theories of change anthropology 393 – cultural construction of hiv/aids josephine macintosh
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Theories of Change
Anthropology 393 – Cultural Construction of HIV/AIDS
Josephine MacIntosh
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
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
Social-level Models of Change
Diffusion Theory Leadership Models Social Movement Theory
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)
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
Individual-level Models
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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