Behavior change theories and models Geoffrey Setswe DrPH SBI Workshop 29 March 2009 AIDS Behavioural theories/models 1. Health Belief Model (HBM) 2. AIDS Risk Reduction Model (ARRM) 3. Stages of Change of the Transtheoretical Model 4. Theory of Reasoned Action (TRA) 5. Diffusion of Innovation Theory 6. Ecological Systems Theory 7. Social Capital Theory 8. Social Cognitive Theory 9. Social Network Theory 10. Theory of Gender and Power 11. Edutainment Programming Model Source: Rachel King's "Sexual behavioral change for HIV: Where have theories taken us?" June 1999 Creation of a theory-based HIV prevention intervention Elicitation Assessment of pre-intervention levels of factors theorized to influence risk and preventive behavior Intervention Design and implementation of targeted interventions to change factors theorized to influence HIV risk and preventive behaviour Evaluation Evaluation of intervention impact on factors theorized to influence STD/HIV risk and preventive behavior and HIV preventive behavior Source: Fisher WA. A Theory-Based Framework for Intervention and Evaluation in STD/HIV Prevention 1. Health Belief Model HBM) is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of individuals. Developed in the 1950s to explain the lack of public participation in health screening and prevention programs Adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS. Condom use Rosenstock, Strecher and Becker, (1994): Key variables of the HBM Perceived Threat: Consists of two parts: perceived susceptibility and perceived severity of a health condition. Perceived Susceptibility: One's subjective perception of the risk of contracting a health condition, Perceived Severity: Feelings concerning the seriousness of contracting an illness or of leaving it untreated (including evaluations of both medical and clinical consequences and possible social consequences). Perceived Benefits: The believed effectiveness of strategies designed to reduce the threat of illness. Perceived Barriers: The potential negative consequences that may result from taking particular health actions, including physical, psychological, and financial demands. Cues to Action: Events, either bodily (e.g., physical symptoms of a health condition) or environmental (e.g., media publicity) that motivate people to take action. Cues to actions is an aspect of the HBM that has not been systematically studied. Health Belief Model (HBM) 2. AIDS Risk Reduction Model The AIDS Risk Reduction Model (ARRM), introduced in 1990, provides a framework for explaining and predicting the behaviour change efforts of individuals specifically in relationship to the sexual transmission of HIV/AIDS. A three-stage model Stage 1: Recognition and labeling of one's behaviour as high risk. Hypothesised influences: knowledge of sexual activities associated with HIV transmission; believing that one is personally susceptible to contracting HIV; believing that having AIDS is undesirable; social norms and networking Catania, Kegeles and Coates, 1990 ARRM Stage 2: Making a commitment to reduce high-risk sexual contacts and to increase low-risk activities Hypothesized influences include cost and benefits; enjoyment (e.g., will the changes affect my enjoyment of sex?); response efficacy (e.g., will the changes successfully reduce my risk of HIV infection?); self-efficacy; knowledge of the health utility and enjoyability of a sexual practice, as well as social factors (group norms and social support), are believed to influence an individual's cost and benefit and self-efficacy beliefs. Stage 3: Taking action. This stage is broken down into three phases: 1) information seeking; 2) obtaining remedies; 3) enacting solutions. Depending on the individual, phases may occur concurrently or phases may be skipped. Hypothesised influences include social networks and problem-solving choices (self-help, informal and formal help); prior experiences with problems and solutions; level of self-esteem; resource requirements of acquiring help; ability to communicate verbally with sexual partner; sexual partner's beliefs and behaviours. AIDS Risk Reduction Model (ARRM) Catania, J.A., Kegeles, S.M., and Coates T.J. (1990). Towards an understanding of risk behavior: An AIDS risk reduction model (ARRM). Hlth Ed Quarterly, 17(1), 53-72. 3. Stages of change model Posits six stages that individuals pass through when changing behaviour e.g. Smoking cessation 10 processes help predict and motivate individual movement across stages. Prochaska, DiClemente and Norcross (1992) 4. Theory of Reasoned Action (TRA) TRA is based on the assumption that human beings are rational and make systematic use of the information to make choices about whether to enact a behavior or not. The theory provides a construct that links individual beliefs, attitudes, intentions, and behavior Breastfeeding (Fishbein, Middlestadt and Hitchcock, 1994) Theory of Reasoned Action (TRA) Ajen,I., Fishbein, M. (1980) Understanding attitudes and predicting social behavior. New Jersey: Prentice-Hall, Inc. 5. Diffusion of Innovations Theory There are four main elements to the diffusion of innovations: (1) the innovation, (2) its communication, (3) in a social system, (4) over a period of time. Innovation – any item, thought, or process that is viewed to be new by the consumer e.g. Femidom Communication – the process of the new idea traveling from one person