restricts their ability to make decisions about their sexual health (Fikree & Pasha, 2004). While increased media access in urban areas has afforded greater exposure to information about HIV=AIDS, obtaining information about sexual risk or prevention strategies is comparatively more difficult (Ministry of Health and Population, 2007). The purpose of the present study is to evaluate the effectiveness through a pilot testing of the Let’s Talk Intervention among a sample of urban Nepalese women between February and May of 2008. This intervention was designed to increase communication about sexual health with other women and in mother– daughter relationships, as well as with men in their lives (male friends, brothers, intimate partners=spouses). We hypothesized that the intervention, which also aimed to change normative attitudes about sexual health, would elicit positive effects aligned with these aims. The intervention also contained an education element in order to target myths and inform participants about HIV and STIs, so an additional, although not central hypothesis was that HIV knowledge would also improve as a result of participation.
Method The intervention involved three 2-hour group sessions held 1 week apart to allow participants to have time to talk with other women in between sessions, but not have too much time elapse in order to ensure greater retention. The formative research that led to the intervention development, recruitment plan, implementation strategies and barriers, as well as the content of the intervention have been described in thorough detail elsewhere (Kaufman et al., 2012). In summary, a group format was used to have an open discussion about sexual communication and answer questions (Session 1), provide information about STIs and HIV, proper condom use, and further facilitate discussions on the topics (Session 2), and role-playing activities were used to discuss sex with female peers and one’s sexual partner (Session 3). Six waves of the intervention were implemented over 4 months in urban Kathmandu. Recruitment for these interventions was conducted primarily using word of mouth referrals from community agencies and personal contacts of the second and third author. Enrollment varied between 10–22 women per wave of the intervention, and the inclusion criteria were that the women had to be fluent in English and older than 18 years of age. Attendance for all three 2-hour sessions was near 100% (N ¼ 88); only 1 woman missed one of three sessions. Participants completed paper-and-pencil surveys at baseline (just before participating in the first session and after obtaining informed consent), immediately at posttest (after finishing the final intervention session), and at a 1-month follow-up, which was completed either at the intervention site or during an in-person visit with the respondent. The follow-up survey was completed by 85% of the participants (N ¼ 75). Because this was a pilot test of the intervention, there was not a control or comparison group.
Measures Participants had the option of completing the surveys in English or Nepali, and 80% (70 of 88 women at baseline and posttest, and 50 of 75 at follow-up) at each time point chose the English language version. Means and standard deviations of the measures across all time points are presented in Table 1.
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Table 1. Means and standard deviations of measures at baseline, posttest, and follow-up
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Baseline (n ¼ 88)
Posttest (n ¼ 88)
Follow-up (n ¼ 75)
Measure
M
SD
M
SD
M
SD
Talk to other women about sex Talk to men about sex Female gender norms and sex Shame about sex Comfort discussing sex Sexual education as empowerment HIV knowledge
2.00 0.43 1.49 1.56 1.87 3.69
1.16 0.77 0.50 0.52 0.53 0.65
2.57 0.21 1.38 1.44 1.47 3.85
1.29 0.95 0.40 0.45 0.42 0.36
2.68 0.69 1.35 1.38 1.48 3.81
1.48 0.77 0.42 0.06 0.44 0.60
10.60
1.86
12.04
1.13
10.56
4.15
Note. Difference between baseline and posttest: p < .05. p < .001. All follow-up means did not differ significantly from posttest scores, except HIV knowledge and talking to men about sex ( p < .01).
Communication about Sex Participants were provided with a check-list of social roles (e.g., mother, daughter, aunt, sister, female friend, brother, spouse=intimate partner), and asked to indicate whether they had spoken to any of these people about sex. The total number of check marks was calculated for each female participant for male and female roles. Attitudes Attitudes concerning communicating about and expressing sexual behaviors were also assessed using a 14-item measure. In an initial analysis of the baseline data (Kaufman et al., 2012), four attitude subscales were identified that assessed female gender norms about sex (four items, e.g., ‘‘Women are not supposed to talk about sex with anyone,’’ a ¼ .67), sexual shame (two items, e.g., ‘‘When a woman talks about sex, it makes her look like a ‘bad’ woman,’’ r ¼ .28), comfort discussing sex (two items, e.g., ‘‘I feel comfortable talking about sex,’’ r ¼ .34), and beliefs that sex education is empowering (one item, ‘‘Knowing about sex helps a woman to take care of her sexual health’’). Each of the items on the attitude measure used a 4-point semantic differential scale ranging from 1 (strongly disagree) and 4 (strongly agree). HIV Knowledge Participants completed an HIV knowledge questionnaire created by the second author for this study, and it contained 15 true=false=I don’t know items about transmission. One point was given for each correct answer (I don’t know was scored as incorrect). The reliability of this scale was good, a ¼ .87.
