Sexual Behavioural Change for HIV Where Have Theories Taken

Sexual behavioural change for HIV: Where have theories taken us?

Joint United Nations Programme on HIV/AIDS

UNICEF • UNDP • UNFPA • UNDCP UNESCO • WHO • WORLD BANK The text was written by Rachel King

UNAIDS/99.27E (English original, June 1999)

© Joint United Nations Programme on HIV/AIDS (UNAIDS) The designations employed and the presentation of the 1999. All rights reserved. This document, which is not a for- material in this work do not imply the expression of any mal publication of UNAIDS may be freely reviewed, quoted, opinion whatsoever on the part of UNAIDS concerning the reproduced or translated, in part or in full, provided the legal status of any country, territory, city or area or of its source is acknowledged. The document may not be sold or authorities, or concerning the delimitation of its frontiers used in conjunction with commercial purposes without and boundaries. prior written approval from UNAIDS (Contact: UNAIDS Information Centre).

UNAIDS – 20 avenue Appia – 1211 Geneva 27 – Switzerland Tel.: (+41 22) 791 46 51 – Fax : (+41 22) 791 41 65 e-mail: [email protected] – http://www.unaids.org Sexual behavioural change for HIV: Where have theories taken us?

Joint United Nations Programme on HIV/AIDS

UNICEF • UNDP • UNFPA • UNDCP UNESCO • WHO • WORLD BANK

UNAIDS Geneva, Switzerland 1999

TABLE OF CONTENTS

Abbreviations...... 4

Introduction...... 5

I. Theories and models of behavioural change ...... 6 (A) Focus on individuals ...... 6 (B) Social theories and models ...... 8 (C) Structural and environmental ...... 10 (D) Constructs alone and transtheoretical models...... 11

II. Key approaches to behavioural change for HIV ...... 13 (A) Approaches aimed aimed at individual level behavioural change ...... 13 Information, education and communication ...... 13 Testing and counselling...... 16 Conclusion ...... 17 (B) Community-level interventions...... 17 Social influence and social network interventions...... 17 Outreach interventions ...... 19 School-based interventions ...... 19 Condom promotion and social marketing ...... 20 Community organizing, empowerment and participatory action research...... 20 Policy level interventions ...... 22 Conclusion ...... 22

III. Examples of the impact of theory-driven interventions ...... 24 (A) Women ...... 24 Sex workers...... 26 Conclusion ...... 26 (B) Men...... 27 Men having sex with men (MSM) ...... 27 Heterosexual men...... 28 Conclusion ...... 28 (C) Youth...... 28 Conclusion ...... 30 (D) Injecting drug users ...... 30 Conclusions...... 31

IV. Challenges...... 32 (A) Design/context issues...... 32 (B) Gender...... 33 (C) Changing epidemic ...... 33 (D) Null findings ...... 33

V. Conclusions ...... 35

3 References...... 37

Tables...... 45

Table 1: Overview of most frequently used theories of human behaviour...... 47 Table 2: Models and theories tested through research or reviews...... 48 Table 3: Models and theories used to guide interventions ...... 50 Table 4: Summary of theories and models by population group ...... 55

ABBREVIATIONS

ARRM AIDS risk reduction model CT Counselling and testing for HIV HBM Health belief model IDU Injecting drug user ILOM Indigenous leader outreach model MSM Men who have sex with men PAR Participatory action research RCT Randomized controlled trial SCT Social cognitive theory STD Sexually transmitted disease(s) SW Sex worker(s) TASO The AIDS Support Organization, Uganda THE Tools for health and empowerment UAI Unprotected anal intercourse

4 INTRODUCTION models as a great number of them have been propelled by the urgency to do anything to slow the epidemic, particularly in resource- poor settings. The primary intention of this Today, in 1999, interventions to stem the review was to look as broadly as possible at all spread of HIV throughout the world are as interventions in order to identify what has varied as the contexts in which we find them. worked in the enormous variety of situations Not only is the HIV epidemic dynamic in addressed. However, this would have implied terms of treatment options, prevention strate- analysing retroactively all prevention pro- gies and disease progression, but sexual grammes to define their theoretical founda- behaviour, which remains the primary target tions, which was not feasible within the scope, of AIDS prevention efforts worldwide, is wide- time and resources of this project. ly diverse and deeply embedded in individual desires, social and cultural relationships, and This review thus focused primarily on the fol- environmental and economic processes. This lowing types of reports: makes prevention of HIV, which could be an essentially simple task, enormously complex • sexual behavioural change interventions involving a multiplicity of dimensions. for HIV explicitly mentioning their theoretical approach Either implicitly or explicitly nearly all preven- • studies testing theoretical models of tion interventions are based on theory. Most behavioural change rely on the assumption that giving correct • and reviews on impact of behavioural information about transmission and preven- changes interventions. tion will lead to behavioural change. Yet research has proven numerous times that education alone is not sufficient to induce Additional examples of developing countries behavioural change among most individuals. projects were used to balance the observa- Thus, second-generation interventions were tions and conclusions drawn from the above developed based on individual psychosocial sources in order to compensate for the lack of and cognitive approaches that educate indi- tested models in these countries. viduals in practical skills to reduce their risk for HIV infection (Kalichman, 1997). More recent- Most of the studies cited in this report include ly, social researchers have come to realize that control or comparison situations and behav- because complex health behaviours such as ioural outcomes. Reports that included only sex take place in context, socio-cultural fac- knowledge and attitudes outcomes were tors surrounding the individual must be con- excluded. Also included were some interven- sidered in designing prevention interventions. tions that used constructs from a variety of Finally, beyond the individual and his or her theories attempting to incorporate social, immediate social relationships lie the larger environmental and cognitive elements, or issues of structural and environmental deter- used constructs alone without testing theories minants that also play a significant role in sex- as a whole. Unfortunately, it was difficult to ual behaviour (Sweat, 1995). identify interventions based both on a transtheoretical approach and strong evaluation The aim of this project was to associate out- components. comes of behavioural interventions around the world with the different models and theo- Finally, this review was organized into four ries on which they were based. There is how- sections, including: ever a dearth of information on tests of the relevance of behavioural change models in • a brief overview of theoretical models of differing contexts, especially in non-industrial- behavioural change ized countries and in regions at later stages of • a review of key approaches used to stem the epidemic. Most intervention reports, sexual transmission of HIV whether in peer-reviewed journals or conference abstracts, often do not explicitly state • a summary of successful interventions tar- the theoretical framework of the project. And geting specific populations at risk in many cases, there was no explicit intent to • and a discussion of remaining challenges. base interventions on behavioural change

5 CHAPTER I

THEORIES efficacy beliefs, intentions and outcome expectations (Kalichman, 1997). Central to AND MODELS OF HIV prevention interventions based on psychological-behavioural theory is the practice BEHAVIOURAL CHANGE of targeted risk-reduction skills. These skills are generally passed on to individuals in a process consisting of instruction, modeling, This chapter is broken into 4 sections that practice and feedback (Kalichman, 1997). The cover the most frequently used theories and psychological theories and models that have models of behavioural change from varied been most instrumental in the design and perspectives (see Table 1). It begins with the- development of HIV prevention interventions ories that focus on the individual’s psycholog- are briefly described below. ical process, such as attitudes and beliefs, then goes into theories emphasizing social Health belief model relationships, and ends with structural factors in explaining human behaviour. This separa- The Health belief model, developed in the tion is artificial as there is inevitable overlap in 1950s, holds that health behaviour is a func- categories. It might therefore be useful, as tion of individual’s socio-demographic charac- well, to see the theories as a continuum of teristics, knowledge and attitudes. According models moving from the strictly individually- to this model, a person must hold the follow- centered to the macro-level of structural and ing beliefs in order to be able to change environmentally focused. behaviour:

(1) perceived susceptibility to a particular (A) FOCUS ON INDIVIDUALS health problem (“am I at risk for HIV?”) (2) perceived seriousness of the condition As HIV transmission is propelled by behav- (“how serious is AIDS; how hard would my ioural factors, theories about how individuals life be if I got it?”) change their behaviour have provided the (3) belief in effectiveness of the new behav- foundation for most HIV prevention efforts iour (“condoms are effective against HIV worldwide. These theories have been gener- transmission”) ally created using cognitive-attitudinal and (4) cues to action (“witnessing the death or affective-motivational constructs (Kalichman, illness of a close friend or relative due to 1998). Nearly all the psychosocial theories AIDS”) originated in the West but have been used for (5) perceived benefits of preventive action AIDS internationally with mixed results. Only (“if I start using condoms, I can avoid HIV one of the psychosocial models discussed infection”) below, the AIDS risk reduction model, was (6) barriers to taking action (“I don’t like developed specifically for AIDS. using condoms”).

Psychosocial models of behavioural risk can In this model, promoting action to change be categorized into 3 major groups: those behaviour includes changing individual per- predicting risk behaviour, those predicting sonal beliefs. Individuals weigh the benefits behavioural change and those predicting against the perceived costs and barriers to maintenance of safe behaviour. Models of change. For change to occur, benefits must individual behavioural change generally focus outweigh costs. With respect to HIV, interven- on stages that individuals pass through while tions often target perception of risk, beliefs in trying to change behaviour. These theories severity of AIDS (“there is no cure”), beliefs in and models generally do not consider the effectiveness of condom use and benefits of interaction of social, cultural and environmen- condom use or delaying onset of sexual rela- tal issues as independent of individual factors tions. (Auerbach, 1994). Although each theory is built on different assumptions they all state Social cognitive (or learning) theory that behavioural changes occur by altering potential risk-producing situations and social The premise of the social cognitive or social relationships, risk perceptions, attitudes, self- learning theory (SCT) states that new behav-

6 CHAPTER I

iours are learned either by modeling the of personal intention in determining whether behaviour of others or by direct experience. a behaviour will occur. A person’s intention is Social learning theory focuses on the impor- a function of 2 basic determinants: tant roles played by vicarious, symbolic, and self-regulatory processes in psychological (1) attitude (toward the behaviour), and functioning and looks at human behaviour as (2) ‘subjective norms’, i.e. social influence. a continuous interaction between cognitive, behavioural and environmental determinants ‘Normative’ beliefs play a central role in the (Bandura, 1977). Central tenets of the social theory, and generally focus on what an indi- cognitive theory are: vidual believes other people, especially influential people, would expect him/her to do. • self-efficacy – the belief in the ability to implement the necessary behaviour (“I For example, for a person to start using con- know I can insist on condom use with my doms, his/her attitude might be “having sex partner”) with condoms is just as good as having sex • outcome expectancies - beliefs about out- without condoms’” and subjective norms (or comes such as the belief that using con- the normative belief) could be “most of my doms correctly will prevent HIV infection. peers are using condoms, they would expect me to do so as well”. Interventions using this Programmes built on SCT integrate informa- theory to guide activities focus on attitudes tion and attitudinal change to enhance moti- about risk-reduction, response to social norms, vation and reinforcement of risk reduction and intentions to change risky behaviours. skills and self-efficacy. Specifically, activities focus on the experience people have in talk- Stages of change model ing to their partners about sex and condom use, the positive and negative beliefs about This model, developed early in the 1990s adopting condom use, and the types of envir- specifically for smoking cessation by onmental barriers to risk reduction. A meta- Prochaska, DiClemente and colleagues, analysis of HIV risk-reduction interventions posits 6 stages that individuals or groups pass that used SCT in controlled experimental tri- through when changing behaviour: pre-con- als found that 12 published interventions with templation, contemplation, preparation, mostly uninfected individuals all obtained action, maintenance and relapse. With positive changes in risk behaviour, with a respect to condom use, the stages could be medium effect size meeting or exceeding described as: effects of other theory-based behavioural change interventions (Greenberg, 1996). (1) has not considered using condoms (pre- contemplation) Theory of reasoned action (2) recognizes the need to use condoms (contemplation) The theory of reasoned action, advanced in (3) thinking about using condoms in the next the mid-1960s by Fishbein and Ajzen, is months (preparation) based on the assumptions that human beings (4) using condoms consistently for less than 6 are usually quite rational and make systemat- months (action) ic use of the information available to them. (5) using condoms consistently for 6 months People consider the implications of their or more (maintenance) actions in a given context at a given time (6) slipping-up with respect to condom use before they decide to engage or not engage (relapse) in a given behaviour, and that most actions of social relevance are under volitional control In order for an intervention to be successful it (Ajzen, 1980). The theory of reasoned action must target the appropriate stage of the indi- is conceptually similar to the health belief vidual or group. For example, awareness rais- model but adds the construct of behavioural ing between stage one and two. Groups and intention as a determinant of health behav- individuals pass through all stages, but do not iour. Both theories focus on perceived sus- necessarily move in a linear fashion ceptibility, perceived benefits and constraints (Prochaska, 1992). As with previous theories, to changing behaviour. The theory of rea- the stages of change model emphasizes the soned action specifically focuses on the role importance of cognitive processes and uses

7 CHAPTER I

Bandura’s concept of self-efficacy. Movement ue to provide important guidance to inter- between stages depends on cognitive-behav- ventions in formulating design and evaluation ioural processes. with diverse populations in a wide variety of settings. Theories also help in understanding Among others (see Table 3), the CDC has study results. It is important, however, to pay used the Stages of Change model in its AIDS particular attention to these theories across Community Demonstration Projects for mar- cultures and genders as nearly all the individ- ginal populations in the US and in a research ually based theories were developed in the project aiming to change women’s sexual West with little focus on the role of gender. behaviour with their main partners (Galavotti Although numerous studies have proven the 1998). usefulness of these theories, it has become increasingly evident that alone they do not entirely explain why some populations have AIDS risk reduction model higher HIV prevalence than others nor the The AIDS risk reduction model, developed in complex interactions between contextual fac- 1990 (Catania et al), uses constructs from the tors and individual behaviour. health belief model, the social cognitive theory and the diffusion of innovation theory (a social model described below), to describe (B) SOCIAL THEORIES AND the process individuals (or groups) pass MODELS through while changing behaviour regarding HIV risk. The model identifies 3 stages Overemphasis on individual behavioural involved in reducing risk for HIV transmission, change with a focus on the cognitive level has including: undermined the overall research capacity to understand the complexity of HIV transmis- (1) behaviour labelling sion and control. Focus only on the individual (2) commitment to change psychological process ignores the interactive (3) taking action. relationship of behaviour in its social, cultural, and economic dimension thereby missing the In the first stage, knowledge about HIV trans- possibility to fully understand crucial determi- mission, perceived HIV susceptibility, as well nants of behaviour. Aggleton (1996) points as aversive emotions influence how people out that, in many cases, motivations for sex perceive AIDS. The commitment stage is are complicated, unclear and may not be shaped by four factors: perceptions of enjoy- thought through in advance. ment, self-efficacy, social norms and aversive emotions. Again, in the last stage, aversive Societal norms, religious criteria, and gender- emotions, sexual communication, help-seek- power relations infuse meaning into behav- ing behaviour and social factors affect peo- iour, enabling positive or negative changes. A ple’s decision-making process (Catania, main difference between individual and social 1990). models is that the latter aim at changes at the community level. Sociological theories assert Programmes that use the AIDS risk reduction that society is broken up into smaller subcul- model focus on: tures and it is the members of one’s immediate surroundings, the peer group that some- • clients’ risk assessment one most identifies with, that has the most • influencing the decision to reduce risk significant influence on an individual’s behav- through perceptions of enjoyment or self- iour. According to this perspective, effective efficacy prevention efforts, especially in vulnerable • clients’ support to enact the change communities that do not have the larger soci- (access to condoms, social support). etal support, will depend on the development of strategies that can enlist community mobi- Conclusion lization to modify the norms of this peer network to support positive changes in behav- These psychosocial theories and constructs iour (Kelly, 1995). A greater interest in the were very useful early in the epidemic to iden- context surrounding individual behaviour led tify individual behaviours associated with to increased numbers of interventions guided higher rates of HIV transmission. They contin- by the following theories and models.

