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

Theories of Change
Anthropology 393 – Cultural
Construction of HIV/AIDS
Josephine MacIntosh
Theories of Change
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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)
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Providing information, behavioural skills, removal
of perceived barriers
– integral to the maintenance of individual-level
behaviour change
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But… w/o personal motivation to integrate risk
reduction strategies, little changes
Individual-level Models
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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
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Diffusion Theory
 Leadership Models
 Social Movement Theory
Individual-level Models
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Health Belief Model
– 1950’s U.S. Public health model designed by health
psychologists in the 1950’s
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Fundamental assumption
– Conscious, rational decision-making processes
determine health behaviours
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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
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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
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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
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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
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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
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Theory of Reasoned Action
– Fishbein, Middlestack & Hitchcock, 1994
– Most socially relevant behaviours are under
volitional control
– Should be predictable by intention
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Goal is to strengthen behavioural intent
– Should increase the enactment of preventative
behaviours
Individual-level Models
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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
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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
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Addresses importance of changing attitudes, social
norms and emotional responses that are
contradictory to sexual & reproductive health
Individual-level Models
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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
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Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination
Individual-level Models
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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
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Transtheoretical Model
 The two greatest challenges
Prochaska et al., 1994
– 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
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BUT… individual-level theories offer little insight
into how to shift social norms to support safer
behaviour
Social-level Models of Change
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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
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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
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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
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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
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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