Theories of Change

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 labelthe behaviour as risky • Must make a commitment to reducing risk and increasing prevention efforts • Rational assessment of perceived cost and benefits • Must consistently enactbehavioural 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