Conceptualising and operationalising a structural approach to HIV prevention Justin Parkhurst LSHTM / LIDC

Calls not new The importance of structural factors, or strategies for prevention dealing with underlying causes seen before 2000 special issue of AIDS dedicated to structural approaches 1990s – articles identifying and calling for greater inclusion of structures or enabling environments. Yet little progress in policies/plans dealing with structures Focus has remained on individual interventions, or searches for magic bullets Language has remained simple – e.g. Science 2008 what works – reducing multiple sexual partnerships Little though about how to achieve this. few demonstrated replicable approaches to reducing multiple sexual partnerships (Potts et al 2008)

Structural factors, structural drivers? Many factors are associated with risk behaviour Macro/Statistical correlations Descriptive works have highlighted potential causal drivers of risk behaviour Complexity involved with any determinant of behaviour Multiple structures will influence patterns of behaviour. Often no single start point per se, or direct cause.

Can classify structural factors By risk group: IDUs OVCs Females/girls MSM Etc. By sector: Legal Economic Education Socio-cultural Etc.

Other models/classifications Structures affecting interventions: Availability Acceptability Accessibility (Blankenship et al, 2000)

Cohen and Scribner (2000)

Causal Levels Superstructural Structural Environmental Individual (Sweat and Denison, 1995)

Distal-Proximal determinants of HIV infection (Barnett and Whiteside, 2002)

Useful for planners? Key issues appears to be identifying to planers: What they can (practically) do Where they can act (what levels, what issues) How to act in a structural way Key needs are therefore: A conceptual model which identifies points of potential action A strategy to guide planning

Points of potential action Most useful/applicable elements of past models appear to be: Level of activities – local, mid-level, national/international Proximity of factor to ultimate risk behaviour of interest

Strategy for planning Structural approaches effectively call for targeting activities to community needs. 2 ways to do so: 1. Enabling approach Set up structures so that local (target) communities can identify needs and act on them 2. Diagnostic approach Approach intervention by first researching your target population and identifying drivers of risk behaviour.

DistalProximal - More direct causal impact - Easier to monitor and measure impact - Typically affects smaller population group - Typically shorter duration of impact Suits: – Local planners addressing a specific community (e.g. young women in a village); - Programme officers with specific HIV remit; - Planners with concern for specific target groups (e.g. IDUs) - More indirect impact - Longer causal chain - Difficult to monitor and measure impact - Typically affects larger population group - Typically longer duration of impact Suits: – National planners addressing large populations; - Programme officers with broader development remit; - International donors. POVERTYPOVERTY Inability to meet key needs Unable to meet education costs Food insecurity No spending on health care Pull child out of school to work on farm Transactional sex Sugar daddy to support school fees Diseases untreated

Challenges/Issues How to move forward our conceptions of structural factors? A clear framework that is understood and useful to planners Can we make guides for different types of actors? A set of guidelines for planning? How to make useful recommendations? When can we generalise? How to assess if contexts are similar enough, etc. How to evaluate and determine causality?

How to shift thinking away from sets of magic bullet interventions? What can be learned from other disciplines on similar issues? Do other social policy fields face similar challenges in conceptualising, and addressing complex drivers of behaviour? How are they conceptualised? How do policy makers think in other areas?