From prevention research to prevention practice

Barry D Adam

University Professor Senior Scientist & Director of Prevention Research

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Influence of behavioural models on prevention research

◦ Critique 

Where my research fits in this picture

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How do we get from research to effective prevention?

 selection of research methods & paradigm assumptions strongly impact: ◦ ◦ ◦ ◦ ◦ How “behaviour” is defined and understood What the primary factors and conditions are that lead to outcomes (such as unprotected sex or HIV transmission) What are identified as the “levers” for change How policy and interventions proceed What counts as “real”

Starting points

Objectivity

 Epi terms ◦ MSM ◦ Endemic  Behaviour & variables   Measurement ◦ Differences between averages How much?

Terminology

Subjectivity

   Social terms ◦ Gay & bisexual men ◦ African, Caribbean & black Culture, practice & discourse Multiplicity & diversity ◦ Meaning  Why?

objective

   Variable ◦ Fixed container that everyone falls into Can measure central tendencies of category Compare differences in these tendencies

subjective

     Social construction, practice or performance Affiliations & social networks Can stress or disguise Deploy situationally Changes according to audience

For example, ethnicity

VALUING OBJECTIVITY VALUING SUBJECTIVITY

   Pre-determining factors impel behavioural outcomes Cause effect Biomedical individualism    People navigate through risks and opportunities in a social context Mutually reinforcing or diminishing inter actions Acting in a historically moving social context

Some (over-simple) contrasts

OBJECTIVITY

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Measurable traits as primary determinants “calculating, rational, self interested subject”

◦  Smart 2003:7 But impaired by discoverable impediments

SUBJECTIVITY

  Cultural currents and historical changes that shift the meaning and workings of apparently “independent” variables discursive resources available for making sense of conduct

OBJECTIVITY

 pathological outcomes  “the result is to portray gay men as beset by a number of serious psychological conditions, ranging (on the ‘victim’ end of the scale) from internalized homophobia, survivor guilt, and post traumatic stress disorder to (on the pathological end) low self-esteem, addictive personality syndrome, sexual compulsiveness, and lack of self-control.” ◦ David Halperin. 2007. What Do Gay Men Want? Ann Arbor: University of Michigan Press, p 12

SUBJECTIVITY

 multiple and conflicting “rationalities”  “ contextual and situational factors, where the practice of safer sex is extremely difficult or where unprotected sexual practices are seen as meaningful, logical and naturally expected outcomes, given the cultural context and specific circumstances” ◦ Díaz R, Ayala G (1999). Love, passion and rebellion. Culture, Health & Sexuality 1: 277–293.

Objective Subjective

   Provide overviews of large numbers Average behaviours & general trends How phenomena vary together    Document how world appears to people How people account for their own actions Interactive & mutually influential effects

Strengths

Techno-fix

    Vaccines Circumcision Microbicides PEP, PrEP

Socio-cultural

    How people on the cutting edge of the epidemic are networked with each other?

What awareness they have of their own sero-status and of those in their immediate social environments?

Perceptions of risk; exigencies & vulnerabilities What circuits/micro cultures/social niches are particularly vulnerable?

Prevention research

 How gay & bisexual men experience risk and make decisions about un/safe sex ◦ ◦ ◦ ◦ Barry D Adam, Alan Sears and E Glenn Schellenberg. 2000. “Accounting for unsafe sex” Journal of Sex Research 37 (1):259-271. Barry D Adam, Winston Husbands, James Murray and John Maxwell. 2005. “Risk construction in reinfection discourses of HIV-positive men”

Health, Risk and Society 7 (1):63-71.

Barry D Adam, Winston Husbands, James Murray and John Maxwell. 2005. “AIDS optimism, condom fatigue, or self esteem?” Journal of Sex

Research 42 (3):238-248.

Barry D Adam. 2005. “Constructing the neoliberal sexual actor”

Culture, Health and Sexuality 7 (4):333-346.

My work

 The men having unprotected sex most or all of the time who were interviewed for this study, then, typically participated in a circuit with some degree of shared culture that they presumed to be common among those they considered as prospective sex partners….Nevertheless this construction of the situation did not take into account the understandings of men in other circuits in the gay scene, or of men whose unsafe practice was less a question of careful risk assessment than of resolving condom and erectile difficulties, momentary lapses and trade-offs, personal turmoil and depression, or a byproduct of strategies of disclosure and intuiting safety.

Barry D Adam, Winston Husbands, James Murray and John Maxwell. 2008. “Silence, assent, and HIV risk” Culture, Health and Sexuality 10 (8):759-772

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 How risk is socially organized, i.e. social niches & circuits ◦ Barry D Adam, Winston Husbands, James Murray and John Maxwell. 2008. “Circuits, networks, and HIV risk management” AIDS

Education and Prevention 20 (5):420-435.

 Who is more at risk and what are they thinking?

My work

Recent campaigns

currently

   Schools ◦ Barry D Adam. 2009. Sexual Diversity in Schools. Ottawa: Public Health Agency of Canada.

Business ◦ Baths & bars: setting a tone, providing condoms Health care ◦ Access to gay-friendly testing & care

Structural change

    evaluate grass-roots initiatives arising among frontline prevention workers, create working partnerships to select, try out, and evaluate DEBIs that may be relevant to our context, work with the AIDS Bureau to develop and evaluate interventions, such as the current hivstigma.com campaign, and explore new initiatives such as internet and clinic-based interventions

Prevention Network Action Committee

      What do we mean by "effective" in HIV prevention? What forms of evidence and evaluative methods are most appropriate for assessing effectiveness? When is it most appropriate to employ RCT methodology? How is effectiveness demonstrated for prevention strategies that do not fit the RCT model, e.g. social marketing? What kinds of evidence will be most useful for frontline work? What forms of evidence are granting agencies willing to recognize?

Conversation on forms of evidence