Theories of Change

Anthropology 393 – Cultural Construction of HIV/AIDS

Josephine MacIntosh

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

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

Social-level Models of Change

Diffusion Theory Leadership Models Social Movement Theory

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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