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Conceptualising and operationalising a structural approach to HIV prevention

Conceptualising and operationalising a structural approach to HIV prevention. Justin Parkhurst LSHTM / LIDC. Calls not new. The importance of structural factors, or strategies for prevention dealing with underlying causes seen before

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Conceptualising and operationalising a structural approach to HIV prevention

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  1. Conceptualising and operationalising a structural approach to HIV prevention Justin Parkhurst LSHTM / LIDC

  2. Calls not new • The importance of structural factors, or strategies for prevention dealing with underlying causes seen before • 2000 special issue of AIDS dedicated to structural approaches • 1990s – articles identifying and calling for greater inclusion of structures or ‘enabling environments’. • Yet little progress in policies/plans dealing with structures • Focus has remained on individual interventions, or searches for ‘magic bullets’ • Language has remained simple – e.g. Science 2008 ‘what works’ – ‘reducing multiple sexual partnerships’ • Little though about how to achieve this. • “few demonstrated replicable approaches to reducing multiple sexual partnerships” (Potts et al 2008)

  3. Structural factors, structural drivers? • Many factors are associated with risk behaviour • Macro/Statistical correlations • Descriptive works have highlighted potential causal drivers of risk behaviour • Complexity involved with any determinant of behaviour • Multiple structures will influence patterns of behaviour. Often no single ‘start point’ per se, or direct cause.

  4. Can classify structural factors • By risk group: • IDUs • OVCs • Females/girls • MSM • Etc. • By sector: • Legal • Economic • Education • Socio-cultural • Etc.

  5. Other models/classifications • Structures affecting interventions: • Availability • Acceptability • Accessibility (Blankenship et al, 2000)

  6. Cohen and Scribner (2000)

  7. Causal Levels • Superstructural • Structural • Environmental • Individual (Sweat and Denison, 1995)

  8. Distal-Proximal determinants of HIV infection (Barnett and Whiteside, 2002)

  9. Useful for planners? • Key issues appears to be identifying to planers: • What they can (practically) do • Where they can act (what levels, what issues) • How to act in a ‘structural’ way • Key needs are therefore: • A conceptual model which identifies points of potential action • A strategy to guide planning

  10. Points of potential action • Most useful/applicable elements of past models appear to be: • Level of activities – local, mid-level, national/international • Proximity of factor to ultimate risk behaviour of interest

  11. Strategy for planning • Structural approaches effectively call for targeting activities to community needs. 2 ways to do so: • Enabling approach • Set up structures so that local (target) communities can identify needs and act on them • ‘Diagnostic’ approach • Approach intervention by first researching your target population and identifying drivers of risk behaviour.

  12. Distal Proximal Inability to meet key needs Sugar daddy to support school fees P O V E R T Y Unable to meet education costs Pull child out of school to work on farm Food insecurity No spending on health care Transactional sex Diseases untreated - More indirect impact - Longer causal chain - Difficult to monitor and measure impact - Typically affects larger population group - Typically longer duration of impact - More direct causal impact - Easier to monitor and measure impact - Typically affects smaller population group - Typically shorter duration of impact Suits: – Local planners addressing a specific community (e.g. young women in a village); - Programme officers with specific HIV remit; - Planners with concern for specific target groups (e.g. IDUs) Suits: – National planners addressing large populations; - Programme officers with broader development remit; - International donors.

  13. Challenges/Issues • How to move forward our conceptions of structural factors? • A clear framework that is understood and useful to planners • Can we make guides for different types of actors? • A set of guidelines for planning? • How to make useful recommendations? • When can we generalise? • How to assess if contexts are similar enough, etc. • How to evaluate and determine causality?

  14. How to shift thinking away from sets of ‘magic bullet’ interventions? • What can be learned from other disciplines on similar issues? • Do other social policy fields face similar challenges in conceptualising, and addressing complex drivers of behaviour? • How are they conceptualised? How do policy makers think in other areas?

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