Results Participants Of the 88 women who participated in the intervention, all lived in Kathmandu and were fluent in English. They ranged in age from 18 to 61 years, with an average of 26.86 years (SD ¼ 8.78). More than 60% of participants were unmarried (60.2%),
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with the remainder identifying as being in a marital relationship, 21.6% of which were arranged (1 woman did not report her marital status). Twenty-five women reported having children (28.4%). Women reported belonging to more than 15 separate castes, but the largest number of participants were members of the Brahmin caste (46.8%). Only 26 (29.5%) of the women reported current employment, and their education level was high for this population: þ2 (n ¼ 28, 31.8%); bachelors (n ¼ 31, 35.2%); master’s (n ¼ 18, 20.5%). Demographic characteristics are presented in Table 2. We conducted repeated-measures analyses of variance, with variables from baseline, posttest, and follow-up entered as within-person factors. Talking to Other Women and Men about Sex Our primary hypothesis was that participants would start talking more openly with other women and men about their sexual health as a result of the intervention. As predicted, a significant effect was found, F(2, 51) ¼ 10.51, p < .001. Women at posttest and follow-up reported speaking with more women about sex than they had at baseline. The difference between posttest and follow-up was not significant, but because of the way the construct was measured, we could not calculate the total number of friends, aunts, daughters, and so forth that women had spoken to, only numbers of women in these social roles in relation to the participant. Similarly, we found effects for increased communication with men, F(2, 51) ¼ 5.65, p < .01. Women at posttest and follow-up reported speaking with more Table 2. Demographic characteristics of the intervention participants (N ¼ 88)
Characteristic Marital status Single Married Type of marriage Love marriage Arranged marriage Employed Educational level High school or less þ2 Bachelor’s or equivalent Master’s or equivalent Caste Wearers of the sacred thread (Brahmin, Chettri, Newar) Matwali ‘‘alcohol drinkers’’ (Gurung, Magar, Rai, Limbu, Newari) Other (e.g., Dalit, Moktan, Saki, Sunwar, Thakur) Religion Hindu Buddhist Other
n (%) 53 (60.2) 34 (38.6) 14 (15.9) 19 (21.6) 26 (29.5) 5 28 31 18
(5.7) (31.8) (35.2) (20.5)
60 (67.3) 11 (12.4) 17 (19.3) 76 (86.4) 4 (4.5) 3 (3.6)
Note: Data were missing for some participants when total number does not equal 88. Caste categorizations taken from Bennett, Dahal, and Govindasamy (2008).
