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Theories and Models in AIDS PREVENTION Theories tell us why people do what they do.

Models tell us how they do it. Today, HIV Prevention Programs can draw from many different social and behavioral theories. It is important to remember that it may be necessary to select an intervention based on more than one theory or model. Selecting an intervention with multiple theories or models may be the key to address successfully the behavioral determinates that place your population at risk of acquiring or transmitting HIV. Refer to the theory(s) that were the foundation of the original science based intervention. Although a specific theory is the foundation of your intervention, it is very likely that other theories may influence your intervention. If you formulate your own intervention based on theories alone, it is necessary for you to select singular or multiple theories as the foundation for intervening. AIDS Risk Reduction Model The AIDS Risk Reduction Model believes change is a process individuals must go through with different factors affecting movement. This model proposes that the further an intervention helps clients to progress on the stage continuum, the more likely they are to exhibit change. This model includes elements of several other theories/models (health belief model, self-efficacy theory, and psychological theory) and is applicable to sexually active or injecting drug using individuals. This was developed specifically for the context of HIV perception. Individuals must pass through three stages: 1. Labeling – one must label their actions as risky for contracting HIV (i.e. problematic). Three elements are necessary. a. b. c. 2. a. b. c. d. Knowledge about how HIV is transmitted and prevented. Perceiving themselves as susceptible for HIV. Believing HIV is undesirable. Commitment – this decision-making stage may result in one of several outcomes. Making a firm commitment to deal with the problem. Remaining undecided. Waiting for the problem to solve itself. Resigning to the problem. Weigh cost and benefits - giving up pleasure (high risk) for less pleasure (low risk).

Major Factors –
   

response efficacy (effectiveness to change), perceived enjoyment (acts being added or eliminated), self-efficacy, and relevant information and social norms.

3. respected people who can assist in dispensing the message. Enactment – This includes three stages: Seeking information. Perceived severity – belief that harm can be done by the condition. Preparation – the person intends to change the behavior sometime soon and is actively preparing. a. People receive/accept messages at different time intervals. and accepted by. but not committed to the behavior change. People learn new behaviors through direct experience or modeling after others by observation. and Enacting solutions. 4. 1.recognizes behavior puts them at risk and is thinking about changing their behavior. b. Perceived benefits of performing a behavior – what they are going to get out of the change. Health Belief Model The Health Belief Model maintains that health related behaviors depend on four key beliefs that must be operating for a behavior change to occur. Perceived barriers of performing the behavior – what keeps them from changing. members of a group or population. Social Cognitive Theory The Social Cognitive Theory maintains that behavior changes are dynamic and influenced by personal and environmental factors. Self efficacy – a person’s belief about his/her ability and confidence in performing behaviors. c. Outcome expectations . Obtaining remedies.the extent the person values the expected outcome of a specific behavior. 1. Diffusion of Innovation Model The Diffusion of Innovation Model looks at how new ideas are communicated to. 3. Time and Process – required to reach community or group. Contemplation . Opinion Leaders – visible. 3. Communication Channels – for dispensing an innovative or new message. The six stages are: 1.1. Stages of Change Model (Transtheoretical Model) The Stages of Change Model maintains that behavior change occurs in stages and that movement through the stages varies from person to person. . 2. Perceived susceptibility – personally vulnerable to the condition. The three major components of this theory are 1. 2. not aware of risk. Pre-contemplation – no intention to change behavior. 2. Will it lead to a positive or negative outcome? 2.

Action . Intentions are influenced by two major factors. What is the role of theory in HIV prevention? What is theory and how can it help? A theory describes what factors or relationships influence behavior and/or environment and provides direction on how to impact them. Termination – individuals are presumed to have no intention to relapse and possess a complete sense of selfefficacy concerning their ability to maintain healthy behavior. What significant other thinks about performing the behavior.” yet these intuitive beliefs about why people do what they do are very useful and often similar to concepts found in formal theories conceived by academics. 3. and generalizable to various communities. a. 1. Three core elements of this theory are: 1. theory can show what factors should be targeted and where to focus interventions. b. 2. Belief in performing the behavior is based on positive or negative outcomes. Attitudes towards the behavior. Populations for change – individual/group level. 6.person has changed risky behavior recently (within the past six months). participatory dialogue and action. Focus group strategies – gathering information and finding solutions with the community. Theories used in HIV prevention are drawn from several disciplines. especially if the program hasn’t been evaluated.4. including psychology. Both formal and informal (or implicit) theories first begin with an individual’s observation about a person or phenomenon. 2. . Subjective norms about the behavior. Informal theories—those conceived by service providers— are not usually “tested. Evaluation of consequences to performing behavior. A theory becomes formalized when it is carefully tested with the results repeatable in a number of different settings. Empowerment Theory The Empowerment Theory maintains people change through a process of coming together to share experiences. Maintenance – person has maintained behavior change for a period longer than six months. a. Also. b. Participatory education – listening. When designing or choosing an intervention. Theories can help define the expected outcome of an intervention for evaluation purposes. Theories can help providers frame interventions and design evaluation. understand social influences. 5. sociology and anthropology. and develop solutions to problems. basing programs on a tested theory gives it scientific support. Theory of Reasoned Action The Theory of Reasoned Action maintains a person must have an intention to change. Motivation to perform behavior based on subjective norms.