8 CHAPTER I

Diffusion of innovation theory Social network theory

The diffusion of innovation theory (Rogers, The Social Network Theory looks at social 1983) describes the process of how an idea is behaviour not as an individual phenomenon disseminated throughout a community. but through relationships, and appreciates According to the theory, there are four essen- that HIV risk behaviour, unlike many other tial elements: the innovation, its communica- health behaviours, directly involves 2 people tion, the social system and time. People’s (Morris, 1997). With respect to sexual rela- exposure to a new idea, which takes place tionships, social networks focus on both the within a social network or through the media, impact of selective mixing (ie how different will determine the rate at which various peo- people choose who they mix with), and the ple adopt a new behaviour. The theory posits variations in partnership patterns (length of that people are most likely to adopt new partnership and overlap). Although the intri- behaviours based on favorable evaluations of cacies of relations and communication within the idea communicated to them by other the couple, the smallest unit of the social net- members whom they respect (Kegeles, 1996). work, is critical to the understanding of HIV Kelly explains that when the diffusion theory transmission in this model, the scope and is applied to HIV risk reduction, normative character of one’s broader social network, and risk behavioural changes can be initiated those who serve as reference people, and when enough key opinion leaders adopt and who sanction behaviour, are key to compre- endorse behavioural changes, influence oth- hending individual risk behaviour (Auerbach, ers to do the same and eventually diffuse the 1994). In other words, social norms are best new norm widely within peer networks. When understood at the level of social networks. beneficial prevention beliefs are instilled and widely held within one’s immediate social net- One application of the Sexual Network work, individuals’ behaviour is more likely to Theory for HIV prevention is the concept of be consistent with the perceived social norms ‘bridge populations’ that form a link (Kelly, 1995). between high and low prevalence groups (Morris, 1997). In Thailand, men who have Interventions using this theory generally both commercial and non-commercial sex investigate the best method to disperse mes- partners form an important bridge popula- sages within a community and who are the tion, which was an integral aspect of the leaders able to act as role models to change spread of HIV in Thailand. Programmes community norms. using this theory to guide them would investigate:

Social influence or social inocula- • the composition of important social net- tion model works in a community • the attitudes of the social networks towards safer sex This educational model is based on the con- • whether the social network provides the cept that young people engage in behaviours necessary support to change behaviour including early sexual activity partly because • whether particular people within the of general societal influences, but more social network are at particularly high specifically from their peers (Howard 1990). risk and may put many others at risk. The model suggests exposing young people to social pressures while teaching them to examine and develop skills to deal with these pressures. The model often relies on role Although few network-based interventions models such as teenagers slightly older than have been tried, the concept has proven programme participants to present factual complementary to individual-based theories information, identify pressures, role-play for the design of prevention programmes by responses to pressures, teach assertiveness focusing on the partnership as well as the skills and discuss problem situations (Howard, larger social group. Analysis of network mix- 1990). Social influence model has been used ing provides the means to see efficiency of to reduce smoking among young people as transmission and effective points of inter- well. vention.

9 CHAPTER I

Theory of gender and power Theory for individual and social change or empowerment model Unlike the psychosocial theories which are essentially gender-blind, the theory of gender This theory asserts that social change hap- and power is a social structural theory pens through dialogue to build up a critical addressing the wider social and environmen- perception of the social, cultural, political and tal issues surrounding women, such as distrib- economic forces that structure reality and by ution of power and authority, affective influ- taking action against forces that are oppres- ences, and gender-specific norms within het- sive (Parker, 1996). In other words, empower- erosexual relationships (Connell, 1987). Using ment should increase problem solving in a this theory to guide intervention develop- participatory fashion, and should enable par- ment with women in heterosexual relation- ticipants to understand the personal, social, ships can help investigate how a woman’s economic and political forces in their lives in commitment to a relationship and lack of order to take action to improve their situa- power can influence her risk reduction choic- tions (Israel, 1994). Werner (1997) states that, es (DiClemente, 1995). “empowerment is the process by which disadvantaged people work together to take Programmes using the theory of gender and control of the factors that determine their power would assess the impact of structurally health and their lives”. For this to happen he determined gender differences on interper- explains that feelings of powerlessness, which sonal sexual relationships (perceptions of can come from lack of skills and confidence, socially prescribed gender relations). have to be cast off. Although empowerment can only come from the group itself, enabling Conclusion empowerment is possible by facilitating its determinants. The common struggle against Social theories and models see individual gender or ethnic oppression, economic behaviours embedded in their social and cul- exploitation, political repression or foreign tural context. Instead of focusing on psycho- intervention is what builds necessary confi- logical processes as the basis for sexual dence (Werner, 1997). behaviour, it tends to be social norms, relationships and gender imbalances that create A distinction is made between personal, orga- the meaning and determinants of behaviour nizational and community empowerment. and behavioural change. These theories dic- Personal empowerment has to do with the tate that efforts to effect change at the com- psychological processes and is similar to self- munity level will have the most significant efficacy and self esteem. Organizational impact on individuals who are contemplating empowerment encompasses both the changes and on those who have made processes that enable individuals to increase changes but need support to sustain those their control within the organization and the changes. Social theories have been increas- organization to influence policies and deci- ingly used with populations especially vulner- sions in the community. An empowered com- able to effects of partners and peers. These munity uses the skills and resources of indi- theories and models have been developed in viduals and organizations to meet respective the West and few examples have tested their needs (Israel, 1994). relevance in developing countries. Interventions using empowerment approaches must consider key concepts such as beliefs and practices that are linked to interpersonal, (C) STRUCTURAL AND organizational and community change. ENVIRONMENTAL Intervention activities can address issues at the community and organizational level such Determinants of sexual behaviour can be as central needs the community identifies, seen as a function not only of individual and and any history community organizing among social but of structural and environmental fac- community members. The theory would pre- tors as well (Caraël, 1997, Sweat, 1995, Tawil, scribe including participants in the planning 1995). These factors include civil and organi- and implementation of activities. zational elements as well as policy and economic issues.

10 CHAPTER I

Social ecological model for health economic strain in a alien culture (Caraël, promotion 1997). In such situations, HIV concerns take a very low priority in a risk hierarchy, and any According to this model, patterned behaviour previous or planned efforts for the control of is the outcome of interest and behaviour is HIV transmission are disrupted, if not viewed as being determined by the following: destroyed.

(1) intrapersonal factors – characteristics of Conclusion the individual such as knowledge, attitudes, behaviour, self-concept, skills Community level theories, models or factors (2) interpersonal processes and primary see human behaviour as a function not only of groups formal and informal social network the individual or his or her immediate social and social support systems, including the relationships, but as depending on the com- family, work group and friendships munity, organization and the political and (3) institutional factors – social institutions economic environment as well. They are mul- with organizational characteristics and for- tidimensional with an emphasis on linking the mal and informal rules and regulations for individual to the surrounding larger environ- operation mental systems. Interventions using this (4) community factors – relationships among approach, thus, target organizations, commu- organizations, institutions and informal nities and policy. networks within defined boundaries (5) public policy – local, state and national laws and policies (McLeroy, 1988). (D) CONSTRUCTS ALONE AND Intervention strategies range from skills TRANSTHEORETICAL MODELS development at the intra-personal level to mass media and regulatory changes at other Perception of risk construct levels (Laver, 1998). The theory acknowledges the importance of the interplay between the As behavioural interventions are designed to individual and the environment, and consid- reduce higher risk behaviours, perception of ers multi-level influences on unhealthy behav- risk is a construct in most individual psy- iour (Choi, 1998). In this manner, the impor- chosocial behavioural models and some inter- tance of the individual is de-emphasized in ventions use the construct without applying the process of behavioural change. any of the models in their entirety. Increasing perception of risk has been shown numerous times to increase HIV protective behaviour Socioeconomic factors (Stevens, 1998). Yet most behavioural models Several studies have shown that economic measure risk as individually determined which factors have a strong influence on individual might not be relevant in many contexts. Not sexual behaviour, mostly through poverty and surprisingly, many women often perceive underemployment. Cross-nationally, countries themselves at risk not because of their own with the lowest standards of living are also the behaviour, but because of the past or current, ones with the highest HIV incidence (Sweat, perceived or real behaviour of their sexual 1995; Tawil, 1995). Within both rich and poor partner. In addition, perception of risk as a countries, poverty is associated with HIV, and predictor of future behavioural change has HIV intensifies poverty (Sweat, 1995). further complexities in circumstances where individuals report high perception of risk and The proposed mechanisms for this relation- high self-reported behavioural change. This ship are: non-cohabitation between young situation may demonstrate limited realistic married couples which can arise from critical further behavioural change options, or feel- economic situations forcing urban migration, ings of fatalism. seasonal work and truck driving, sex work, civil disturbances and war. Civil disturbance Sexual communication and war lead to displaced and refugee populations who not only lose their social and Sexual communication has been noted in var- familial support systems but become highly ious situations to be predictive of condom vulnerable to HIV owing to intense social and use. Among incarcerated Latino adolescents

11 CHAPTER I

with high numbers of sexual partners in the USA, it was reported that youth who communicated with their sex partners about each others’ sexual history were significantly more likely to use condoms (Rickman, 1994). In central Africa condom use was more likely if women reported discussion with their sexual partner about STDs or condoms (van der Straten, 1995). Sexual communication has also been reported as a means to self-efficacy among heterosexuals in Holland (Buunk, 1998).

12 CHAPTER II

KEY APPROACHES (A) APPROACHES AIMED AT TO BEHAVIOURAL INDIVIDUAL LEVEL BEHAV- IOURAL CHANGE CHANGE FOR HIV Information, education and communication Early in the AIDS epidemic, results of population survey research alerted public health offi- Mass and small group education cials of the diversity of sexual behaviours and of the need to act quickly. The first interven- As information was initially, for many, thought tions as well as the first applications of theo- to be the key to behavioural change, HIV pre- ries were propelled by the urgency to do any- vention programmes began with a focus on thing to slow the alarming crisis at hand. increasing awareness about the modes of Through popular public health channels, transmission and prevention (Cohen, 1992). information was disseminated to populations Mass education for HIV prevention can take at risk. many forms but is often seen as a key component of a comprehensive AIDS prevention Today, many of the interventions for the pre- programme (Holtgrave, 1997). Mass media, vention of HIV transmission, rather than using for example, are directed to the general pub- one of the behavioural theories in its entirety, lic and aim at teaching people essential facts, have developed programmes based on one promoting healthy behaviour, quieting anxi- or many constructs often depending on the ety about casual transmission and preventing socio-cultural, political, or economic situation discrimination. and on the stage of the epidemic. Drawing on various models and modifying them to suit An analysis of the messages adopted by the the population and context has been critical information and education programmes of to implementation of prevention projetcs, national AIDS control programmes of 38 dif- especially in international settings, as nearly ferent countries found that over 90% focused all theories were developed in the West. on correcting misperceptions about AIDS. These transtheoretical approaches are guided About 80% provided information about per- by critical constructs such as risk perception, sonal risk assessment (Cohen, 1992). In many social norms and sexual communication to countries, mass education provided the first form the basis of interventions worldwide. step to national AIDS control programmes. Many mass education efforts successfully This section looks principally at the most com- raised AIDS awareness by informing individu- mon approaches used to influence HIV risk als of the risks of HIV infection, and in some reduction. Although these approaches are not cases education-based programmes were suf- consistently or directly derived from behav- ficient to change high risk behaviours, ioural change theories or models, they draw increase condom sales, and reduce new HIV on the multiple constructs mentioned above. infections (Kalichman, 1997). The channels The section is split between individual and that national AIDS control programmes have community-level interventions, where the used for mass education include targeted approach is described and then specific media, printed media and electronic media examples of its use are reviewed. See Table 2 (Cohen, 1992). for a summary of models and theories tested by research or reviews. A review of 49 studies covering 18 countries to identify empirical outcomes or evaluate impact of HIV-related mass-media campaigns in 1996 concluded that most campaigns aiming at “individual-level goals of knowledge, attitude or behavioural changes were generally successful at achieving these goals” (Holtgrave, 1997). However, behavioural end- points of the projects reviewed were not mentioned. In addition, as the author himself

13 CHAPTER II

pointed out, a substantial number of the pro- tion from randomized controlled trials of the- ject reports reviewed lacked methodological ory-based skills-building programmes (see details; they were reported in conference chapter III for impact of theory based inter- abstracts. It is therefore difficult to conclude ventions). Several independent reviews of the on the relative meaning of the term “success- literature as a whole found that small group ful”, particularly in relation to behavioural out- HIV risk-reduction interventions result in comes. meaningful changes in HIV risk behaviour (Kalichman, 1998). Small-group AIDS education is taking place all over the world, advancing general knowl- One innovative approach targeting hard-to- edge of HIV in numerous communities. Small- reach populations in the USA with information group AIDS prevention programmes can be and counselling was a multiple session inter- seen as having 3 main components: vention designed to be delivered over the telephone. One reason for this method was to • content reach populations that do not want to meet a • context health care provider face-to–face. In an evalu- • strategies (Kalichman, 1998). ation of the study, the researcher found significant effects of their telephone-based Content includes goals, objectives, and activ- counselling including a decrease in unpro- ities. The main content areas in most small- tected intercourse from 47% to 26% of the group intervention activities include: basic men who completed the programme education about AIDS, sensitization to one’s (Roffman, 1997). personal risks for HIV, instruction in individual actions that can reduce one’s risk and explor- Another study in Uganda looking at gender ing new ways to communication with sex part- differences and perception of risk noted that ners. Entire interventions or research ques- participation in small-group AIDS education tions are built on any one of these content was associated with some protective behav- areas. iours for women with evidence of a dose response effect. The author suggests that The second component in small group HIV these AIDS education events may also pro- prevention is the context. The different vide a socially sanctioned opportunity for aspects of the intervention should be peer group interaction for women (Bunnell, designed to fit the cultural, gender and devel- 1996). opmental issues of participants. For example, one investigator felt concerns of stigma and Especially in the USA, small-group AIDS pre- sexual identity were paramount to African vention efforts have evolved since the begin- American gay men and dedicated an entire ning of the epidemic from providing basic session of this small-group intervention to information in community groups and sensi- concentrate on those issues (Kalichman, tizing people to personal risk sensitization. 1998). Subsequently, interventions began instructing people on condom use skills, eroticizing safer The third component, strategy, is the process sex, and building safer sex communication itself, where emphasis is placed on how the skills. Through interventions encompassing interventions are implemented between par- these elements, many people have reduced ticipants and group leader. Key elements to high-risk sexual behaviour, but not everyone consider include how to foster trust, build is sensitive to small group behavioural inter- group cohesiveness, encourage motivation ventions. For example, small-group projects and mutual support among participants and targeting heterosexual men for HIV preven- between participants and the facilitator tion have not shown significant intervention (Kalichman, 1998). effects. Longer-term behavioural changes require ongoing support and modifications in Although evaluations of small-group interven- the larger social environment within which tions have focused on content and facilitation these behaviours take place. skills, all three components have been found to be critical to the success of this approach. The literature reports strong evidence for the beneficial effects of small-group HIV preven-