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men in their lives about sex than they had at baseline. In addition, there was a marginally significant difference between posttest and follow-up, with women speaking to more men (e.g., friend, sibling) about sex at follow-up than at immediate posttest, t(53) ¼ 1.97, p ¼ .06. As with the female roles, we again could calculate only total numbers of roles—not individuals—because of the way the construct was measured. We also wanted to explore whether communication increased significantly between the female participants and their intimate partners. Thirty-six participants reported being married or having a boyfriend, and these women were significantly more likely to talk with their intimate partner about sex after participating in the intervention compared with baseline, F(2, 70) ¼ 4.48, p ¼ .02, partial g2 ¼ .11. The increase was evident at immediate posttest, t(35) ¼ 3.16, p < .01, with 13 women reporting speaking to their husbands or boyfriends about sex compared with only 5 at baseline. There was no significant change from posttest to follow-up, p > .05. Female Gender Norms As predicted, attitudes about female gender norms around sex improved as a result of the intervention. A significant effect was found, F(2, 150) ¼ 3.53, p ¼ .03, and a post hoc comparison of paired means indicated the largest difference was between baseline and posttest, t(83) ¼ 1.94, p ¼ .05. Although the differences between posttest and follow-up means were not significant (p > .05), the mean was slightly more positive at follow-up, indicating the attitude held stable since the end of the intervention. Shame about Sex Shame about sex and sexuality decreased after the intervention for participants, F(2, 152) ¼ 3.54, p ¼ .03. A post hoc comparison indicated baseline scores were significantly higher than posttest, t(85) ¼ 1.98, p ¼ .05; and follow-up, t(77) ¼ 1.98, p ¼ .05. However, differences between posttest and follow-up were not significant (p > .05). Comfort Discussing Sex As predicted, women reported greater comfort discussing sex after participating in the intervention, F(2, 150) ¼ 28.09, p < .001. The posttest showed significant improvements in comfort level from baseline, t(86) ¼ 5.90, p < .001, and this attitude remained stable from posttest to follow-up due to there being no significant differences between the means (p > .05). We conducted an analysis of variance to determine whether comfort discussing sex as rated at posttest would be positively related to the number of women participants reported talking to about sex at the follow-up survey, controlling for the number of women that were reported at posttest. The results of this analysis were marginally significant, F(4, 49) ¼ 2.66, p ¼ .06, indicating the increased comfort to discuss sex obtained as a result of being in the intervention was related to discussing sex with more female friends and family members over time. Sex Education as Empowerment Although we predicted women would feel sexual education is important for their sexual health, and hence be empowering, we did not find significant differences across
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time points on this item, F(2, 154) ¼ 2.09, p ¼ .13. There was a slight trend, as indicated by the means presented in Table 2, towards endorsing this item more strongly after the intervention.
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HIV Knowledge Our repeated measures analysis was found to be significant for HIV knowledge, F(1.30, 112.93) ¼ 11.38, p < .001. This effect was, however, quadratic, F(1, 87) ¼ 37.00, p < .001. A post hoc analysis using paired t tests indicated that correct HIV scores were significantly higher at follow-up than baseline, t(88) ¼ –7.89, p < .001, but dropped significantly again at posttest, t(88) ¼ 6.61, p ¼ .001, to baseline levels. It is important to note the standard deviation of the mean at follow-up was quite large (4.15) compared with the baseline survey (1.86), so the drop in HIV knowledge scores was not as strong for some participants compared with others.
Discussion The Let’s Talk Intervention appears to be not only feasible to implement in Nepal (Kaufman et al., 2012), but also effective at promoting communication between women and men about sex, improving attitudes about being knowledgeable about sex, and changing gender norms around sexual health. This intervention was culturally sensitive to the way communication about sexual health occurs in Nepal because it aimed to develop and enhance channels of communication between women and the individuals in their lives about sex, and because there are few formal educational or societal resources in the Nepalese environment to substitute for these. Although this program is not the first dialogue-based interpersonal communication intervention demonstrated to change behaviors in Nepal (e.g., Dialogues for Life; Bingham et al., 2011), it is the first that we are aware of that addresses communication about sexual health generally, and also addresses education and prevention for HIV and STIs. Recent qualitative interviews in Nepal with dating young adults in urban settings have cited a need for formal and informal discussion groups around sexual health (Regmi et al., 2011), so formal implementation of this intervention with women in Nepal could address this need. Unfortunately, in the present study, we measured only whether women spoke to other women and men in certain social roles (e.g., aunt) rather than total numbers of individuals at each time point. Therefore, it is highly likely the intervention was even more effective than reported here, as there were ceiling effects for each social role category. For example, a woman may have reported speaking with one aunt or sister at pretest, and she may have spoken to multiple sisters and aunts over the course of the intervention. On the basis of the response options provided, this variability would not have been captured. The fact that significant changes were found even across social roles is important, and future assessments evaluating this intervention should measure total numbers of individuals in each category to determine the strength of this change. Because it is stigmatizing for women to be knowledgeable about sex in Nepal, another aim of the intervention was to alter gender norms about sex, because this could help increase communication about sex as well. We learned through formative research (described in Kaufman et al., 2012) that Nepali women support women and girls in their communities being more knowledgeable about sexual health issues, being able to have more control over their sexual experiences, and