community. drug abuse. based on Paulo Freire’s popular education model. How can theory guide programs? Answering the questions in the framework below can help in selecting the most appropriate theories and interventions for a particular community: Which communities/populations are targeted for services? What are the specific behaviors that put them at risk for HIV/STDS? What are the factors that impact risk-taking behaviors? Which factors are the most important and can be realistically addressed? What theory(ies) or models best address the identified factors? What kind of intervention can best address above factors? Behaviors that place people at risk for STDS/HIV acquisition and transmission are often the result of many complex factors operating at multiple levels. thus influencing the social determinants of individual risk behavior. and are spread into and then accepted by a community. and structural and environmental factors.HIV prevention providers are frequently required to use theory in the development of prevention interventions. sexism). though. Theories of behavior change usually address one or more these levels and include individual. the program seeks to foster strong relationships in a community with high rates of violence. Following are select theories and models and examples of programs that use them. Because many providers are not trained or supported in using theory. It’s common. solutions are jointly proposed. Diffusion of Innovation helps understand how new ideas or behaviors are introduced to. is a community organizing intervention based on empowerment theory that aims to increase the involvement of women of color in all aspects of HIV prevention. classism. Women . norms and values are no longer functioning. high rates of violence. racism. Once the issue is fully understood by community members. including laws. drug abuse and HIV infection. Social Disorganization Theory states that where social institutions. Theory of Gender and Power views the differences in labor. Voices of Women of Color Against HIV/AIDS (VOW) in New York City. Structural and policy level These theories look at societal and environmental influences on health. poverty and disease occur. This seeks to promote health by increasing people’s feelings of power and control over their lives. policies. Community level Empowerment Education Theory. they can miss the opportunity to use it as a process for thinking critically about a community in the development of programs. power dynamics. interpersonal. economic conditions and social inequalities (e. engages groups to identify and discuss problems. Many researchers and providers use a combination of factors from several theories to guide their programs. NY. Designed to address a broad range of social issues. agreed. and relationship-investment between women and men as structures that can produce inequalities for women and increase women’s risk and vulnerability to HIV. Family to Family is a structural intervention that strengthens family functioning and the bonds that connect families to each other in Harlem.g. and acted upon. for providers to pick a theory based on their intervention. customs.

VOW has met with legislators. and helps women advocate for formulating or changing policies. poverty and drug abuse. VOW organizes trainings on topics of highest concern. Centers for Disease Control and Prevention. Harm Reduction accepts that while harmful behaviors exist. Social Support/Social Networks describes the impact of social relationships on health and well-being. Theoretically speaking: overview and summary of key health education theories. that works with Latino gay men and is based on social support and social cognitive theories. which often go beyond HIV prevention to address violence.htm . The program features four skills-based workshops held in a local Latino dance club. Two primary components of this theory are: 1) modeling of behaviors we see others performing. Funders need to accept both tested and implicit theories as a valid base for programs. Contemplation. the main goal is to reduce their negative effects. STAND prepares teens to initiate conversations with their peers about sexual risk reduction. Individual level The Health Belief Model proposes that in order for persons to change their behaviors they must first believe they are susceptible to a particular condition. and 2) self-efficacy. Action and Maintenance. Evaluating CDC-Funded Health Department HIV Prevention Programs. where social networks refers to a web of social relationships and social support is the aid and assistance received through those relationships. Peer educators reported a sevenfold larger increase in condom use and a 30% decrease in unprotected intercourse. given public testimony and organized a women’s policy conference. HIV prevention training topics are sequenced to match each of the stages of change. What else is there? Besides tested and implicit theories. Theory of Reasoned Action sees intention as the main influence on behavior. from having no intentions to changing.http://www. Community Organizing/Mobilization approaches encourage communities to advocate for healthier conditions in their lives. Intentions are a combination of attitudes toward the behavior as well as perceived opinions of peers. 2. Interpersonal level Social Cognitive Theory views the adoption of behaviors as a social process influenced by interactions with a person and others in their environment.277-281. 2001:2. CA. to maintaining safer behaviors. and that the severity of that condition is serious. Health Promotion Practice.cdc. Says who? 1.meet monthly to discuss HIV/AIDS issues. then assess a person’s stage of change and suggest specific activities. Participants who complete all four workshops can become “Compadres” or community leaders who serve as a support network or “second family” for new workshop participants. The five stages are: Precontemplation. Providers have tremendous insight into what puts their clients at risk for HIV and why. Goldman KD. Preparation. Students Together Against Negative Decisions (STAND) is a peer educator training in a rural Georgia county that is based on stages of change and diffusion of innovations theories. Lista Para Accion is an intervention in Long Beach. there are strategies that are used as frameworks for programs. both heavily influenced by social norms. Stages of Changeexplains the process of incremental behavior change. a person’s belief that s/he is capable of performing the new behavior in the proposed situation. Schmalz KJ.gov/hiv/aboutdhap/perb/hdg. December 1999.

