behaviour change in hiv prevention in the workplace kevin joubert ‘the microbe is nothing, the...
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Behaviour Change in HIV Prevention in the Workplace
Kevin Joubert
‘The microbe is nothing, the terrain everything’ - Louis Pasteur on transmission of infectious diseases
The Systems at Play
• Ecosystem
• Community systems
• Peer Group systems
• Individual systems
• Intra-individual systems
Ecosystem
Cultures
Value systems
Power structuresMedia
LeadershipRole models
PoliciesInstitutional Practices
Power relationsCoordination
Ecosystem
Communities(Inter-personal)
PovertyMigration
UrbanisationUnemployment Social cohesionSocial Capital Role Models
Individual
Sexual Emotional
Cognitive
Spiritual
Communities
Peer Groups
Family
Culture
Value system
Power structuresMedia
Ecosystem
Sexual Process
BiologicalVolition / control
Emotional
Power
Desire
Personalityfactors
Status
Tradition
Masculinity / femininity
Values
Self-careView ofmy risk
Rational
Systems are autonomousPeople are not passive absorbers of values,
information, and culture
There are different cultural and belief systems (majority and minority) and we ‘choose’ between these
We are able to accept some parts and reject others
We are able to act contrary to the normative culture
We tend to tune out info that is not in line with our existing beliefs
Behaviour Change Process
Behaviour Change Process
Acceptance that I am
at risk
Intentionto changebehaviour
Behaviourchange
Newbehavioursustained
Ecosystem influence and perturbation
Individual interpretation and selection
It is all constantly in a state of flux
Intervention
Behaviour change theories
• Social ecological model for health
promotion
• Health belief model
• AIDS risk reduction model
• Stages of change model
• Theory of reasoned action
• Intrapersonal factors
• Interpersonal processes
• Institutional factors
• Community factors
Social Ecological Model
The Transtheoretical Model (Prochaska & DiClemente, 1984)
Six stages of behavior change:
• Precontemplation: not even thinking about it.• Contemplation: thinking about it.• Preparation: Taking steps to change
behavior.• Action: person tries behavior• Maintenance: person does behavior
regularly.• Relapse: person slips up & needs to make
adjustments.
The Transtheoretical Model
• Key assumptions of the model:• Change is an incremental process and
not a discrete outcome.• Change takes time.• Relapse is the rule, not the exception.
AIDS Risk Reduction Model
• Recognising and labelling behaviour as high risk
• Making a commitment to change• Taking action
Information seeking Obtaining remediesEnacting solutions
National Successes• Leadership• General awareness campaigns• Targeted prevention programmes• Strong civil society involvement and response
Also• Sustained stigma reduction• Access to VCT• Universal ART
Examples: Uganda• Strong political leadership• Use traditional systems of authority• Social mobilisation• Challenged social norms inhibiting
behaviour change
• Delayed sexual debut (for 2 years)• Decreased median number of sexual partners• Increase in condom use
Examples: Uganda• Highly clustered sexual networks• Limited links between clusters• Low physical mobility and urbanisation• High social differentiation• Significant ethnic and linguistic divisions
• Reorganisation of sexual clusters and disappearance of hubs in networks
• Entire sexual network became fractured:• Decline in practices such as wife-sharing,
widow cleansing and inheritance, sexual licence dring circumcision ceremonies
Examples: Uganda
• More open discussion – personalising risk• More likely to receive AIDS info from
friendship and personal networks• Societal change programmes (Not
individually targeted programmes)• Increase in social cohesion
Examples – USA Gay Community • General awareness in community• Targeted prevention interventions• Development of open dialogue• Social cohesion• Personalisation of risk
Social cohesion• People have a sense that they are
engaged in a common enterprise• Are facing a shared challenge• Are members of the same community• And are hopeful of success
Social Capital• Social cohesion• Community networks• Community participation• Positive local identity• Sense of solidarity and equality• Norms of trust, reciprocal help, support
and co-operation
But it depends:• Sport club members: lower prevalence,
more condom use• Stokvel members: higher prevalence,
women more casual sexual partners, more alcohol use
Examples – India • Combined HIV/STI intervention• Community based• 15-20 day campaigns every 6 months• House-to-house visits – provide info and
encourage visit to health camp• Health camps: free STI screening and
treatment• 2001: 71 million people attended a
health camp
Examples – Others • Thailand: Condom use at brothels• Benin and Abidjan: Condom use amonst
sex workers• USA: telephone contact with difficult to
reach populations• Brazil: combined general awareness,
targeted prevention, ready access to VCT, universal ART, supportive policies
Some thoughts on Systems
Each individual will be unique:• In the systems which influence• The weight of the influence• The interpretation given to interactions
with the systems
• SO the most accurate and influential interaction happens on an individual level
Some thoughts on Systems
But groups of people will be similar in their culture, world-view etc.
So it is possible to target groups for interventions
BUT this may not be as accurate and powerful
Some thoughts on Systems
The higher up the system hierarchy
The more diffuse and diluted the intervention?
Some thoughts on Systems
Developing and encouraging an existing system process which supports what you want to achieve
is easier
than trying to develop a new system process or block a system process which acts against what you want to achieve
Some thoughts on Systems
It may sound obvious but world view is subtle and profoundly influences success of interventions
Interventions which focus on the individual and on individual decision will be inappropriate for those who operate in a community-focused world view
Intervention choices
• Which systems do you want to target• Technological or social change• Which target group and how specific do
you need to be• Which point/s in the behaviour change
process are you targeting• What messages do you need to portray
‘Learning to masturbate is the start of a life-long love affair’ – Oscar Wilde (?)
Individual
Sexual Emotional
Cognitive
Spiritual
Communities
Peer Groups
Family
Culture
Value system
Power structuresMedia
Ecosystem
Behaviour Change Process
Behaviour Change Process
Acceptance that I am
at risk
Intentionto changebehaviour
Behaviourchange
Newbehavioursustained
Ecosystem influence and perturbation
Individual interpretation and selection
It is all constantly in a state of flux
Intervention
Lover Boys and Girls This high-risk group consists of (mostly) single
people who are promiscuous. The gender breakdown of this group is
approximately 55% male and 45% female. This group does not believe that Aids really
exists. They believe that listening to the HIV/Aids message only spoils the fun; that HIV/Aids is not serious and that it can be cured
Lover Boys and Girls• Members of this group are embarrassed about
using condoms and believe that sex is more enjoyable without them. They do not believe that the risk of getting HIV/Aids is reduced by having fewer sexual partners and will not discontinue sexual intercourse with a partner if the partner is HIV-positive.
• A significant proportion believes that HIV/Aids can be spread by mosquitoes, and that it is mostly spread by women. They also believe that the virus is spread by “dirty blood”. Some further claim that they don’t know how one gets HIV/Aids and others say that it can be cured by having sex with a virgin.
Break-away Groups• Kevin Joubert• Joy Beckett• Ulrika Beukman• Ben Brown• Cal Bruns• Colin Cane• David Dickensen • Caron Foster• Colleen Goosen • Karien Liebenberg• Tembela Mahlati• Betty Maropefela • Brad Mears• Engela Roos • Renee Selfe • Gillian Thomson• Jackie Tau• Anita Volker
• Pierre Brouard• Jill Cawse• Francesca Conradie• Phumelele Dlamini• Petra Kruger• Sarah Luthuli• Elna McIntosh• Elaine McKay• Mel Mentz• Racuni Naidoo• Sonto Ncongwane• Mariana Otto• Peter Philip• Lebo Ramafoko• Conny Setjeo• Bernadette Smith• Judith van Niekerk• Daryl Wearne
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