1. Theories of Change Anthropology 393 – Cultural Construction of HIV/AIDS Josephine MacIntosh

2. Theories of Change Popular theoretical models for HIV/STI risk reduction highlight importance of –Motivating target audiences think & talk about own need for behaviour change (Peterson & Di Clemente, 2000) Providing information, behavioural skills, removal of perceived barriers –integral to the maintenance of individual-level behaviour change But… w/o personal motivation to integrate risk reduction strategies, little changes

3. Individual-level Models Health Belief Model AIDS Risk Reduction Model Social Cognitive Theory Theory of Reasoned Action Theory of Planned Behaviour Information-Motivation-Behavioural Skills Transtheoretical Model

4. Social-level Models of Change Diffusion Theory Leadership Models Social Movement Theory

5. Individual-level Models Health Belief Model –1950’s U.S. Public health model designed by health psychologists in the 1950’s Fundamental assumption –Conscious, rational decision-making processes determine health behaviours Knowledge should lead to preventative if –Susceptible or vulnerable –Risk is severe (negative health outcomes), –Benefits of prevention outweigh the costs (both physical and social)

6. Individual-level Models AIDS Risk Reduction Model –Stage model of behaviour change –Designed specifically for HIV intervention –Dolcini, Coats, Catania, Kegeles & Hauck, 1995 –Prevention efforts must build upon one another –Complex behaviours are more likely to be enacted if the individual has first integrated lower level acts Dolcini, Coats, Catania, Kegeles & Hauck, 1995

7. Individual-level Models AIDS Risk Reduction Model –Effectiveness depends on ability to systematically utilize learned harm reduction techniques Must label the behaviour as risky Must make a commitment to reducing risk and increasing prevention efforts –Rational assessment of perceived cost and benefits Must consistently enact behavioural changes that reduce risk –May entail engaging in novel, complex activities

8. Individual-level Models Social Cognitive Theory Bandura, 1994 –Self-efficacy is the key to effecting positive changes in health behaviour Best described as the sense of control over motivation and environment, and especially behaviour –Central Information, Development of self-regulatory and risk-reduction skills Increased feelings of self-efficacy Social supports that facilitate change – Impart the skills & self-beliefs that enable consistent engagement in the desired behaviours

9. Individual-level Models Theory of Reasoned Action –Fishbein, Middlestack & Hitchcock, 1994 –Most socially relevant behaviours are under volitional control – Should be predictable by intention Goal is to strengthen behavioural intent –Should increase the enactment of preventative behaviours

10. Individual-level Models Theory of Planned Behaviour –Fishbein, Middlestack & Hitchcock, 1994 –Adds perceived behavioural control as a construct –Accounts for the influences of factors which undermine personal control (perception of ability to act on intentions) sexual arousal gender-based power differentials alcohol and drug use –When personal control is perceived to be absolute, TPB reverts to TRA

11. Individual-level Models Information-Motivation-Behavioural Skills Model (IMB) Fisher & Fisher, 1998 –designed specifically to address HIV integrates theory & research from HIV prevention & social psychology –maintains that information and motivation are independent constructs –when found in conjunction with well-defined behavioural skills sets are causally related to the enactment of preventive behaviours

12. Individual-level Models Information-Motivation-Behavioural Skills Model (IMB) Fisher & Fisher, 1998 –Main assumption If an individual is well informed, highly motivated and possesses the necessary behavioural skills Then likely to initiate and maintain preventive behaviours Addresses importance of changing attitudes, social norms and emotional responses that are contradictory to sexual & reproductive health

13. Individual-level Models Transtheoretical Model Prochaska et al., 1994 –stage model designed for HIV prevention (like the AARM) approaches change as a non-linear process –six stages of change Precontemplation Contemplation Preparation Action Maintenance Termination

14. Individual-level Models Transtheoretical Model Prochaska et al., 1994 –Progress hinges on a decisional balance –Earlier stages rely on experiential processes Consciousness raising Awareness Self re-evaluation –Later stages depend on behavioural processes Reinforcement Counter-conditioning Helping relationships

15. Individual-level Models Transtheoretical Model Prochaska et al., 1994 The two greatest challenges –Finding a means to motivate precontemplators to process the information necessary for change –Finding reinforcements that will promote perseverance among those in the later stages

16. Summary Individual-level theoretical models for HIV/STI risk reduction highlight the importance of –Accurate information –Motivation –Behavioural skills social norms which support safer behaviours BUT… individual-level theories offer little insight into how to shift social norms to support safer behaviour

17. Social-level Models of Change Social models can shape the norms, values, & interests of at-risk social groups –Necessary adjuncts to any large-scale intervention –Norms and referents have a strong influence on individual intention to act HIV highlights issues that are social –Individual-level risk-reduction enhanced by addressing group and subcultural norms Capitalizing on existing community and interpersonal networks to improve public health delivery Removing social barriers that hinder safer behaviours

18. Social-Level Models of Change Diffusion Theory –Anthropological and sociological model –Examines a culture or subculture to determine which innovations are most likely to be adopted –Also concerned with how innovation will be used differently within a culture or sub-culture other than the one in which it originated Dearing, Meyer & Rogers, 1994

19. Social-Level Models of Change Leadership-Focused Models –Capitalize on influences of peers & esteemed referents –Enlist pre-existing group leaders to champion harm reduction innovations –Thru observation of social networks identify local leaders recruit and train –Use existing networks and principals to diffuse prevention messages may be a useful means of jump-starting social movements –Friedman, Des Jarlais & Ward, 1994

20. Social-level Models of Change Social Movement Theory Typically originate from the efforts of individuals & local leaders in response to a threat to the community On occasion, inspired by outside intervention Especially useful if a high degree of local participation is necessary if opposition is likely –Context = HIV prevention  may be resistance small groups (partners resistant to condom use) local leaders (needle sellers who resist needle exchange progs) political or economic elites (those who control the distribution of experimental treatments)

21. Effective HIV & Pregnancy Prevention Programming –Focus on reducing one or more specific HRSB –Theory-based –Advocate avoiding sexual risk-taking –Provide accurate information –Attend to social pressures –Model sexual communication & negotiation skills –Use interactive teaching methods –Appropriately targeted: age, sexual & cultural exp –Adequate in length –Include and train teachers and peer leaders Kirby, 2001