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the idea of increasing communication in families and communities (particularly among women) about sexual health issues. We therefore thought this aim would be appropriate, despite the fact that sex is a male domain in Nepal, because it would benefit the sexual health of women. We found greater positivity towards this factor in our analysis as a result of participating in the intervention, and this improved attitude held constant at posttest. It is important to acknowledge that the reliability of the gender norm subscale was minimally adequate (George & Mallery, 2010), but it is common for one or more scales in a measure to have lower alphas in the .60 to .69 range, especially if there are only a few items in the scale (which was the case here; Leech, Barrett, & Morgan, 2005). Formal implementation of this intervention should include additional items in the evaluation assessment aimed to improve this reliability. Feeling shame about sex and female sexuality also decreased as a result of the intervention, and this effect held over time as well. Women also reported feeling more comfortable communicating about sex after participating in the intervention and this effect held constant over time. This comfort was marginally predictive of talking with greater numbers of women about sex over time. As mentioned earlier, this effect may have been even greater had the measure used for this construct been more sensitive. There was also a slight trend for women to report sex education as being empowering; however, the sensitivity of this item was not strong given it was measured using only one question on the survey. A more sensitive measure containing additional survey items should be used in future evaluations. The primary purpose of this pilot intervention was to determine whether increases in communication between women and men about sexual health could be increased and whether norms about communication could be changed. In addition, we wanted to examine whether the intervention itself could improve knowledge about HIV=STIs. Although there were immediate improvements at the end of the intervention, there appeared to be a decay effect, as the improvement disappeared as soon as 30 days after completion. Intervention effects may have been impacted by the small sample size, as there might have been statistically significant improvements for some demographic groups and not others. Given this was a pilot intervention and significant effects were found for several of the outcome variables targeted, the sample size for this initial test was deemed adequate for these purposes. However, the sample size should be increased for future tests of the intervention in order to provide greater statistical power to assess other outcomes such as HIV=STI knowledge and communication with spouses or boyfriends. English-speaking women were targeted for this intervention because this was a pilot study led primarily by the second author. English-speaking women, while more common in Kathmandu, is not the norm. However, we were most concerned with feasibility and acceptability for this testing, so decided to do the sessions primarily in English so that the primary investigator (second author) could monitor the comfort level and potential topics of confusion of the participants, because such taboo and sensitive topics were discussed. Naturally, a requirement for English-speaking participants led to a highly educated sample. This is an obvious limitation of this study that would have to be addressed in a randomized controlled trial of the intervention, which would be better implemented in the local language. For the purposes of this study, an English delivery was acceptable. We do not believe the English language requirement affected our results because despite the sample being highly educated, HIV scores were quite low at baseline, and many women reported wishing there had been more time or intervention sessions to thoroughly discuss more of the material (Kaufman et al., 2012). Given the fact that much of the intervention was dedicated to dispelling myths and educating about topics such as basic anatomy, teaching about HIV
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and STI transmission was challenging to fit into the time frame allotted for the topic. Past surveys have found that 24.2% of women in Nepali urban settings believe condoms cannot protect someone from HIV infection (Gill & Stewart, 2011), so the amount of time dedicated to addressing basic deficits in information is not surprising in retrospect. A formal implementation of the intervention would likely benefit from including a pretest to assess HIV knowledge before the education sessions, and then tailoring the educational components of the intervention to work from the knowledge level of the group. Furthermore, an additional HIV= AIDS information component would likely be more effective, as would a booster session to reinforce learned material.
Conclusions In summary, the Let’s Talk Intervention showed demonstrated improvements in increased communication with men and women about sex, and also changed gender norms to be more positive about being knowledgeable about sex, which is stigmatized in Nepalese culture. Given recent increases in HIV infections and societal changes occurring in Nepal, such as increased property ownership for women (Pandey, 2010) and greater political participation (UNdata, 2011), now is an opportune time to more fully implement intervention efforts addressing gender inequality issues around sexual health.
Funding This research was funded by a Fulbright Research Fellowship to Michelle Kaufman.
Acknowledgments Many thanks to Dr. Mary Crawford, Beena Mahat and the Family Planning Association of Nepal, and the USEF Office in Kathmandu.
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