14 CHAPTER II

Peer education In these various situations, peer educators performed differing tasks ranging from devel- Peer education is one approach to small- opment and distribution of IEC materials group HIV prevention usually aimed at indi- including video clips and pamphlets, as well vidual behaviour. The peer health educator as condom discussion and distribution to con- approach recruits leaders in communities at versations with peers on diverse topics such risk to be implementers of the education pro- as empowerment, health and human rights, gramme to their peers (Sepulvede, 1992). and basic AIDS information. Selection of peer educators is a key to the success of a programme and often involves: Surprisingly, all of the above studies, even though many were not randomly controlled, • acceptance by other members of the indicated positive results. But here again, group many of these reports were conference • being an opinion leader, thus well abstracts lacking methodological details. respected in the group Nevertheless, they show the astonishing • willingness to be trained diversity of populations and contexts with • committed to the goals of the programme which peer education is being practised throughout the world. Many interventions combine peer education with other approaches such as the use of In one study that randomized 40 factories in social networks, condom social marketing Zimbabwe into counselling and testing with (Roy, 1998) and outreach (Seema, 1998 & or without peer education, results reported a Boontan, 1998) as these approaches can be 34% lower HIV incidence in peer education complementary. Outreach work using peers than in control group (Katzenstein, 1998). In has resulted in increased participation of tar- Zambia, authors noted dramatic declines in geted community members as well as syphilis seropositivity in 3 test vs. 3 control increased diversity of participants sites (by 77%, 47% and 58%) after a 3-year (Broadhead, 1998). peer education programme that reached 417,000 men and 385,000 women (Kathuria, The benefits of working with peers rather than 1998). with ‘experts’ from outside the social network are many depending upon the group at risk. Wingood noted that peer educators may be a Two studies analysed cost-effectiveness of more credible source of information for peer education interventions among IDUs in women, may communicate in a more under- the USA and factory workers in Zimbabwe. In standable language, and may serve as posi- Zimbabwe costs compared favorably to other tive role models (Wingood, 1996). Other HIV prevention programmes (Katzenstein, studies have suggested that when the group 1998), and the US researchers found that the at risk is very different culturally from the peer-driven intervention cost one thirtieth as majority, peers know the cultural risks and much as the traditional (external) intervention most appropriate and realistic risk-reduction (Broadhead, 1998). strategies from experience. As any other approach however, peer educa- The peer educator approach has been used in tion has its limits. For example, in Brazil, par- as diverse populations as: dock workers in ticipants of a target group became health Nigeria (Ogundare 1998), Arabian prisoners agents and lost their solidarity and support in Italy (Vacondio, 1998), street youth in within the group, which is a key element to Thailand (Boontan, 1998), in-school youth in successful peer education (Leite, 1998). Armenia (Ter-Hoyakimyan, 1998) secondary Another example comes from a convenience school students in Argentina (Bianco, 1998), sample analysis of several peer education taxi drivers in Cameroon (Moughutou, 1998), programmes across the USA that found a low- and middle-class general population in structural tendency for peer education pro- Zambia (Kathuria, 1998), factory workers in grammes to employ low-income people and Zimbabwe (Katzenstein, 1998), sex workers in treat peer educators as the most marginal India (Seema, 1998, Roy, 1998), drug users in sector of the organization’s staff (Maskovsky, USA (Broadhead, 1998) and traditional heal- 1998). ers in South Africa (Green, 1994), among many, many others.

15 CHAPTER II

Testing and counselling ing drug users, women) risk reduction was not significantly associated with counselling and testing (Higgins, 1991). In increasing numbers people in industrialized countries are receiving their HIV test results as therapeutic options become available to An updated review of 35 studies conducted more people. Research has shown many rea- by Wolitski et al. in 1997 found similar results sons developing nations should make volun- to those of Higgins et al for some population tary testing and counselling (VTC) accessible groups. The clearest evidence for positive to their populations (UNAIDS, 1998). Early behavioural effects of HIV VTC has been het- detection of the virus enables referral for clin- erosexual sero-discordant couples where HIV ical care and psychosocial support. Ethically counselling and testing was a significant moti- people have a right to know their serostatus vating factor to risk reduction. Studies of in order to protect themselves and others. MSM have also indicated significant risk And knowing their own serostatus and the reduction but it was not clearly related to their options can motivate people to change high- testing for HIV. Yet a UNAIDS report notes er risk behaviours (De Zoysa, 1995). In addi- that among a sample of HIV-infected homo- tion, De Zoysa notes that HIV testing and sexual men in Norway the number of sex part- counselling may have an important social ners decreased from an average of 4.3 a year impact through people knowing their serosta- before to 1.6 after counselling and testing tus sharing it with others and laying the (UNAIDS, 1998). In HIV serodiscordant cou- groundwork for changes in social norms ples a consistent reduction in sexual risk prac- about HIV and AIDS. A positive HIV result has tices followed HIV testing and counselling. also encouraged some people to give per- Similarly, in most injecting drug users studies, sonal testimonies in community fora, a conse- counselling and testing proved to be benefi- quence that can have a powerful effect on cial in reducing dangerous sexual practices individual attitudes, behaviours and social (Wolitski, 1997). Across populations, individu- norms. In cultural contexts where fertility is als who learn they are HIV positive have been highly valued, testing and counselling profound to be more likely to change behaviour vides an important behavioural-change alter- than those who learn they are HIV negative. native to consistent condom use. More recently a randomized controlled trial in The theoretical foundation on which interven- 3 developing countries (Kenya, Tanzania and tions providing testing and counselling are Trinidad and Tobago) showed that couples built principally involves the stages of change receiving counselling and testing reduced model (De Zoysa, 1995). HIV testing and unprotected intercourse among their spous- counselling may promote progression across es, especially among serodiscordant and the continuum of the stages of change. For seropositive concordant couples (Coates, example, in rural southwestern Uganda, a 1998a). However, results specifically found setting with high HIV prevalence, the majority that VTC produced significant changes in of respondents in a research study reported reducing high-risk sexual practices with non- that they had already made behavioural primary partners (Coates, 1998). changes because of AIDS, but making further changes to protect themselves was contin- In the USA, a randomized controlled trial eval- gent on knowing their HIV serostatus uating HIV post-test prevention counselling (Bunnell, 1996). It has thus been suggested was conducted in 5 STD clinics comparing 3 that counselling promotes risk reduction arms: (1) HIV education including 2 sessions through increasing perception of risk, self-effi- with brief HIV/STD messages, (2) HIV preven- cacy and personal skills, and through reinforc- tion counselling, 2 sessions aimed at increasing social norms or responsibility (De Zoysa, ing risk perception, (3) enhanced counselling, 1995). 4 sessions based on theoretical constructs of behavioural change; self efficacy and per- In 1991, in an extensive review of 50 testing ceived norms, over a 12-month period. They and counselling studies in Africa, Australia, found marked changes in condom use with Europe and North America, Higgins et al both main and other partners across arms of found substantial risk reduction only among the study (Kamb, 1996). After 12 months, heterosexual couples with one infected part- there were 19% fewer new STD cases in the ner. In other groups (homosexual men, inject- brief counselling group, and 22% fewer in the

16 CHAPTER II enhanced counselling group, compared with (B) COMMUNITY-LEVEL the group that had received only educational INTERVENTIONS messages (Kamb, 1998). These findings support other studies showing benefits of client Community-level approaches grew out of the centered counselling combined with HIV test realization that, despite the considerable risk results. reduction through individual-level behavioural change approaches, different approaches Other, non-randomized studies in Rwanda, were needed as well. Social epidemiology, Uganda, Kenya and Zaire reported VTC to be pointing to differences in prevalence among a motivating factor especially for couples to different social categories within a given risk change behaviour (Allen, 1992; Campbell, category in a community suggested interven- 1997; Choi, 1994; Alwano-Edyegu, 1996). ing along these lines (Friedman, 1997). The The AIDS Support Organization (TASO) pro- programmes in this section encompass the vides counselling and support services to a most widely publicized approaches to com- variety of clients with AIDS in urban and rural munity level HIV prevention including: inter- Uganda. In an overall evaluation of TASO, it ventions based on social influence and social was noted that 90% of all clients had revealed networks, outreach programmes, school- their HIV status to somebody following TASO based programmes, condom promotion and services. In contrast, a study in the Gambia social marketing, community organizing and showed no effect of individual post-test coun- empowerment and policy level interventions. selling on condom use among prostitutes Each of these types of interventions either try who already had high rates of condom use to reduce individual vulnerability to or trans- before the intervention (Pickering, 1993). missibility of HIV, change community norms, limit dispersal of high seroprevalence net- Wolitski sums up by noting that “there is no works or change community organizational question that HIV VTC can and does motivate structures making them less dangerous behavioural change in some individuals”, but (Friedman, 1997). Changing community cul- also that VTC alone does not always lead to tures or community norms provides motiva- changes and does not have the same effect in tion and reinforcement for individual HIV risk all populations and in different situations reduction. Many of the following programmes (Wolitski, 1997). As with most other approach- use ideas from the theory of reasoned action, es, the stage of the epidemic and surround- the diffusion of innovations model and the ing contextual factors will contribute to the theory of social influence to mobilize peer outcome of the intervention. In addition, the pressure or to ostracize individuals who con- quality of the counselling provided is a key tinue high-risk practices. Policy level changes variable in predicting the impact of the inter- such as closing of bathhouses and enforcing vention. condom use in brothels also account for significant impact in community risk practices.

Conclusion Social influence and social network interventions After years of experience with HIV prevention and the variety of interventions aimed at indi- Based on the theories of social influence, dif- vidual behavioural change tested in diverse fusion of innovation, reasoned action and situations, certain characteristics of successful social cognitive theory, these interventions programmes point to key elements of use peers and social networks to disseminate approaches to behavioural change pro- information. Social influence interventions grammes. These elements include: increasing identify key persons in communities who are participants ability to communicate effective- capable of influencing others. The social cog- ly about sex; helping participants increase nitive theory posits that trusted role models their condom use skills; personalizing risk, are an important factor in the environment achieving participants perception of risk and the environment has a reciprocal relation- avoidance as an accepted social norm, pro- ship both with behaviour and the individual. viding reinforcement and support for sustain- In the theory of reasoned action, perceptions ing risk reduction. For individual level inter- of social norms have a critical influence on ventions to be successful, context specific behaviour. Social norms created by opinion information and skills are critical. leaders will ideally have a strong effect on behaviour. Diffusion of innovation theory

17 CHAPTER II

asserts that changing behaviour will more Sikkema et al. tested a comparable approach likely happen if the new behaviour is compat- with women living in urban, low-income hous- ible with accepted social norms of a specific ing developments. The intervention included social network, is simple to do, and has outreach, small groups and community activi- observable outcomes (Kalichman, 1998). ties to encourage social norms supportive of One’s social network can be a source of emo- safer-sex as well as reduction of individual tional and instrumental support and a refer- high-risk behaviour (Kalichman, 1998). ence that establishes social norms. Women who were identified as opinion leaders participated in a 4-session skills-building Research implemented using peer educators intervention centered on HIV prevention to influence social networks in gay communi- knowledge and behaviour. These women ties showed significant self-reported changes recruited other women who participated in in safer sex practices after intervention the same intervention and the cycle contin- (Auerbach, 1994). Encouraging results in ued until about half the women in the housing changing social norms and safer sex behav- development were reached. At the same iour have also been noted in a number of time, social norm-changing events were community-level social influence interven- being implemented. Results of this random- tions in the USA. One programme imple- ized controlled trial found that condom use mented among men frequenting gay bars in reported by women in the intervention site three Southern cities began by identifying increased from 29% at baseline to 41% at 3- and recruiting opinion leaders. Project staff month follow-up (Kalichman, 1998). then trained leaders in risk-reduction, and the final stage involved opinion leaders in dis- seminating prevention messages to friends The National AIDS Demonstration Research and other members of their social networks Projects implemented in more than 60 sites in (Kalichman 1998, Kelly, 1992). In a later study the USA to evaluate strategies among IDUs, using the same methods, researchers used a combined research methodologies but randomized experimental design with four focused on the social networks of IDUs as the test and four control cities and showed a primary target group. The Indigenous Leader decrease in population-level rates of risk Outreach Intervention Model which combines behaviour after one year (Kelly, 1997). medical epidemiology and community ethnography guided the project. Former IDUs The Mpowerment project was similar to the were employed as outreach workers whose above studies but focused on young gay men job was to identify and access the social net- in a midsize urban community in the USA, and work, document the norms, values and situa- included in the intervention package a public- tional factors relating to risk practices. Former ity campaign and small group sessions con- IDUs were also responsible for delivering the centrating on individual behavioural change HIV prevention services. After a four-year (Kegeles, 1996). In the test city, there was a intervention, incidence of HIV decreased from 26% reduction in unprotected anal inter- 8.4 to 2.4 per 100 person years. Sex risk prac- course compared to 3% in the control city. A tices decreased less dramatically than drug follow-up study examined the effectiveness of risk, but went from 71% to 45% (Wiebel, the different programme components (small 1996). The same model was tested among groups, social events, and outreach) on post- sex workers in Indonesia with encouraging intervention sexual risk-taking. The small results (Gordon, 1998). groups had a large effect size, but reached substantially fewer men than social events and outreach. Although not as powerful, the Interpreting these results for social influence social events and outreach were critical to the interventions indicates that multi-component, effectiveness of the programme as sources of individual and community level that combine recruitment to the small groups and as a cognitive-behavioural and norm-changing means of reaching men not interested in activities can result in positive changes for attending small groups. Authors concluded MSM and heterosexual women. Despite the that the effectiveness of programme compo- fact that all published reports described here nents were not independent; the synergy cre- were based on interventions in the USA, since ated by the whole programme makes the net they are based on conversations with peers effect of the intervention activities greater one could assume that they would be ideal for than the sum of its parts (Kegeles, 1998a). other populations (even non-literate) as well.

