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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

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Theories of Change

Anthropology 393 – Cultural Construction of HIV/AIDS

Josephine MacIntosh


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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


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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


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Social-level Models of Change

  • Diffusion Theory

  • Leadership Models

  • Social Movement Theory


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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)


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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


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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


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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


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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


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    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


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    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


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    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


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    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


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    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


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    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


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    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


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    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


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    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


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    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


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    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)


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    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


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