Smith MU. Bandura A. New York. Presented at the International Conference on AIDS. Health Behavior and Health Education: Theory. Abst. Elcock S. In DiClemente RJ (ed) Preventing AIDS: Theories and Methods of Behavioral Interventions. New Brunswick. Rietmeijer K. 1999. NJ: Rutgers University Press.dpuf Teaching Tip Sheet: Attitudes and Behavior Change Social Psychology Courses Important Issues or Topic in Psychology . 1992. Atlanta . American Journal of Health Promotion.See more at: http://caps. 12.6:197-205. 2000. Diffusion of Innovations. Vogan S. 13.27:539-565. 1991. 6. Abst # 335553. New York. Middlestadt SE. 14. Using the theory of reasoned action as a framework for under-standing and changing AIDS-related behaviors. Social cognitive theory and exercise of control over HIV infection. 1998. Fullilove MT. Fullilove RE.47:1102-1114. GA. 17. Glanz K. Social disorganization. 7. #443.3. 15.ucsf. Buitron M. Atlanta. New York. Switzerland. empowerment and health: implications for health promotion programs.30:441-449. Strecher VJ. Preventive Medicine. AIDS. . Third edition. GA. Application of the theory of gender and power to examine HIV-related exposures. Wallerstein N. Merrill FE. San Francisco: Jossey-Bass. Rosenstock IM. Corby N. 10. 11. STAND: A peer educator training curriculum for sexual risk reduction in the rural South. M Minkler. The health belief model and HIV risk behavior change. Inc. New York. DiClemente RJ. HIV and harm reduction for injection drug users. 1994. Marcus Lewis F. In DiClemente RJ (ed) Preventing AIDS: Theories and Methods of Behavioral Interventions. DiClemente CC. Elliott MA. Wingood GM. NY: The Free Press:1983. DiClemente RJ. Rogers EM. 1989. 2000. Health Education and Behavior. Presented at National HIV Prevention Conference. Presented at the National HIV Prevention Conference. ed. 1992. Green L. 1961. Powerlessness. Norcross JC. Applications to addictive behaviors. 2000. Freeman A. NY: Harper. In search of how people change. 1999. risk factors and effective interventions for women. Goodman D. Community organizing and community building for health. Fishbein M. American Psychologist. NY: Plenum Press.14S1. 5. 16. Rimer BK. NY: Plenum Press. AIDS. Research and Practice.2NjRU71k. 9. 1997. In Wasserheit JN (ed) Primary Prevention of AIDS: Psychological Approaches. 18. 4. Prochaska JO. Bridging theory and practice: a course on apply-ing behavioral theory to STD/HIV prevention. Rhodes F. Eds.S63-S67. Creating a culturally appropriate behavioral prevention intervention for Spanish speaking gay men from an existing risk-reduction program.edu/factsheets/theory/#sthash. et al. Brettle RP. Becker MH.5:125-136. 2nd Edition. The Family to Family pro-gram: a structural intervention with implications for the prevention of HIV/AIDS and other community epidemics. 8. 1994. 1997. Geneva. Women of color doing it for ourselves: HIV prevention policies. Abst #263.