18 CHAPTER II

Interventions using outreach as a strategy Outreach interventions have been carefully tested in the USA among diverse populations and have shown encour- Outreach interventions are conceptualized in aging results. This approach lends itself as a similar manner to social influence interven- well to hard-to-reach populations and has tions in that they use individuals to pass on been used in many parts of the world though information within social networks, however randomized controlled trials have not been the influential person may or may not be from reported outside the USA. the targeted community. The outreach worker enters the social system to instigate behavioural change as an individual change agent. Targeted communities are often hard-to- School-based interventions reach groups such as drug users, sex partners of drug users, sex workers as well as isolated By the early 1990s, school-based pro- rural populations. The aims of outreach have grammes for HIV education existed in about often been harm reduction strategies such as three quarters of industrialized countries and providing condoms to sex workers, but not 60% of developing countries according to a necessarily addressing sex work itself. survey of 38 countries (Cohen, 1992). Besides interventions that simply provide basic AIDS information in the classroom, multi-dimen- Three large-scale research trials in the USA sional school-based programmes generally examined the effects of outreach delivered include classroom skills-building sessions, primarily to injecting drug users. The National school-wide peer-led activities, and social AIDS Demonstration Research Projects tar- norm changing programmes. Promotion of geted over 36,000 out-of treatment injecting condom use was the theme most frequently drug users. Results indicated that sexual prac- adopted in programmes for youth in and out tices were much more difficult to change than of school (Cohen, 1992). An extensive review sharing of drug using equipment. The pro- of school-based interventions revealed that jects did show reductions in sex risk practices, no comprehensive school-based HIV-preven- but less dramatically than for drug risk prac- tion interventions evaluated showed signs of tices (Wiebel, 1996). promoting sexual acting out or hastening the onset of sexual intercourse (UNAIDS, 1997). It A second initiative entitled the AIDS was found that effective interventions had a Evaluation of Street Outreach Projects sup- number of characteristics in common: ported by the CDC was conducted in six US cities, and showed promising outcomes as • accurate information was provided about well as being cost-effective. Again, this pro- the risks involved in unprotected sex, ject found drug using behaviour easier to enabling informed behavioural decision change than sexual behaviour. A third out- making reach project (AIDS Community • programmes included skills building ses- Demonstration Projects) was implemented in sions enhancing self-efficacy for safer-sex five US cities and had multiple target groups negotiating practices including: IDUs and their partners, MSM, • components were often based on social female sex workers, street youth and men cognitive theory including modeling of who have sex with men but do not identify as safer behaviours (Kirby, 1994) gay. The health belief model, social cognitive theory, the theory of reasoned action and the • activities were conducted in small groups transtheoretical stages of change model guid- or had a minimum of 14 hours of contact ed the outreach intervention. Following for- • opportunities for youth to personalize mative research, volunteer outreach workers information were provided implemented the intervention, by disseminat- • social pressures to engage in sex were ing innovative, carefully designed materials addressed with strategies for resisting and messages. The evaluation indicated that peer pressure the communities moved across the continu- • reinforced supportive group norms and um of stages of change following the inter- appropriate individual values for engag- vention. A dose-response effect was noted ing in safer behaviour were emphasized according to exposure to the intervention • extensive training was provided for teach- materials (Guenther-Grey, 1996, Kalichman, ers and/or peers who were to implement 1998) the training.

19 CHAPTER II

The element distinguishing school-based pro- which necessitates asking the consumer grammes from other interventions for youth always and often about his or her point of was the supportive structural aspect played view. Modifying products requires a good by schools and teachers, and the interaction understanding of the culture of the target between school, parents, students and com- group. Availing condoms at non-traditional munity (Peersman, 1998, Kalichman, 1998). outlets such as truck stops, bars, and hotels is integral to social marketing success. Flooding these non-traditional outlets with condoms Condom promotion and social aims not only to increase availability but also marketing to increase social acceptability (World Bank, 1997). It has now been proven numerous times that correct use of condoms is an effective method Results of these programmes have shown dra- of preventing HIV transmission. Yet, countless matic increases in condom sales in countries, research studies have identified obstacles to such as Côte d’Ivoire, Uganda, and Malaysia their use in settings throughout the world, where condoms were practically unavailable including inaccessibility and partner commu- before social marketing campaigns (World nication among other factors. Bank, 1997). After a 3-year peer-led condom promotion programme among sex workers in Most initial HIV prevention programmes West Bengal, India, found that condom use included condom promotion and free distrib- rates rose from 3% to 81%, a social marketing ution as part of a comprehensive HIV preven- campaign was launched. Six months into the tion package. Free distribution was essential- project using peer education and community ly aimed at introducing condoms where they participation, free distribution of condoms were not previously available or distributing had decreased by 50% and the same amount them to destitute populations at high risk of condoms had been sold (Banerjee, 1998). such as sex workers and refugees. Although Social marketing programmes have also been this approach accomplished its intended out- developed in Mexico, Dominican Republic, come of making condoms accessible without Canada, Brazil, Vietnam, Pakistan, Zambia, delay to large populations, the lack of sus- Botswana, Cameroon, South Africa and Haiti tainability and reliability of free condom dis- for HIV prevention (Holtgrave, 1997, PSI, tribution programmes commanded the intro- 1998). Evaluations have shown success in duction of condom social marketing strate- increasing condom use especially among gies especially aimed at certain populations. adolescents in Zambia and among married women in small urban areas in Pakistan (PSI, Condom social marketing, which may well be 1998). the most developed of public health communication approaches, aims to remove the bar- Besides condom promotion, social marketing riers to condom use by using commercial techniques have also been effective for other marketing techniques such as advertising and HIV prevention strategies such as promotion packaging to make the product accessible, of testing and counselling for adolescents in affordable and attractive to all types of peo- the USA (Futterman, 1998), and the recruit- ple. The theories underlying social marketing ment of research participants in Puerto Rico programmes derive from many different disci- (Torres-Burges, 1998). plines including operant conditioning and social cognitive theories as well as economic and marketing principles. Social marketing Community organizing, empower- has been termed a ‘strategic planning’ ment and participatory action approach based on the theoretical ‘principal research of exchange’ which explains that people will only change their behaviour to something Empowerment approaches are built on the less pleasant (like condom use) if they per- premise that positive public health impact is ceive an adequate benefit (Kennedy, person- fostered by recognizing the relationship al communication). Social marketing tech- between social structure and health, and by niques highlight the importance of adapting recognizing that lasting change is a process the campaign to suit the characteristics of the that initiates from within a community. population group being targeted. It dedi- Empowerment in connection with HIV in the cates sufficient time to formative research, USA has its historical roots in public health

20 CHAPTER II

and community psychology (Beeker, 1998). men; the physical environment by including From the field of education, Wallerstein access to appropriate services and materials defined empowerment as: such as battered women’s shelters and both male and female condoms; the structural “Empowerment education, as developed environment such as opportunities for women from Paulo Freire’s writings, involves peo- to change their economic status; and the pol- ple in group efforts to identify their prob- icy/legal environment such as businesses pro- lems, to critically assess social and histori- viding paid leave for community service and cal roots of problems, to envision a child care (Beeker, 1998). healthier society, and to develop strategies to overcome obstacles in achieving Community participation at all levels of imple- their goals. Through community participa- mentation is an integral aspect of community tion, people develop new beliefs in their empowerment approaches. Interventions ability to influence their personal and include community organizing, and participa- social spheres. An empowering health tory action research (PAR) into their pro- education effort therefore involves much grammes (Israel, 1994, Hiebert, 1998). A more than improving self-esteem, self- strength of PAR resides in the ability of partic- efficacy or other health behaviours that ipants in conjunction with committed and cre- are independent from environmental or ative professionals to adapt methods and community change; the targets are indi- content to diverse contexts. The positive out- vidual, group and structural change. comes of PAR arise from its collaborative, Empowerment embodies a broad process trust-building capacity, with direct community that encompasses prevention as well as input that responds to emerging changes in other goals of community connectedness, social, political and economic situations self-development, improved quality of (Stevens, 1998). These interventions seek to life, and social justice.” (Wallerstein, 1988) support communities to be self-determining in their ability to integrate HIV programmes Beeker suggests a definition of an empower- into existing community structures by assessment intervention as follows: ing their own needs and priorities, defining, implementing and evaluating their own work1. “A community empowerment intervention seeks to effect community-wide Empowerment approaches have been used change in health-related behaviours by for AIDS risk reduction through numerous dif- organizing communities to define their ferent strategies and in countless different health problems, to identify the determi- settings and contexts. The literature describes nants of those problems and to engage in empowerment interventions directed at effective individual and collective action women, young gay men, youth, people with to change those determinants.” (Beeker, HIV and AIDS as well as many other commu- 1998). nities at risk. Empowerment approaches assume that health behaviours are not completely under A CDC-funded intervention developed for volitional control of individuals, thus are not young, pregnant women from low income entirely isolated events, but embedded with- communities in the USA, randomly assigned in social, cultural and economic surroundings. women to one of three arms (four sessions AIDS prevention, 4 sessions health promo- The impact of society’s defined gender roles tion, control). The HIV prevention arm on protective health behaviour of women focused on enhancing women’s skills in nego- highlights the importance of empowerment tiating condom use with their partners using approaches, especially for HIV-vulnerable role-play and rehearsal, among other meth- women. Beeker describes ideally what the ods. Consistent with empowerment ideals, components of an intervention based on the content included other health matters in community empowerment for women would addition to HIV prevention and activities were look like. The intervention would address the developed to encourage a feeling of ‘com- cultural environment by recognizing gender munal mindedness’ in the group. The idea roles that define women as subordinate to was to promote mutual support in the process

1 See Israel et al., 1994 or IUCN, 1997 for complete definitions and examples of participatory action research.

21 CHAPTER II

of behavioural change. Results indicated that health issues (Beeker, 1998). Although tools women in the HIV prevention group showed for measurement of single and multi-level greater changes in intention and practice of (from personal to community level) empower- safer sexual behaviours than women in other ment have been developed and tested, they groups (Beeker, 1998). Comments by authors have not yet been used on a wide scale of the report concluded that women in the (Israel, 1994). HIV prevention group gained a sense of perceived control over their lives. Policy level interventions

An intervention using PAR among lesbian Policy level interventions are ‘enabling’ women highlighted the power of community approaches that attempt to remove structural ownership of the project and its continuity barriers at a larger level. Many believe that over time that provided a space for engage- AIDS interventions are moving from solely ment and commitment where women focused investigating individual approaches to multi- on community mores, values, and social dimensional models of community mobiliza- expectations about sexual relating, drug use tion, empowerment and structural policy level and HIV. The feeling of solidarity with peer interventions (Beeker 1998, Parker 1996). educators enabled women to reduce risk behaviours (Stevens, 1998). The earliest and some of the most effective efforts of community level change for HIV Empowerment can have far-reaching positive have resulted from social action. ACTUP, health and welfare benefits. Schuler et al. formed in 1987 in New York, is responsible for describes the impact of involving women in many successful policy initiatives for people credit programmes on contraceptive use. She living with HIV and AIDS as well as advocating found that, in Bangladesh, rural credit pro- for everyone’s responsibility to practise safer grammes for women can play an important sex. role in changing fertility norms and accelerat- ing contraceptive use by strengthening Another widely recognized policy level inter- women’s economic positions and fostering vention is the 100% Condom Programme in women’s empowerment (Schuler, 1994). Thailand that mandated condom use in brothels and during other commercial sex encoun- Other empowerment interventions for sex ters. Components of the programme included workers include a project in Zambia, where a requirement that sex workers use condoms women fish traders who often experience sex- with all clients, that condom use be moni- ual exploitation have been supported in form- tored, that brothel owners and managers ing economic cooperatives as a way of pro- assist in promoting condom use with uncoop- tecting themselves against HIV. A second erative clients and that there should be sanc- example is a programme in India where tions against brothel owners for non-compli- women have been taught how to collectively ance (Aggleton, 1996). The programme save sufficient savings to pay bonds binding showed a dramatic increase in self-reported them to sex work (Aggleton, 1998, Tawil, condom use during commercial sex acts (14% 1995). to 90%), a decline in reported STD attendees in government clinics, and a decline of HIV Importantly, Beeker reminds us that empow- positive army conscripts (Friedman, 1997). erment approaches do not strive to substitute Success of the programme has been attrib- for individual psychosocial interventions, but uted to the fact that it was based on harm to ‘widen the lens to include person-in-envi- reduction in a population at very high risk. It ronment’ approaches. She notes that there is did not try to eliminate the brothels but increased commitment to community partici- attempted to reduce HIV transmission within pation, but that there remains a difficultly sur- them, and it used national policy which mountable gap between empowerment ensured a broad and lasting effort (Friedman, rhetoric and practice. For that gap to be 1997). bridged, one key element is progress in oper- ationalizing new concepts and constructs, and Conclusion testing hypothesized relationships between, for example, community participation and HIV prevention at the community level is an community capacity to effectively address integral component to check further spread of

22 CHAPTER II

HIV. By working with communities, in contrast to individuals, one is focusing on changing policy, social structures, social norms and cultural practices that surround individual risk behaviours. Community level changes working at the level of changing subcultures have potential to effect long-term maintenance of changed behaviours, by changing the environment surrounding individuals to support safer behaviours. At the same time, many of these approaches highlight the importance of participatory methods to include and empower individuals. It is important to note that many of the interventions mentioned above may have initially focused on one level (such as policy, or empowering individuals), but as the programmes developed they generally include more target levels including changing local cultures and subcultures (Friedman, 1997). Programmes discussed here have been the most widely publicized approaches to community level HIV prevention yet many more innovative projects exist worldwide.

Finally, development of methods for implementation and evaluation of community-level programmes has not been operationalized on a broad spectrum. Assessing effectiveness of these programmes introduces a number of challenging issues such as measuring community level changes using the community as the level of analysis rather than the individual. Additionally, identifying elements of the intervention to measure, thus defining new community level indicators and obtaining large enough sample sizes to detect significance add new challenges to community level evaluation. This makes design of such programmes and the ability to carry them out possibly more complex than individual-based programmes.

23 CHAPTER III

EXAMPLES OF THE group, community-wide, media, HIV counselling and testing, individual counselling, IMPACT OF THEORY- classroom education and laboratory experi- ment. Community-wide (12 out of 14) and DRIVEN INTERVEN- small group interventions (13 out of 19) were TIONS more likely to show significant results. Interestingly, Ickovics’ review noted that higher intensity (5 or more sessions) were less effective than low-intensity small-group programmes for women. Authors suggested this Theoretic models that have proven useful in may reflect the more resistant population tar- explaining and predicting changes in HIV- geted. Several international programmes related sexual behaviour provide guidance in incorporated peer-led diffusion of innovations the design and implementation of prevention approaches and all reported statistically sig- programmes (Wingood, 1996). Reviews of nificant increases in condom use (6 studies theory-driven interventions have noted that out of 6). According to this review, less effec- these interventions emphasize both intraper- tive interventions for women overall were sonal and interpersonal factors, provide skills individual counselling (0 out of 4) and HIV training, try to modify social norms and are testing and counselling (3 out of 6) as primary thus more effective at reducing risk behaviour prevention. Testing and counselling and indi- among participants (DiClemente, 1995). (See vidual counselling, however, have shown Table 3.) effectiveness as secondary prevention with serodiscordant couples (Ickovics, 1998). This section summarizes positive outcomes of theory-based interventions by specific popu- A review of randomized controlled trials in the lation groups, including women, men, and USA conducted by Wingood and DiClemente youth. Although injecting drug users fit into found that all effective interventions for any of the above categories, we have placed women had a number of identifiable charac- them in their own group as interventions tar- teristics. In contrast to the review by Ickovics, get them specifically. the four studies mentioned were guided by the social cognitive theory (a theory based on (A) WOMEN the individual, taking into account environmental and behavioural factors, which places A review of 51 reports through 1997 on stud- a strong emphasis on self-efficacy) provided ies worldwide noted the lack of interventions skills in condom use and sexual communica- identifying the mechanisms of preventive tion and emphasized support for continued effects and theoretical frameworks upon maintenance of safer sexual behaviour. In which interventions are built (Ickovics, 1998). addition, all effective interventions were peer- This review found differences in effectiveness led and addressed gender-related influences between target populations and between dif- such as gender-based power imbalances ferent types of interventions. Interventions within the relationship (Wingood, 1996). targeting sex workers were the most likely to find increased condom use, decreased inci- Generally, successful skills training interven- dence of STDs, and reduction in unprotected tions for women consider cultural factors and intercourse (9 out of 10 studies). Effectiveness attempt to personalize messages (Kalichman, for other groups at risk was more varied: 13 1997). Targeting women in the USA, and ado- out of 18 studies of African-American or lescents in the USA and Holland with behav- Latino descent women were effective, as were ioural skills enhancement programmes have 3 out of 10 studies for IDUs, 1 out of 3 for produced positive effects (Kalichman, 1997). partners of IDUs, 2 out of 3 for STD clinic Studies among women in the USA have gen- patients, 4 out of 7 for US college students, erally included four to five sessions and and 6 out of 14 studies for mixed gender demonstrated positive outcomes with medi- community groups (Ickovics, 1998). um-sized effects. Condom use has increased up to double the rate at baseline. Specific Ickovics et al. identified seven types of inter- components of behavioural skills enhance- ventions tried among women globally: small ment that have been tested comprised of: risk

