Behaviour Change in HIV Prevention in the Workplace

Kevin Joubert

‘The microbe is nothing, the terrain everything’ - Louis Pasteur on transmission of infectious diseases

An Ecosystemic Approach

The Systems at Play

• Ecosystem

• Community systems

• Peer Group systems

• Individual systems

• Intra-individual systems

Ecosystem(the Social Context)

Ecosystem

Cultures

Value systems

Power structuresMedia

LeadershipRole models

PoliciesInstitutional Practices

Power relationsCoordination

Ecosystem

Communities(Inter-personal)

PovertyMigration

UrbanisationUnemployment Social cohesionSocial Capital Role Models

Ecosystem

Communities

Peer Groups

Families

Ecosystem

Individual

Communities

Individual

Sexual Emotional

Cognitive

Spiritual

Communities

Ecosystem

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

The Process

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

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 Trans-theoretical Model

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

Some Success Stories

National Successes• Leadership• General awareness campaigns• Targeted prevention programmes• Strong civil society involvement and response

Also• Sustained stigma reduction• Access to VCT• Universal ART

National Successes

•Leadership

– Speed of action– Determination– Consistency of purpose

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

Prevention Interventions

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