to another or from one channel to the individual. Social System – the group of individuals that together complete a specific goal (adoption) Time – how long it takes for the group to adopt an innovation as well as the rate of adoption for individual 1) Innovators, 2) Early adopters, 3) Early majority, 4) Late majority, and 5) Laggards Rogers, E.M. (1995). Diffusion of innovations (4th edition). The Free Press. New York. Different adopter categories are identified as: Innovators (venturesome); Early adopters (respectable); Early majority (deliberate); Late majority (sceptical); Laggards (traditional). Project Accept: VCT 6. Ecological Systems Theory Specifies four types of nested environmental systems, with bi- directional influences within and between the systems. The four systems: Microsystem: Immediate environments (family, school, peer group, neighborhood, and childcare environments) Mesosystem: A system comprising connections between immediate environments (i.e., a child’s home and school) Exosystem: External environmental settings which only indirectly affect development (such as parent's workplace) Macrosystem: The larger cultural context (Eastern vs. Western culture, national economy, political culture, subculture) Recognizes that successful activities to promote health, including HIV risk reduction, not only address changing individual behaviors, but address multiple levels. HIV disclosure 7. Social Capital Theory …Those resources inherent in social relations which facilitate collective action. Social capital resources include trust, norms, and networks of association representing any group which gathers consistently for a common purpose. A norm of a culture high in social capital is reciprocity, which encourages bargaining, compromise, and pluralistic politics. Another norm is belief in the equality of citizens, which encourages the formation of cross-cutting groups. The theory asserts that social life, networks, norms and trust enable participants to act together more effectively to pursue shared objectives, such as HIV risk reduction. Needle exchange programmes Coleman, J.S. (1988) Social Capital in the Creation of Human Capital," American Journal of Sociology (94:Supplement: Organizations and Institutions: Sociological and Economic Approaches to the Analysis of Social Structure) 1988 Social capital theory Source: Narayan and Cassidy (2001) http://www.gnudung.com/literature/dimensions.html 8. Social Cognitive Theory (SCT) SCT explains how people acquire and maintain certain behavioral patterns, while also providing the basis for intervention strategies. Evaluating behavioral change depends on the factors Environment, People and Behaviour. SCT provides a framework for designing, implementing and evaluating programs. The premise of the SCT (or SLT) is that new behaviours are learned either by modeling the behaviour of others or by direct experience. The confidence one feels towards enacting a behavior = Self- efficacy, is a key component of the theory. Positive Prevention and Stepping Stones projects (Bandura, 1997) Social Cognitive Theory (SCT) SCT is relevant for designing health education and health behavior programs. This theory can also be used for providing the basis for intervention strategies Source: Pajares (2002). Overview of social cognitive theory and of self-efficacy. 12-8-04. 9. Social Network Theory SNT views social relationships in terms of nodes and ties. Nodes are the individual actors within the networks, and ties are the relationships between the actors. Looks at social behavior not as an individual phenomenon but through relationships, and appreciates that HIV risk behavior, unlike many other health behaviors, usually directly involves two people. “It takes two to tango”. VCT M.S. Granovetter., "The strength of weak ties: A network theory revisited, " Social Structure and Network Analysis (P.V. Marsden and N. Lin, Eds.). Sage, Beverly Hills CA, 1982, pp. 105-130. Example of a social network map with nodes and linkages 10. Theory for Individual and Social Change or Empowerment Model: Asserts that social change happens through dialogue to build up a critical perception of the social, cultural, political, and economic forces that structure reality, and by taking action against forces that are oppressive. Empowerment should increase problem solving in a participatory fashion, and should enable participants to understand the personal, social, economic, and political forces in their lives in order to take action to improve their situations Men As Partners (MAP), Women’s dialogue Karusa Kiragu and Julie Pulerwitz, "Application of behavior change theory to HIV programs: Lessons learned from operations research at Horizons," unpublished manuscript, 11. Theory of Gender and Power TGP is a social-structural theory addressing the wider social and environmental issues surrounding women, such as distribution of power and authority, and gender-specific norms. There are three major social structures that characterize the gendered relationships between men and women: the sexual division of labor, the sexual division of power, and the structure of cathexis Women’s Empowerment Project 12. Edutainment Programming Model IHDC/Soul City uses this model to inform understanding of how edutainment can be used for social change and communicating HIV/AIDS.
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