24 CHAPTER III

education and sensitization, condom use and advantaged, women in the USA and found safer sex skills training, and sexual communi- that 6 variables representing the four impor- cation skills training (Kalichman, 1998). tant constructs of the model were associated Kalichman notes that behavioural skills with consistent condom use (Kline, 1994). The enhancement training has not been tested strongest predictor of condom use was per- experimentally outside the USA, so it is ceived self-efficacy in influencing the partner’s unclear to what extent it would benefit sexual behaviour, yet no significant relation- women in other countries. ship between condom use and general self- efficacy was detected. The two other partner- An intervention among women in a New York related variables associated with condom use City housing project was based on the diffu- were his seronegativity and his not wanting sion of innovation theory in combination with more children. The respondents’ reproductive community mobilization. Women were intentions were not significantly associated recruited, organized and trained to help with condom use. The three variables that develop role model stories for the project were negatively related to condom use were: newsletters. These women were also expect- having a conflictual relationship with primary ed to initiate discussions with their peers partner, believing that condoms reduce sexu- regarding HIV prevention. Information was al pleasure; and the use of drugs or alcohol in diffused rapidly and seemed to promote dis- the previous four weeks. cussion and condom use among the housing project women. Reported condom use of With regards to the health belief model, female sex partners within the housing pro- among heterosexual adults in Holland barriers ject for IDUs rose from 15% to 45% to condom use, such as reduced pleasure of (Friedman, 1997). sex, were predictive but cues to action were not related to condom use intentions (Buunk, The theory of gender and power provided a 1998). The perception that most others in the model for the design of a successful gender- reference group would engage in condom appropriate social skills intervention for use with new sexual partners was an impor- African American women in San Francisco. tant predictor of condom use intentions and The intervention addressed how to success- emphasizes the importance of the social envi- fully negotiate safer sex and improve partner ronment with respect to AIDS protective norms favorable to consistent condom use in behaviour. comparison to a control group that received similar training in a delayed fashion. The Again internationally, an intervention guided results showed significantly greater consistent by the social cognitive theory and community condom use, greater sexual self-control, health promotion implemented in North-east- greater sexual assertiveness, and increased ern Thailand targeting village women was partners’ adoption of norms supporting con- evaluated using surveys, focus group discus- sistent condom use in the intervention group sions and village meetings. Elicitation (DiClemente, 1995). research identified the importance of including entire villages in the intervention rather The stages of change model was used to than women alone. The evaluation found that guide a 6-month longitudinal study among eight of the nine outcome goals were women in drug treatment, housing shelters, achieved with significant increases in married and hospital clinics in the USA, and showed women taking the initiative in reducing the that women exposed to individual stage-tai- risk posed to them by the sexual activities of lored counselling were twice as likely to their husbands (Elkins, 1997). Specific mea- report consistent condom use with main part- sures taken by women included negotiating ner ‘at last sex contact’ as women receiving condom use with their husbands, and telling free on-site reproductive health counselling their husbands not to visit prostitutes. Men and services (Galavotti 1998). The stage- surveyed, however, did not change their con- based counselling also proved useful at pre- dom use behaviour (Elkins, 1997). venting relapse from consistent use further along in the process of change. One of the rare studies designed to identify the independent effects of intervention com- One study assessed the AIDS Risk Reduction ponents on behavioural outcomes was con- Model (ARRM) with HIV-positive, largely dis- ducted among African American women from

25 CHAPTER III

an inner city US community. Women were ran- and indicated that the four groups of women domly assigned to one of the following: (1) had different levels of knowledge about AIDS, sexual communication skills training, (2) self- different socioeconomic levels, different num- management skills training, (3) combination bers of clients and different self-efficacy. of sexual communication and self-manage- Beliefs about the benefits of condoms were ment skills training, (4) HIV education and risk highly predictive of condom use in 3 of the 4 sensitization. The study found that all four groups. In the group with lower knowledge intervention conditions increased AIDS about AIDS, perceived susceptibility to other knowledge and intentions to reduce risk STDs, rather than HIV, was related to condom behaviours. Communication skills training use. Self-efficacy was highly predictive of con- produced higher rates of risk-reduction dis- dom use in 3 out of 4 of the groups of sex cussions, but combined skills training and workers. In the fourth group self-efficacy was sexual communication resulted in the lowest already high as this group of sex workers do rates of unprotected sexual intercourse at fol- not rely on pimps and contact clients inde- low-up. Authors concluded that a combina- pendently. Authors highlight that sex work is tion of behavioural skills training and commu- a complex business that includes multiple nication is the most effective for reducing risk sub-populations and distinct settings (Ford, among vulnerable women in the USA 1998). These diverse realities must be consid- (Kalichman, 1998). ered in intervention design and implementation.

Sex workers Conclusion Among the numerous studies involving sex workers, only two will be highlighted here. A Interventions targeting women have lagged year-long intervention targeting sex workers, behind those of men historically. Women brothel owners and clients in Thailand used were left out of prevention efforts early in the multiple small group sessions with peer edu- AIDS epidemic especially in Europe and the cators who were experienced women and US. Today, considering gender, relationship were called ‘superstars’. The ‘model brothel’ and contextual issues as central to decisions aspect of the programme worked with owners regarding sexual behaviour were universally to enforce mandatory condom use by sex important for the success of the interventions workers, and clients were educated to use discussed above. Thus using gender-driven condoms. Volunteers were trained to pose as theory across cultures might prove useful as clients to test sex workers’ condom negotia- sexual encounters in some situations can be tion skills. Results indicated that sex workers imposed and gender roles as well as cultural increased their refusal of sex without a con- values and norms sometimes define, or at the dom rate from 42% before the intervention to least, influence sexual behaviour (Amaro, 92% following the programme. The authors 1995). One international review found that concluded that this multifaceted approach peer-led community interventions guided by specifically focusing in sex workers, and the diffusion of innovation theory were more acknowledging the importance of working successful overall than individual level inter- with clients and owners was critical to their ventions. Skills training especially in condom success (Visrutaratna, 1995). use and sexual communication, and perception of risk were important variables among A second study that mentioned the theoreti- women in US studies. As with other popula- cal background and its usefulness for sex tions, interventions facilitated by peers were workers noted the utility of health belief often more successful than those using a facil- model and social cognitive theory. One study itator from outside the target group as peers guided by these two models worked with four can often target more appropriate, context groups of female sex workers in Indonesia specific methods for risk reduction. and found that both increases in knowledge and condom use were significantly related to Only one study, guided by the AIDS risk the number of intervention sessions the reduction model, reviewed here looked women attended (Ford, 1998). Results reflect- specifically at HIV-infected women and found ed the different social context of sexual that factors related to her sexual partner were behaviour of the four groups of sex workers more influential than many personal variables.

26 CHAPTER III

Interventions with female sex workers often rates of unprotected intercourse, with the used the health belief model and the social strongest effects among Chinese and Filipino- cognitive theory with significant results in American men (Choi, 1996). diverse settings worldwide. Successful programmes often realized the importance of In a third study using group intervention including brothel owners and clients in their approach among African American men, activities, thus considering the wider environ- components included: (1) discussions on mental factors associated with the behaviour- being Black and gay or bisexual, building al practices involved. The sex worker study social support, and large-group discussion of conducted in Indonesia highlighted the AIDS misperceptions among Black men, (2) importance of considering diversity among enhancing positive feelings about safer sex, what is often generically termed a ‘sex work- practice of condom application skills, devel- er’ population. By using a theory driven inter- oping plans to use condoms, and (3) dealing vention, investigators were able to identify with issues of partner resistance, analysing critical differences in predictive constructs one’s own hurdles to staying safer, problem- between different sex worker groups. solving safer-sex alternatives, role play exer- cises, maintenance of safer sex, and establishing social norms for safer sex. Participants (B) MEN were randomly assigned to either a single session, a triple session or a wait-list control group. Results indicated that men in the Men having sex with men (MSM) triple-session intervention group significantly reduced unprotected anal intercourse after 12 A recent review of interventions with gay men months of follow-up (Peterson, 1996). found that studies generally fall into 3 types: individually based, small-group and commu- Controlled studies with men who have sex nity-level (Kegeles, 1998). At the individual with men (MSM) have indicated several char- level, the review noted one unique study that acteristics that have enabled men to change randomly assigned men to one of 3 groups: behaviour and maintain safer sex: (1) standard group that analysed HIV-prevention posters, (2) self-justification group that was asked to recall, as vividly as possible, an • eroticizing safer sex materials occasion where they had unsafe sex and then • brief training on establishing and main- justify according to a pre-determined scale, taining safer sex relationships and (3) control group received no interven- • how to negotiate safer sex tion. After 2 months, the self-justification • training on how to reduce stress group was significantly less likely to report • intensive group counselling (Auerbach, unsafe sex than the other 2 groups (Gold, 1994) 1995). Behavioural skills-enhancement interventions One randomized controlled HIV-prevention targeting MSM in diverse cultural settings study in the USA using the small-group have consistently demonstrated increased approach, used a 12-week intervention with 3 condom use during anal intercourse, with the booster sessions among 104 men random- greatest changes occurring with non-primary ized to either receive, (1) the HIV risk-reduc- partners (Kalichman, 1997). tion intervention or (2) a waiting list control group. The four main areas covered in the The diffusion theory has been shown to be intervention were HIV risk education, behav- effective in changing sexual behaviour of men ioural skills training, sexual assertiveness train- who have sex with men of different studies in ing and lifestyle changes for relapse preven- the USA (Kelly, 1991, 1992, Kegeles, 1996). tion. The intervention group showed signifi- The model was tested in 3 small southern cities cant reductions in rates of unprotected anal and results indicated systematic reduction in intercourse and increased rates of condom the population’s high-risk behaviour with 15% use immediately after the intervention, but to 29% reductions from baseline levels (Kelly, 40% relapsed 16 months later (Kelly, 1991). 1992). Kegeles et al. used the diffusion theory Similar intervention components were tested to design an intervention to address determi- among ethnic minority men and were found nants of high risk sex in young gay men in the effective in reducing numbers of partners and USA. The authors identified natural channels of

27 CHAPTER III

communication to highlight sexual risk behav- too optimistic as applying aging results to a iour among the concerns of young gay men dynamic epidemic may not continue to give and to find alcohol and drug-free alternative intended results (Kalichman, 1998). Our environments for them (Coates, 1996). While responses should be evolving as fast as the comparison communities made no significant epidemic changes. More recently innovative changes, intervention communities showed programmes have started aiming at the com- significant changes in unprotected anal inter- munity level rather than the individual. course with primary and non-primary partners Interventions based on the diffusion of inno- (Kegeles 1996). vations theory have shown community level change with gay men in the USA. Most stud- Heterosexual men ies highlight that safer sex is easier with one’s non-primary partner than with one’s primary Within specific populations such as STD clinic partner. attendees, self-efficacy was used to predict risk reduction in two different studies in the Choi points out the limited utility in strictly USA. Unfortunately, there is a dearth of infor- individually-based theories for specific groups mation on behavioural interventions tested at risk such as Asian-Pacific Islander men who among heterosexual men. Kalichman notes have strong cultural demands and community that the behavioural interventions that have stigma against homosexuality. Without con- been tested in randomized controlled trials sidering these powerful contextual influences have not been effective in reducing high-risk on behaviour, interventions cannot expect sexual behaviour (Kalichman, 1997). In one significant results. Peterson describes how randomized controlled trial conducted issues of being an African American MSM among inner-city African American men a were directly addressed in their intervention cognitive-behavioural skills-building interven- along with social support and condom skills. tion was compared with an AIDS educational As with other population groups, the inter- intervention. No significant differences vention must be tailored to suit its population between groups was noted for AIDS related group, that is the group itself should be able knowledge, intention to use condoms or con- to express its needs and priorities for the pro- dom use. Yet, there were some important gramme to be successful. lessons learned from this study. Greater importance should be placed on relevant Despite the impressive results with gay men issues for the specific population. In a popu- in diverse settings, there are few positive find- lation with multiple competing risk practices, ings with heterosexual men in the industrial- a social service programme that can provide ized world. As this group was not seen as vul- AIDS education along with drug treatment nerable early in the epidemic, interventions and job services may be more effective. The concentrated on MSM and IDU populations. other two issues raised by this study were: the STD patients, however have been targeted format of small group discussions was not with mixed results. Two studies in the USA, well received by all men in the study and that guided by the social cognitive theory found cognitive-behavioural skills training pro- increased condom use and one in the UK grammes for HIV risk reduction should not be found no effect on behaviour. In developing assumed to fit all vulnerable populations countries, approaches such as testing and (Kalichman, 1997). Possible reasons suggest- counselling have proven successful at moti- ed by Kalichman were that heterosexual men vating behavioural change among heterosex- may lack a sense of vulnerability for HIV as ual men. Specific population groups, such as they were not identified as engaging in high- farm workers in Zimbabwe were targeted with risk behaviours for HIV as portrayed early in an intervention guided by the social ecologi- the epidemic in the USA (Kalichman, 1998). cal model for health promotion. Conclusion

The first decade of interventions with MSM noted substantial risk reduction with behav- (C) YOUTH ioural theory driven interventions including identifiable characteristics such as eroticizing Globally, most young people have begun sex- safe sex, and improving sexual communica- ual intercourse by the age of 18 or 19 and at tion. Kalichman noted that we should not be least half by the age of 16 (UNAIDS, 1998). In

28 CHAPTER III

the USA about half of all adolescents are esti- teenagers in the US to identify peer and social mated to be sexually active and this percent- pressures that encourage negative health age increases to over 80% in some minority behaviours, to present factual information, groups (Reitman, 1996). Young people teach assertiveness and discuss problem situ- between the ages of 15 and 24 make up the ations. Evaluation results of the programme majority of new HIV infections. Most of them that included 536 students from a low-income live in the developing world, but industrial- population in Atlanta showed that among stu- ized countries also face severe problems. dents who had not had sexual intercourse, USAID has estimated that by the year 2010 those who participated in the programme there will be a total of 41 million orphans who were significantly more likely to continue to have lost their mother or both parents due to postpone sexual activity through the end of HIV/AIDS worldwide (UNAIDS, 1998a). the ninth grade than were similar students who did not participate (Howard, 1990). A Intervention research with young people second carefully implemented intervention shows that the success of the approach guided by social influence theory among US depends heavily on the youth’s level of sexu- middle school students resulted in null find- al experience. Intensive sex education among ings. The authors note inadequate communi- youth that have never had sex has been effec- ty and family-level intervention, possible dilu- tive in delaying onset of intercourse among tion of the messages and perhaps over satu- high school students. ration of students with the programme’s health messages by the 8th grade (Moberg, A comprehensive international review of 110 1998). outcome evaluations with youth (Peersman, 1998) found that effective programmes: In addition one study assessing the use of the health belief model to predict condom use • focused on understanding social and/or among university students in Nigeria found media influences on sexual behaviour to that the major health belief model variables, be able to strengthen group norms including perceived benefits of condom use, against unprotected sex perceived barriers to condom use and cues to • listened to what young people think and action, together with AIDS knowledge and believe to ensure acceptable and appro- male gender, significantly predicted condom priate programmes use (Edem, 1998). • included modeling and practice of communication or negotiation skills Reitman et al. suggest that behavioural con- • integrated pregnancy and STD preven- structs need to target specific behaviours. tion with HIV programmes Their study, guided by the health belief model • focused especially on disadvantaged and the theory of reasoned action, among youth, providing access to resources African American adolescents found that and/or services to address their basic addressing condom use, reduction of the needs (health care, legal aid). number of partners, or the frequency of sexual intercourse all related to different risk reduc- This review also suggested that, although a tion strategies. The adolescents’ positive atti- clear pattern and full understanding are lack- tude toward condoms emerged as the single ing, social learning theories have a greater strongest correlate of actual condom use. potential than other theoretical frameworks in changing youth behaviour. Other cross-sec- Although multiple-session interventions have tional surveys found that the theory of rea- shown effectiveness, one project targeting soned action and the health belief model as African American adolescents demonstrated well as the social learning theory can help that a single-session workshop focusing on understand behaviour of young people. All cognitive behavioural skills training produced successful, theory-based interventions have significant increases in HIV-related knowl- included skills training in addition to informa- edge, reductions in risk promoting beliefs, tion and motivational components for young and lower frequencies of high-risk sexual people (Reitman, 1996). behaviours (Jemmott, 1992).

Howard and McCabe showed success of the One of the few studies that tested theoretical social influence theory using slightly older constructs in a manner that could delineate

29 CHAPTER III

mediators of change was a single-session In a recent review of 19 interventions primari- intervention among US college students to ly in the USA targeting injecting drug users promote STD prevention. Researchers used (IDU), authors found that interventions com- regression analyses to show that changes in prised of: perceived benefits of condom use, acceptance of sexuality, sexual control, attitudes • individual counselling toward condoms, and self-efficacy for con- • HIV testing and counselling dom use were linked to behavioural intentions to use condoms. The authors concluded • group interventions that the mechanisms for change in their inter- • street outreach vention were affective attitudes toward con- • social interventions (Gibson, 1998). doms and condom users, as well as self-efficacy for condom use (Kalichman, 1998). In controlled studies, greater impact on behaviour was shown through intense and Conclusion sustained interventions compared with their comparison conditions. In addition, partici- Together, the results of these studies suggest pants in successful interventions appeared to that constructs subsumed in behavioural the- be more stable and better motivated than ory have greatly enhanced our understanding their counterparts who were a more hetero- of risk behaviour among youth in varied set- geneous group at different stages of behav- tings and situations. The social influences the- ioural change. The latter finding suggests that ory was also useful in one study but a second future interventions should target subgroups study using the same theory showed null find- according to risk (Gibson, 1998). As substan- ings. Skills training, attitudes, norms and self- tial to dramatic behavioural change resulted efficacy have all proven effective in predicting from both test and comparison groups in behavioural change among young people. In many studies, authors concluded that partici- intervention research, these constructs have pating in evaluation research may itself have also been useful in mediating actual risk been a valuable intervention and the impact behaviours. Results have shown that young of behavioural assessments was deemed par- people who have already initiated sexual rela- tially responsible for this finding. One recom- tions must be treated very differently than mendation of this review was to consider a those who have not, and that interventions social change approach to HIV prevention in have to as well target specific behaviours IDUs in order to influence social norms rather than risk reduction in general. Although towards safer behaviour. we noted one study in Nigeria, most theory- based research and intervention has been Globally, it has been noted that IDUs need conducted in the USA. Without further specific information targeting both the indi- research, these results may be difficult to vidual needs of the IDUs and the social/cul- apply in settings outside the USA. Reitman tural context of injecting drug use (Case, correctly concludes that condom use is a 1992). The support of specific health and behaviour that might be especially sensitive social services is critical, for if an IDU has been to situational or contextual variations espe- motivated by a prevention message to seek cially among diverse populations such as the treatment or use condoms, the service must youth. be more readily available than drugs. Among 16 countries surveyed in 1992, the success in reaching IDUs varied widely with France (D) INJECTING DRUG USERS reaching less than 5% of that population and Sweden and Australia reporting over 90% of Drug addiction is a major risk factor for HIV IDU population reached. The gaps identified infection in about 80 countries worldwide in IDU prevention programmes centre around (Gibson, 1998). Behaviours associated with not addressing the social construction of drug use that are risk factors for HIV transmis- addiction including poverty and social sion are sharing of drug injection equipment inequities that are strong predictors of HIV and unprotected sex with an infected partner. infection. If programmes only focus on harm As this report is focusing on sexual transmis- reduction without approaching the larger sion, the sharing of drug injection equipment issues, success will remain limited (Case, will not be discussed. 1992).

30 CHAPTER III

A recent study in Puerto Rico randomly assigned 1004 IDUs to one of two interventions, either a NIDA-developed standard intervention or the standard plus an enhanced intervention. The enhanced intervention consisted in a client-centred approach focusing on the individual’s perception of risk, continuous risk evaluation and motivation to change as well as environmental resources (such as availability of condoms and access to services). The stages of change model guided the intervention and was used to track individual’s passage through a behavioural change process. Participants of the enhanced intervention were found twice as likely as participants in the control group to use condoms during vaginal sex and 11 times as likely to use condoms during anal sex regardless of HIV serostatus. Increase in condom use was more pronounced among HIV and other STD- positive subjects, and with casual more than steady partners (Robles, 1998).

Conclusions

In contrast to what was commonly thought about IDU populations, reviews have noted substantial risk reduction among drug users especially as a result of sustained interventions. Reports on drug users generally emphasize drug use risk rather than sexual risk, but those reports that consider both have noted that sexual risk reduction is much more difficult to achieve than drug use risk. However, a review in 1998 stated that nearly all studies that assessed sexual practices found significant reductions in the number of sexual partners reported by subjects and/or increased use of condoms (Gibson, 1998). Numerous studies have identified drug and alcohol intoxication as associated with high risk sexual behaviour, thus highlighting the importance of understanding and addressing the social construction of drug use. The stages of change model has been useful at guiding interventions with drug users. As with all of the above population groups, IDUs as well are an extremely diverse community, that should be seen and addressed in its complexity. Thus, interventions should target subgroups and consider the social construction of addiction to be effective.

Table 4 summarizes the theories and models that have been applied to different population groups.

31 CHAPTER IV

CHALLENGES The range of outcome measures encountered in doing a review such as this one, makes ‘success’ difficult to define. Many interventions oriented by theory rely on reported changes in behaviour as their behavioural outcome measure. Some however were satis- fied with ‘intentions’ to change as intentions (A) DESIGN/CONTEXT ISSUES often predict behaviour. Others use markers such as changes in rates of STD infection, or HIV infection. All of these outcomes were Design treated as valid in this report, but were noted for the reader to distinguish the differences. Interventions based on theory have a better chance of success and theory can make it eas- One of the greatest limitations of interven- ier to understand why an intervention was or tions and studies assessing these interven- was not successful. Despite their contributions was short follow-up time. Lack of follow- tions to the understanding of the psychologi- up time can undermine an intervention by not cal processes individuals go through while allowing positive feedback, not waiting for attempting to change behaviour, the limita- possible changes in social and cultural norms, tions of the psychological theories of behav- and not taking maintenance of behavioural ioural change have been well described in the change into consideration. literature (Auerbach 1994). Most of these models are based on behaviours that are under intentional and volitional control, ignor- Targeting ing the fact that sexual behaviour involves two people, is often impulsive and is influ- There has been much discussion around the enced by sociocultural, contextual as well as issue of targeting AIDS interventions. From an personal and subconscious factors that may epidemiological perspective it has been be difficult to influence. Numerous studies argued that to have an impact on the sexual have identified alcohol and drug intoxication transmission of HIV, interventions need to as influencing sexual behaviour highlighting reach those most at risk of acquiring or trans- the importance of understanding the social mitting the infection especially early in the context around sexual behaviour. epidemic (Sepulveda, 1992). In information and education campaigns, many suggest that In a comprehensive review of behavioural messages are more effective when they can interventions for HIV/AIDS prevention, be directed toward a specific target popula- Oakley et al. found that the most popular tion as the language and approach ought to type of intervention was giving information. fit specific needs and solutions appropriate The review looked at 68 separate outcome for different communities (Cohen, 1992). evaluations among young people and adults, Recent simulation studies have also argued and suggests that sound and effective inter- that targeting interventions to priority groups ventions are most likely to be skills-based would be an efficient and effective approach interventions provided by peers or clinical for HIV prevention in developing countries psychologists in community settings using (Morris, 1997). For example, when addressing interviews or role plays and targeting behav- specific groups such as youth, it has been iour or combined behaviour and knowledge shown that interventions must look at those outcomes (Oakley, 1995). who have initiated sex as a different group from those who have not, to be effective. The The range of study designs is important to danger arises, when the epidemic spreads note. Randomized controlled trials were not into the general population, targeting most at considered exclusively for this report, as these risk populations is no longer sufficient to conditions are almost inevitably only found in reduce transmission. Another concern with the industrialized world. In order for this regards to targeting to reduce transmission is report to consider countries with the highest how to define the target group, by occupa- prevalence, the least amount of resources and tion, age group, geography (Morris, 1997). some of the most innovative responses the Identifying populations at risk and targeting criteria remained broad. too quickly can miss important vulnerable

32 CHAPTER IV

groups, such as male sex workers in Asia (Amaro, 1995). Wingood suggests a transition (Ford, 1995). Targeting populations that are that will use gender-specific theories for more vulnerable should not be seen as sin- research and programme development for gling them out and therefore increasing stig- women and HIV (Wingood, 1995). ma. Working with priority groups is still important at any stage of the epidemic, but should The same arguments apply with regards to sex be combined with other activities to reach a workers in particular. de Zalduando empha- broader population equally at risk. sizes that the women within the broad category of sex workers represent an exceedingly Targeting according to risk of transmission is diverse group with varied life histories and one aspect, but a second issue is how much conditions. Without considering the actual sit- of the limited resources to place on primary uations within which these women live and prevention and how much on secondary pre- work, it is impossible to envisage the services vention. Some studies address specifically tar- or supports needed by this vast range of range geting prevention efforts at already infected people. She advocates the use of enthno- individuals. graphic methods to understand key norms, sexual situations and interactions from the women’s point of view (de Zalduando, 1990). (B) GENDER (C) CHANGING EPIDEMIC A significant number of studies have shown that gender influences HIV risk behaviour (Auerbach, 1994, Amaro, 1995). As Ulin (1992) As the HIV epidemic and the responses to the notes when referring specifically to women HIV epidemic evolve, people’s experience who are poor and dependent on their male accumulates predicting the need to update sexual partners, reducing the risk of HIV transtheoretical models and response. Since the mission often means changing the balance of development of anti-retroviral therapies, power in the relationship and could mean fail- some studies have assessed preventive ure in their roles as women which are inextri- behaviour in relation to attitudes regarding cably linked to their fertility. Many women are combination therapies (Remien, 1998). In torn between the value of motherhood and Uganda, where the epidemic has matured rel- the risk of HIV for either them or their child. ative to many communities in the world, the The fear of their partner’s violence has also need to incorporate temporal dimensions been shown to predict whether women use into measurements of sexual behaviour and condoms (Gomez, 1993). In Uganda, stark perceived risk is clear (Bunnell, 1996). The gender differences were shown in perceptions impact of an epidemic where over 50% of the of risk, women being more likely to perceive population in a community knows more than risk than men (Bunnell, 1996). The sexual dou- 30 people who have died of the disease is ble standard that sanctions many partners for profound. Measuring perceived risk should men while restricting female sexuality has delineate risk due to past and present behav- engendered confusing HIV prevention mes- iour as interventions must target these risks sages, such as reducing numbers of partners differently. In a more mature epidemic where this may not be protective. Data glob- Bunnell suggests “a theoretical framework ally affirm that, not only are many women which recognizes that perceptions of risk and monogamous already, but it is unsafe for them sexual behaviour are not always individually to assume they are safe in their monogamous determined, that gender and context are crit- situation (Heise, 1995). Especially in high ical determinants of individual control over prevalence communities rates of discordance behaviour, that fear plays different roles at dif- among married couples can be between 15% ferent stages of an epidemic and that lay and 20% (Allen, 1992, Serwadda, 1995). communities can understand and utilize risk Amaro notes that there is a growing body of information” (Bunnell, 1996). knowledge that HIV among women has to be seen within the larger context (Amaro, 1995). She suggests strategies such as participatory (D) NULL FINDINGS education that stress longer-term goals assessing root causes of gender differences Few studies report on null findings but those including disempowerment and poverty that do are critical to complement our under-

33 CHAPTER IV

standing of the relationships between context, population group, approach, intervention and theoretical background. In some populations behavioural skills training has failed to produce significant differences compared to control conditions. For example, non-impact has been shown with inner city African American men and STD clinic patients in the USA (Branson, 1996). Other reports of null findings include a randomized controlled trial among STD patients in the UK. The intervention was guided by the social cognitive theory and results indicated little difference in self reported behavioural change. It is suggested that community as well as individual interventions should address the environment in which risk behaviours take place (James, 1996, 1998). Two interventions that showed little effect were among youth. One was a brief programme based on constructs from the SCT and the theory of reasoned action. Authors suggested a longer intervention that addresses the multiple problems of this group that was drawn from a detention center and STD clinic (Gillmore, 1997). The second was based on the theory of social influence among middle-school students. Authors noted that inadequate community and family- level interventions, possible dilution of messages and over saturation of students with health messages by the 8th grade may have been responsible for the lack of positive results (Moberg, 1998).

34 CHAPTER V

CONCLUSIONS approaches, despite showing great potential, have not yet been operationalized on a large scale. At this stage programmes should emphasize trans-theoretical approaches that combine individual level constructs with com- Safer sexual behaviour remains the single munity-level projects that focus on subcultur- most effective method of preventing HIV al norm changing. Community organizing can infection. Although tremendous challenges have the powerful affect of imparting a uni- still plague public health and the social sci- fied sense of purpose and new beliefs in the ences globally regarding AIDS prevention, possibility of change (Stevens, 1998). much has been learned as well. It has become clear that effective HIV risk reduction inter- An important element highlighted by a review ventions extend beyond basic information by Oakley and Darrow was that the quality of giving and help: sensitize people to personal evaluations was highly variable and often risk, improve couples sexual communication, inadequate, which makes it difficult to con- increase individual’s condom use skills, the clude generalizable lessons about what works perception of lower risk practices as an where from the heterogeneous literature. On accepted social norm, and help people the positive side, it is now possible to report receive support and reinforcement for their that prospective experimental studies and efforts at changing (Kelly, 1995). These princi- long term follow-up in many different settings ples form the foundation of successful HIV are feasible (Oakley, 1998). prevention strategies, but differences in individual, social, cultural and economic condi- Despite the many advances in the field and tions dictate different design and implemen- many changes in behaviour observed, popu- tation of programmes. Even if the principles lations at highest risk have not received their underlying programmes are the same, tailor- share of the attention and resources allocated ing to specific groups in specific settings will to AIDS interventions globally. The countries make programmes look very different (Kelly, with the highest prevalences of HIV are those 1998). Not only should programmes be mod- with the least resources and strained medical ified to fit certain cultural settings, but within and social support systems. These countries cultural groups individuals may be at very dif- with rapidly changing epidemics do not have ferent stages of readiness to change and suc- the means alone to develop randomized con- cessful interventions should take individual trolled trials to test behavioural interventions, differences into consideration as well. yet they are the communities needing the interventions the most urgently. Most theory- Changes in behaviour, such as dramatic driven intervention research has been con- increase in condom use, in very diverse popu- ducted in industrialized countries with very lation groups have taken place and some con- different epidemics to those in developing clusions can be drawn. As Ulin suggests, when countries. It is therefore critical to test models interventions have enabled the participants and approaches across cultural, economic themselves to take part in mobilizing and set- and social situations. ting goals themselves, efforts have been highly successful (Ulin, 1992). Highlights have Following the findings of the importance of included the normative changes gay men in social norms and sexual communication for many US cities and sex workers in Thailand various groups including youth, MSM and have made within their communities. heterosexuals, authors recommend community level interventions aiming at strengthening Another important point stressed by this the perception that others also practice safe broad overview of approaches to behavioural sex (Buunk, 1998). Gender and power imbal- change is the need to see different levels HIV ances were also noted in many studies point- prevention initiatives as complementary. ing to the necessity to build gender con- Individual approaches have shown impact, structs into theories, models and interven- but to stem transmission on a larger scale for tions (Buunk, 1998). longer term maintenance of changed behaviour, community and structural level pro- Recommendations for interventions aimed at grammes are a critical complement. These women include greater emphasis on gender-

35 CHAPTER V

related influences of behaviour. Studies in the USA and in Africa emphasize that self-protec- tion, especially for vulnerable women may be affected by abusive partners, economic factors, and norms within sexual relationships (Wingood 1996, Bunnell, 1996, van der Straten, 1998). These recommendations apply to many different situations. In both West and Central Africa it has been noted that the ability to discuss sex and contracep- tion with sexual partners as well as the imbal- ance of gender relations have a potentially significant impact on the capacity to enact changes in sexual behaviour (Edem, 1998, van der Straten, 1995). As Bunnell states, sharp differences in perceptions of risk between males and females in Uganda reflect underlying differences in societal power- the case in multiple settings around the world. To address women’s needs for HIV prevention especially in developing countries, the development of female-controlled methods needs greater emphasis as well as a wider approach to HIV prevention that considers the social position of women.

In an epidemic where changes are occurring rapidly at the level of the virus, treatment context and within populations at risk multi-dimen- tional interventions based on theories and models which address individual as well as contextual and sociocultural variables such as gender, class and ethnicity, and their influence on sexual behaviour are urgently needed.

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TABLES

Pages

Table 1 Overview of most frequently used theories of human behaviour...... 47

Table 2 Models as theories tested through research or reviews ...... 48

Table 3 Models and theories used to guide interventions...... 50

Table 4 Summary of theories and models by population group...... 55

to account for behaviors eduction esistance skills mal help-seeking ception e r ceived risk ce behaviour change essur ficacy & risk r ms ms, per VIOUR einfor

easoned action riers of changing behaviour t to r

y of r oup mal networking, for

theor mation including community leaders elations ficacy , intentions and outcome expectations , intention ms t ception, aversive emotions and knowledge ead infor ficacy ficacy ganizing ms in the social gr ms, self-ef ception evention (condoms) ceptions of enjoyment, self-ef e of gender r uctur

ogramme Application ganizing, mass media vices fective means to spr e the influential people in community ess social str ease level of risk per ease in knowledge, skills development, influence risk per easing access to pr Assess composition of social network Who ar Most ef Community or Assess and influence beliefs about benefits/ bar Addr Assess and influence outcome expectations nor Modeling of safer behaviours Assess and influence outcome expectations nor Assess and influence self-ef Assess and influence self-ef Incr Assess and influence attitudes Assess and influence nor Assess and influence behavioural intentions Sexual communication, need for social suppor Assess and influence nor Assess and influence communication, infor Assess type of social networks in community Equip young people with social skills including peer pr Assess, build up social suppor Assess key activities of the community and facilitate alliance building Incr Influence beliefs of severity Advocacy Advocacy; Community or Social ser Assess community priorities Assess and influence social nor Assess & influence per Assess and influence risk per Examples of Pr Incr Y USED THEORIES OF HUMAN BEHA . It was developed by one of the authors )

easoned action riers

y of r

minants

egulation ms & power dynamics r ception of risk)

theor ms ganization t evention ds & punishments ms ganizational, cultural ewar ces; Living conditions ficacy ceived susceptibility ceived severity ceived benefits & bar attitudes, per (social networks) econtemplative eparation Social networks Communication channels Change agent Social, or Social sexual nor Action Pr Self-ef Pr Contemplative Subjective nor Per Cues to action Attitudes Behavioral intentions Outcome expectancies Maintenance Enactment & maintenance Context Social r Social suppor Community building Intra-personal (knowledge, Political factors ( Context of social interactions Per Per Policy Resour Community or Social nor Commitment Labelling Behavioural Deter Access to pr VIEW OF MOST FREQUENTL ol. is an update of the s contr y y y omotion ment ning Theor ABLE 1: OVER

y or Model Model T Action* y of Reasoned

y of planned behavior onmental Factors Empower y of Gender & Power

Theor Social Influences fusion of Innovation Socioeconomic & Stages of Change Health Belief Model Theor AIDS Risk Reduction theor for Health Pr Envir Social Lear Social Network Theor Dif , Social Cognitive Theor Social Ecological Model ces beyond the individual’ y Theor ecent theor e r e subject to for

Level community Social & Individual level Level *A mor that ar

47 . - - , - ficacy ms ficacy ventions. rier beliefs) evention elate of con , marital status r , expecting e lower per . e knowledge of HIV is ongest cor elated to condom use. ficacy equency of sex in conjunc elated to high-risk sexual e r edicted safer sexual behaviour ’. Wher eater knowledge, experience and elated, but susceptibility to HIV e condom beliefs, self-ef e wer ongly r et and descriptive social nor elated to condom use. Self-ef oup would use condoms with new egr elated to beliefs about AIDS pr

Results ficacy not r d condoms was str . ception of higher risk linked other sexual ence gr ucted by low female autonomy egnancy r ease pleasur efer ficacy to engage in safer behavior ficacy ug use significantly pr ficacy was most str , anticipated r oup self-ef ol and per e condom beliefs and self-ef elated to intentions use condoms and past condom use. ficacy r elated to condom use wer . oup, condom use r ception, but obstr ficacy ceptions of self-ef eductions in risk behavioral with cognitive-behavioural inter e as well self-ef s positive attitude towar tners) eflect social context of sexual behaviour e independent gr ficacy to practice safer sex was significantly associated with condom use in e significantly cor , susceptibility to STDs and pr ee variables (condom benefit beliefs, cues to action, condom bar onger per fective behavioural change associated with gr elated to condom use. elated condom use wer and economic status, alcohol consumption, labor migration. Ef personal risk per Psychosocial variables associated with incident high risk sex wer ceived behavioural contr practices Significant r past 6 months. Cultural ideas such as shame and fatalism influenced condom use and self-ef Self-ef fewer negative outcomes of condom use, and less fr Str tion with alcohol or other dr Adolescent’ A limited number of well described variables can explain variance in intention to use condoms: self ef (belief that most others in the r For tourists, factors r In a mor Thr practices. dom use, and lower self-ef and pleasur r In higher priced gr sexual par susceptibility of STD infection, and knowledge. For sex workers factors r ‘Results r low wer and belief that condoms can incr - - - - fer e e dis tners ed ques , in dif views including edictors of intention oom setting. oups of SW opositive youth ed questionnair

ch Methodology y 6 months vey inter elated to risk taking. ent gr e ever

Resear es r fer osexual adult females and males views and self-administer views of Chinese, Filipino, and views viewed viewed for pr vey on 4 college campuses omen of childbearing age wer ietnamese adults identified in needle esting of 2 behavior change models W Review of cognitive-behavioral inter ventions for ser inter tionnair Inter Inter V exchange, jail, night clubs, and bars Sur to use condoms with new par Inter Individual sur questions on AIDS/STD knowledge, sexual behavior and psychosocial measur Self-administer tributed in classr Heter inter T in 4 dif ent socioeconomic settings

oup (n),

countr osexual men

get gr onegative MSM

ar omen (1294),

T outh, USA W Zimbabwe Y Ser (2000), Canada Asian community (254), USA College students, USA (923) African- American youth (312), USA Male sex workers (80) & clients (100), Indonesia University students (395), Nigeria and women at risk (711), Holland Heter Indonesia –Female sex workers , - y , y of

uct y y ABLE 2: MODELS & THEORIES TESTED THROUGH RESEARCH OR REVIEWS y T et, Social y/Constr ception of risk y egr easoned action, ning theor y ficacy y of r y of planned behavior ms Model/Theor otection Motivation Theor easoned action, Social cogni Knowledge; Per Cognitive-behavioral Theor Theor Social lear Social cognitive theor Self-ef Health belief model, Theor r tive theor Social cognitive theor Health belief model, Pr Anticipated r Health belief model Health belief model + Social cognitive theor Health belief model nor

, , 1992

ear y

Y , 1998

Author y us, 1998 d, 1995 d, 1998 egson, 1998 Gr Rotheram- Bor Alar Nemoto, 1998 Reitman, 1996 O’Lear Buunk, 1998 For For Edem, 1998

48 - - - t - ol. , syphilis ug use was ted condom use) elation. epor r tners about each others’ sex ceived behavioural contr tner e clients. Sex workers with lower omotion and distribution activities ficacy) otected sex, but poly-dr e en

Results edictor of the sexual behaviours. tners, low rates of condom use. course was per edicted intentions to use condoms and per ease in the use of condoms Lusaka. e likely to use condoms. edicted unpr e childr ms pr ficacy to influence par ol significantly added to the cor tner educe sexual pleasur t want mor oduct appealing, the Price acceptable, Placement conve -negative ms) ugs and/or alcohol e significantly mor ceived self-ef e likely than those with higher SES to be infected HIV esponsible for an incr edictor of intention to use condoms (and r y wer tner HIV tner doesn’ e mor ed to those with a higher socioeconomic status (SES), sex workers y association variable pr ongest and most consistent pr Conflicts with par Use of dr Belief condoms r Par Par High per ease in the number of people who hang out with others use condoms ease in number of people who used condoms the last time they had sex ease in number of people who feel confident that they can tell their sex par ➢ Negatively influencing condom use: ➢ ➢ ➢ ➢ ual histor High numbers of lifetime sexual par Respondents who communicated with their sex par Factors influencing condom use: ➢ Compar SES wer and hepatitis B. lower SES worked longer hours and had mor Memor The best pr Findings suggest that condom marketing, pr have been r Incr (community nor Incr (behaviour) Incr ners that they want to use a condom (self-ef ceived behavioural contr and of having sex without anal inter Attitudes and subjective nor the str - - - ed ques evalence of y and con cial marketing, ‘4 Ps’ (making the Pr ding their sex om New Jersey vice agencies egar vey in 1990 with views. , syphilis, hepatitis B, . edictors.

ch Methodology vey , 6 month follow-up visits. e on a variety of health viewed r e. Resear t study viewed. e inter ticipants completed a confidential vey in 1996. oss sectional study of pr ual communication histor Sexually active adolescents detained in Los Angeles county juvenile hall wer dom use. HIV infected women fr medical and social ser inter antibodies to HIV behavioral factors and socio-economic factors. Par questionnair behaviors and pr Evaluation sur Cr Cohor Face to face inter Comparison of sur sur Confidential self-administer tionnair - ounds including the commer -

oup (n),

countr ent backgr cerated Latino get gr -infected opositive gay ved populations fer

ar omen & men evention agen

T Incar adolescents (2132), USA HIV women (215), USA Men and women (579), USA Pr cies for under ser (youth, IDU), USA Sex workers (600), Brazil Ser men (96), Canada W (806), Zambia Adolescents (179), USA ds ms uct om many dif ticular audience), operant conditioning and social cognitive theories. , ficacy y/Constr ed to a par eduction model y of planned behavior y of planned behavior ceived community nor ceived self-ef Model/Theor Sexual communication AIDS risk r Implicit cognition Theor safer sex Behavioral intention towar Per Per Socio-economic factors Theor Condom social marketing* omotion tailor

, , 1998

ear

Author , 1998 Rickman, 1994 Kline, 1994 Newcomb Godin, 1996 Levy Lurie, 1995 Jemmott, 1992 PSI, 1998 nient, and the Pr *Theories behind social marketing come fr

49 - - - ed r cep

last eased tner at y high per . eased use & educe risk, assisted ried women taking initia om 64% to 70% of client - women in the study ted changes to r t condom use with main par

Results eater sexual communication & incr monal contraceptives incr e achieved with mar ting condom use. epor tner negotiations, and began to change communi oject suppor geting clients. eased dramatically in first 6 months. Relapse occur geting clients. ease in mean condom use fr ms suppor ARGET GROUPS WORLDWIDE om 10% to 100 % as sex workers identified ver of condoms ealm of par mation about hor ose fr

always use educing risk posed to them by the sex activities of their husbands. ARIOUS T ted condom use incr and eased consistent condom use, gr ticipants in the r tners’ adoption of nor omen exposed twice as likely to r educed attrition among both HIV+ and HIV Condom use r W after 3 years. Recommend tar tion of risk. Repor Eight of the nine outcome goals wer tive in r Incr Statistically significant incr contacts. Recommend tar par ty conventions about sexual expectations and practices. Outcomes suggest that the pr Access to and infor r par sex ------ven veys, . ough SW vention includ ovided with family vention e pr viewing & individual oup sessions led by omotion.

ch Methodology ee condoms vices and methods ed by trained peer para ed individual counselling evention education in an -pr oup discussions and village

Resear vention included peer education vention was village-based includ ms ticipants wer ofessional counselors based on Education conducted thr opinion leaders; video, discussion and condom demonstration conducted. Behavior change counselling inter tion deliver pr stage-tailor sessions. SW followed over 4 year study Inter and condom pr Inter ing training, motivational audio-drama, posters and village meetings. Evaluation consisted of: KAP sur focus gr meetings. Community based inter ing 5, 2 hour gr peer educator focusing on gender and ethnic pride, knowledge, skills & nor SWs attending STD clinics given week ly talks and fr intense 2 year inter Collective consciousness-raising quali tative field inter ized HIV Par planning ser - -

y/ - y of

uct omo omo mation

Constr uctural

Model/Theor AR & NS –audiovisual aids to influence attitudes & behaviors Stages of change peer education & condom pr tion Str SCT and communi ty health pr tion SCT & Theor NS- infor and accessibility of condoms Gender and Power P Peer education

y -positive VENTIONS BASED ON MODELS & THEORIES WITH V

oup (n), countr

get gr

T omen (586), Rwanda illage women (600) & Female sex workers (30), Ghana 1289 at risk & 322 HIV women USA Female sex workers (107), Ghana W V men (479), Thailand African American women (128), USA Female sex workers (134), Honduras Lesbian and bisexual women (3665) ABLE 3: INTER T

ear* orkers

Y e, 1994

Author omen Opar Galavotti, 1998 Asamoah-Adu, 1994 King, 1995 Elkins, 1997 DiClemente 1995 Fox, 1993 Stevens, 1998 W Sex W

50 - - - - oup ven ol gr e was a fective for stu ch om 42% to 92% fol eased. Condom esear vention vs. contr eased AIDS knowledge ogramme. Ther efusing sex without a con e five times less likely to have ticipants in r ogramme was not ef e e not in the pr hea rates in inter eased between baseline and follow-up. r ogramme wer Results eased significantly between baseline and follow- efusal of sex without a condom fr ficacy to use condoms. ease in gonor ogramme was associated with incr om 18-75%) and (29-62%) clients of SW in both inter eady initiated sex. eased their r ovement in negotiation skill, always r grade students in the pr ogramme. th t-building activity dless of method used, must involve par ticipation in the pr onger influence on girls than boys. The pr Mobilizes the community and changes cultur Accurate sensitive data collected Rappor Regar Significant impr Knowledge and condom use incr up for both SW (fr tion sites. dom and significant decr use among sex workers and clients incr Sex workers and clients knowledge about AIDS STDs incr By end of 8 Par and intentions self-ef lowing the pr Sex workers incr dents who had alr begun sex than similar students who wer str - - - - - e t - oup - ough esent om ease vices. ch ch t fr . Incr ee distribu y & compr e and a esear esear tiveness and esponses to ms; sharing mation, out ease knowl ticipants pr ecover vention. Small gr mation, identifying ed condom use thr ch Methodology oblem situations othel owners and health ole-playing r omotion with fr ficacy training. each workers. ceived susceptibility and equir oom periods led by teenagers es, teaching asser Resear es, r -long inter elated to condom use and par vention included a pr f. othels r orks on changing nor essur essur W behavioral values 3 session series to: incr ner negotiation among SW knowledge among clients and pimps using outr edge, per skills r Involving sex workers in r Involving sex workers in r peers and br staf hensive, client oriented STD ser Condom negotiation, suppor discussing pr Health education using film, peer edu cators distribute educational materials, condom pr tion and later cost r pr come expectancies about condom use and self-ef post-test + factual infor ing factual infor pr Inter A year sessions with SW & peer educators. Br owners & education of clients. Specially trained volunteers posed as clients to test SW negotiation skills. 5 classr slightly older than par - - - - o

y/ y

uct y

Constr ception of risk,

Model/Theor AR- – though not AR – though not ILOM model Health belief model & Social cognitive theor P stated explicitly P stated explicitly Behavioral (sexual communication) tion, condom pr motion & STD ser NS - health educa vices Social Cognitive Theor Per condom negotia tion, policy Social influence - e

y oth

oup (n), countr

get gr

T iet Nam Female sex workers Indonesia (500) Female sex workers (300) & clients (300), Indonesia Female sex workers India Female sex workers V Female sex workers, Singapor (128) Female sex workers Nigeria African American adolescents, (109), USA el owners & clients, Thailand Female sex workers (500) br low income youth USA (536) , ,

ear d, 1990

Y , 1998 Author don, 1998 utaratna d, 1996 illiams, 1995 outh isr Y Gor For Kelly Basu, 1998 Chan, 1996 W Jemmott, 1992 V 1995 Howar

51 - - - fi o grade. th tners than ficient to induce y par om baseline in the ventions, possible dilu oblem-solving about fects sequentially ception overall. vention not suf oblems. e able to translate messages as n of ef oup in: knowledge, beliefs, self-ef ol gr tners, consistency of condom use, high risk

Results tions of young gay men engaging in unpr eductions of 15% to 29% fr essing multiple pr opor oup with discussion and pr osexually active high risk adolescents. Authors ole models and wer es (no. par eatest maintenance of risk behaviour change among vention vs. contr eful implementation of school-based component. ; adolescents had low risk per vention addr e positive r eductions in pr course with all men, but higher among secondar oduced systematic r fects in inter s high-risk behaviour with same patter elationship issues. ences among conditions; skill based inter eduction and gr fer vention pr , and risk behavior scor tners, diagnosis of other STD) eatest r

peer gender specialists’ eplicated in all 3 cities. Significant (27%) r boyfriends. tected anal inter ‘ Peer educators wer Few dif men in cognitive-behavioural gr personal r r population’ Null findings despite car Authors note, inadequate community and family-level inter consistent condom use in heter tion of message, & over saturation students with health messages by 8 suggest longer inter Gr Significant ef cacy Inter par - - - - - ns - eate ed 6-ses elapse e contract ventions: natives and opriate, inten elationships or ventions: cognitive- ee alter oup boosters. eduction & r oup, used natural e randomly assigned to

ch Methodology ug-fr ol ol gr oject vention.

Resear oup skills training that empha sizes negotiating skills for condom use comic book videotape gr ticipants wer evention, cognitive-behavioural risk esting of 3 behavioral inter eduction & personal r to place HIV risk among the concer of young gay men. channels of communication to cr alcohol and dr Implemented in 2 small communities with 1 contr Peer education workshops and com munity pr Middle school students assigned to either of 3 conditions using blocked randomization: age appr School based, teacher deliver sion inter sive and contr T • • • Par one of 4 1-day inter behavioural risk r pr r the same 2 with 3 months of follow-up telephone and gr Sequential stepwise lagged design, in 3 cities, opinion leaders wer ed to have conversations with peers endorse actively and visibly the impor tance and acceptability of behavioral change as well to convey strategies for change implementation. - y -

y/ y of y y - , and

uct y ticipator y & Theor

Constr fusion theor fusion theor

Model/Theor easoned action nance ioral + mainte Cognitive-behav Dif Health belief model, Social cog nitive theor methods NS – par Social influence a model of Social influence Dif r Social cognitive theor

y gentina

oup (n), countr continued…

get gr

T oung MSM (300), USA outh (72% Black or Hispanic) outh (389), Ar outh (2483), USA outh in detention and at STD MSM (1/3 ethnic minority) (429), USA Y Y (1316), USA Y Y Y clinic (396), USA MSM USA ABLE 3: T

, e, 1997 ear g, 1998 , 1993 Y , 1996 , 1992 Author alter Kelly Kegeles, 1996 W Kelly Ré, 1996, 1998 Mober Gillmor

52 - - - - fer e tners. ted behav ug risk eased self- tners, and epor es, incr ticipation in y condoms, no dif r vention than compari ol scor tners. fect on self-r y par om 8.4 to 2.4 per 100 person om 26.4% to 36.9%. Significant . oup C to car eases in inter eased fr nal locus of contr eased fr espect to condom use with main par

Results vention had no ef eater incr e likely than gr -positive, STD diagnosis, and par eased but much less dramatically than dr onger with non-primar fect with r espect to condom use with non-main par ception of vulnerability fect str nal and lower exter eased knowledge about AIDS, better attitudes pr e found with r e significantly mor ogram. Ef eater inter . mation only , and higher per ved incidence of HIV infection decr eas wer ease in rates of STDs in: brief counselling (19%), enhanced (22%) . oup A wer edictors of condom use: HIV ficacy enhanced pr Significant interactions indicating gr son ar similar but non-significant ef Use of condoms during vaginal sex incr pr vention, gr Obser years. Sex risk behaviour decr behavior ef Subjects showed incr Decr vs. infor Gr ence between A & B or C. Inter iour ------view ception vention etical e consid oup B, s per eater number oblem solving evention ser vention + eceived a 5 -pr ficacy ces wer oup A, gr vention materials eduction inter vention esour vention took place out

ch Methodology eatment - r eduction beliefs, attitudes oups (gr ease self-ef fice, included 8, 45 minute geting IDU social networks in

Resear ovided HIV education, social d risk r onmental r A - counselling inter leaflet + condoms B - leaflet + condoms C - no inter e developed for each specific pop oup C) ed. esidential tr Small media inter wer ulation focusing on key theor behaviour change variables as well condoms. Enhanced inter side of sessions using ‘motivational inter ing’ drawing on individual’ of risk, motivation to change, continu ous risk evaluation, negotiation and communication skills, Community and envir er Ex-addicts deliver HIV vices tar community settings session HIV risk r that pr competency skills and pr training. and behavioural intentions, skills train ing to incr Substance dependent adolescents in r RCT – 3 gr gr • • • RCT – of 3 strategies: (1) educational messages, (2) brief counselling, (3) enhanced counselling (gr of counselling sessions) with steps towar

y/ ms y of uct ficacy and y

Constr ceived nor

Model/Theor easoned action Stages of change Stages of change ILOM model Social cognitive theor SCT+ Theor r self-ef per Cognitive- behavioral

y t gay tners of

oup (n), countr continued… , MSM who don’

get gr osexual STD patients to Rico ar

T ug users (80% male) (1004), ug-dependent youth (19), Dr Puer IDUs, female sex par IDU, SW identify USA IDU (641), USA STD patients (492), UK Heter (4328), USA Dr USA ABLE 3: T ug Users

, Dr

ear

Y ence 1994 Author iebel, awr njecting Robles, 1998 Fishbein, 1996 W 1996 L James, 1996 Kamb, 1996, 1998 I STD Clients

53 - - o e - eac ough vention tner r es at post- oup. ms. eduction course. Ther ol gr eduction inter elated knowledge, intentions to vention and contr cent of condom use in vaginal inter otected vaginal inter oups on any of the measur ceived safer sex social nor tners was significantly higher among pr ception of riskiness drinking, driving and

Results ticipants in HIV risk-r eased AIDS-r ols, per educed unpr ted per y , condom use skills, expectations of par oject eduction higher in females than males. oup, par equency and per ent between inter epor fer ehensive national policy on HIV/AIDS in 1997 thr ficacy ences between gr ol of pr fer ch, dialogue and consensus-building. eases in both fr s first compr ventions significantly incr esear e significantly dif ed to comparison gr nment’ ted incr vention or follow-up assessments. e no significant dif ticipants took contr SCT = social cognitive theor ug use epor Elements of SCT (self-ef Statistically significant self r dr Both inter change HIV risk behaviors, and r wer years of r Par Gover Compar tion) wer inter r course occasions, self-esteem, positive condom attitudes and risk r behavioural intentions. Risk r ject-contacted students than contr Consistent condom use with new sex par , - - - ol - - mation ol trial tners tiveness, native oach based cion to vention in com ment and use cement of safer ganization and action, esistance to peer eligion + business; esist coer

ch Methodology mational comparison einfor oups including infor ventions (1) randomized evention appr ning, r oup empower

Resear e, life skills competencies and RCT = randomized contr nment + r -STD pr ticipants defining needs and figur get gr essur isits to hospital and detention center Gover od, or (2) infor condition. 7 SCT inter same-sex gr video with question and answer peri decision-making about alter choices, analysis of media that influ ence consumption. RCT of a 4 session cognitive behav ioral skills training inter parison with an HIV education contr condition. Par ing out how to meet those needs making changes at the policy level Random assignment to one of 2, 7 session, skills building (asser negotiation to r behaviour V peer education strategies & training, social lear pr engage in high-risk behaviour and to initiate communication with par about condom use or other safer sex practices), self-management of risk behaviours, r HIV on community or tar of opinion leaders as peer educators - t , - ,

y/ y gani epor ch ficacy y uct ment esear y of y

Constr ticipator fusion theor uctural

Model/Theor Par Str changes ioral (self-ef Cognitive-behav Social cognitive theor Dif Empower Theor Reasoned Action action r personal risk assessment) community or zation - - n y not stated in the r y NS = theor

oup (n), countr continued… ficials, Kenya

get gr -city African American het

T osexual men (81) Canada Community leaders and gover mental of Seriously mentally ill patients (89 men & 103 women), USA STD & health agency patients, USA (3706) University students (37,000), Sweden Hispanic, Native American, Anglo, USA er Inner ABLE 3: T oups

, 1988 , 1998 ear t, 1998 y

Y , 1998 y

Author = indicates year of publication allerstein alichman,1997 Minority Gr Others Hieber Henr Otto-Salaj, 1998 O’Lear W K Svenson, 1996 *

54 ms t, sexua edictive eatment, e pr tner nor ent studies. evalence settings. elated variables eal. ug tr fer -r tner , social suppor oving par eater than 50% course e par ug users ug risk practices ess self-identity vention. , was used in Indonesia. vention based on impr edictive of condom use among university edictive for gay men in Montr nationally eductions in dr e pr d easing condom use wer ficacy and the benefits of condoms wer eater r TION GROUP edicted condom use especially in low HIV pr eased condom use in diverse youth populations the USA ol was most pr eases in condom use among dr ventions (especially in the USA), suggesting skills training and ventions with gay men in the USA a few dif eases in STDs among men STD clinic attendees edictors of incr oved following an inter fective than standar ventions with women inter ficacy and incr mative beliefs about risk-taking. Skills training included talking with e ef fective inter ventions in the USA. In US study among women dr edict decr ongest pr riers and cues to action wer ms and mobilizing the community to Rico found incr tner nor vention among African American men to addr ent sub-populations, but self-ef edictor of condom use among African American adolescents ceived behavioral contr eased self-ef fer ovided guidance to inter e useful to pr ceived bar course in Chinese and Filipino men. ong pr eductions in sex risk practices, but gr oups in Indonesia. ed counselling mor , and condom use skills impr ms wer ticularly useful among youth in the USA who have not yet had sexual inter ceived peer or par ficacy e useful for dif fectively in among low income women the USA fectively in community inter y has been useful in guiding ef om both models, per ceived nor otected anal inter ucts wer ds condoms - a str ucts fr uct has been used in studies with women Africa and pr each model has shown r easing sexual communication skills. vention guided by this model in Puer fusion theor ficacy & per ent constr ventions guided by SCT have incr educing risk among many gr tners about sex and condom use practicing skills. ceived benefits to condoms, per fer eduction in unpr Psychological theories such as SCT pr strategies to modify per Authors noted that in this US-based study the str Elements such as self-ef Per This model was used ef par Among African American women in the USA, this model helped guide an inter and incr investigators found stage tailor of r communication and behavioural commitment. students in Nigeria This model has been par This model emphasizing changing cultural nor r This model was useful in guiding an inter This constr This model was used ef Using constr Self-ef Attitudes towar Dif This outr An inter Inter Stages of Change model was used to guide inter The dif Comments A combined behavioral model was used with Asian and Pacific Islander men in the USA found gr Y OF THEORIES AND MODELS BY POPULA y y easoned y (SCT) y y of r

y/Model ILOM fusion Theor ABLE 4: SUMMAR ception of Risk ILOM Model

Theor T Social Influence Dif y of Gender and Power Stages of Change Stages of Change fusion of Innovations Per Health Belief Model TRA & SCT combined SCT & TRA combined HBM & TRA combined fusion of Innovations with Action (TRA) combined Social Cognitive Theor Social Cognitive Theor Dif Community Mobilization AIDS Risk Reduction Model AIDS Risk Reduction Model Dif Theor Social Cognitive Theor HBM, SCT & Theor The HBM and SCT used together omen

oup orkers osexual W osexual Men outh Heter Heter Y Homosexual Men Sex W Population Gr IDUs

55 Notes: The Joint United Nations Programme on HIV/AIDS (UNAIDS) is the leading advocate for global action on HIV/AIDS. It brings together seven UN agencies in a common effort to fight the epidemic: the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the United Nations International Drug Control Programme (UNDCP), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Health Organization (WHO) and the World Bank.

UNAIDS both mobilizes the responses to the epidemic of its seven cosponsoring organizations and supplements these efforts with special initiatives. Its purpose is to lead and assist an expansion of the international response to HIV on all fronts: medical, public health, social, economic, cultural, political and human rights. UNAIDS works with a broad range of partners Ð governmental and NGO, business, scientific and lay Ð to share knowledge, skills and best practice across boundaries.

Produced with environment-friendly materials Joint United Nations Programme on HIV/AIDS

UNICEF • UNDP • UNFPA • UNDCP UNESCO • WHO • WORLD BANK

Joint United Nations Programme on HIV/AIDS (UNAIDS) 20 avenue Appia, 1211 Geneva 27, Switzerland Tel. (+4122) 791 46 51 – Fax (+4122) 791 41 65 e-mail: [email protected] – Internet: http://www.unaids.org