etc. This section will focus on research on attitudes and behavior relevant to condom use. Other conceptual models such as the Health Belief Model (Becker & Joseph. Lessons Learned From HIV/AIDS Social science research on HIV/AIDS has provided some important lessons about how attitudes about specific HIV/AIDSrelated attitudes predict or correlate with HIV/AIDS risk behaviors. the Centers for Disease Control and Prevention (CDC) declared that (male) condoms when consistently and correctly used. 1993). attitudes towards sex. In the context of HIV/AIDS research. Because HIV infection is transmitted primarily through behaviors such as unprotected sex and injection drug use. Although research on attitudes is dispersed among many topics such as the measurement of attitudes. attitudes about the preventive efficacy of condoms.g.. research on the relationship between attitudes and behavior has consistently been one of the most prominent and debatable topics in the field of social psychology (Eagly & Chaiken. or self-efficacy.) predict or correlate with HIV/AIDS protective behaviors (e.. many social scientists had already begun examining whether people's attitudes about condoms influence condom use. p. using condoms. are the most effective way to prevent the sexual transmission of HIV. risk perception. social scientists have examined how attitudes about a variety of HIV/AIDS related topics (e. places. contemporary research on attitudes has empirically demonstrated that attitudes correlate most reliably with behaviors when an aggregate of attitudes is related to an aggregate of attitude-relevant behaviors. condoms. these studies have often included measures of respondents' attitudes about HIV/AIDS-related topics along with other variables such as knowledge about HIV/AIDS. In addition to the aforementioned studies. Attitudes are "psychological tendenc[ies] that [are] expressed by evaluating a particular entity with some degree of favor or disfavor" (Eagly & Chaiken.g. Rather. In general. etc.).The study of attitudes has had a long and preeminent history in the field of social psychology (Eagly. the structures of attitudes and beliefs. and things) attitude objects.). the Health Belief Model also focuses on attitudes about behaviors that will reduce the health threat. Intuitively. researchers have focused most of their attention on the attitudes and behaviors relevant to condom use.g. Nonetheless. being more selective about sexual partners. 1975). changing risky sexual practices. most of the studies on the attitude-behavior link have not been specifically designed to measure the relationship between HIV/AIDS-related attitudes and behavior.. Even before the federal agency's announcement. and when a single attitude is related to a single attitude-relevant behavior (Eagly & Chaiken. Since the beginning of the epidemic. many studies have applied conceptual models of health-related behavior change to the study of HIV/AIDS risk behaviors. For example.. 1993). and theories of attitude formation and change. many of these studies have yielded fairly consistent findings . 1). purchasing condoms. 1989) often include some attitudinal component. However. 1992.) would provide a more reliable measure of condom use when these behaviors are matched to an aggregation of a person's attitudes toward condoms (e. etc. The topic of attitudes is intrinsically appealing to psychologists and non-psychologists alike. the issue of how peoples' attitudes about HIV/AIDS relate to their HIV/AIDS risk behaviors is an especially important topic in contemporary social psychology. the perceived consequences of contracting HIV. In general. Eagly & Chaiken. 1993). reducing the number of sexual partners. these studies provide social scientists with important lessons about how HIV/AIDS-related attitudes are associated with behaviors to reduce transmission of the virus. In 1993.. carrying condoms. the availability of condoms. we all hold attitudes about many different abstract (e. in addition to people's perceptions of the severity of the health threat and their susceptibility to it.g. ideologies such as democracy and liberalism) and concrete (e. Kirscht & Joseph. Since most of the cases of HIV/AIDS in the United States have been sexually transmitted. 1988. etc. the association between a person's attitudes and her or his behavior makes sense. people.g. attitudes about the enjoyment of condoms. an aggregation of condom-relevant behaviors (e. carrying condoms.g. the ease of use of condoms.. 1993. using condoms. Attitudes toward a specific behavior are a cornerstone of the Theory of Reasoned Action (Fishbein & Azjen.

1992. 1992). Each of the strategies is designed to prompt students to think critically about how attitudes relate to behavior within the context of the HIV/AIDS epidemic. and subjective norms. 1993).about the condom attitude-behavior link. Ciarletta. In reality however. smoking-cessation or avoidance. Shnell. have strongly predicted intentions to use condoms in populations such as adolescents (Basen-Enquist & Parcel. These results have important implications for HIV/AIDS prevention messages and interventions targeted to people whose sexual behaviors may place them at risk for the disease. Ajdukovic & Prislin. 1991). European-American values that assume that people are motivated to act "rationally" and that people have the resources and skills to make certain decisions about their behaviors. 1995) and people who are poor or members of racial and ethnic minority groups (Cochran & Mays. Specifically. Tschann. Wilson. other studies have found no or weak links between attitudes and HIV/AIDS protective behaviors (Adjukovic. Gomez & Kegeles. although the Fishbein et al. subjective norms are also important. Fishbein and Azjen (1975) designed the theory to explain the psychological processes that mediate peoples' attitudes and behaviors. current or future (Valdiserri. 1988). Fishbein. Arena. Beeker. in combination with subjective norms. it has emerged as a one of the most successfully applied models of HIV/AIDS-related attitudes and behaviors. sexually active heterosexuals (Zimmerman & Olson. 1992). Using this theory. The theory posits that an individual's intention to engage in a certain behavior is the best predictor of that behavior. socialcontextual factors such as poverty and gender roles may mediate the relationship between attitudes about HIV/AIDS prevention practices. According to Cochran and Mays (1993). This exercise is useful for demonstrating how attitude-behavior correlations are influenced by the aggregation of attitude-relevant behaviors. Specifically. The theory is composed of three determinants: intention. For example. & Mallon. Although the Theory of Reasoned Action is not an HIV/AIDS specific theory. a person's positive evaluation of condoms is likely to be the single greatest predictor of whether he or she will report condom use in the past. gay men who lived in Seattle. 1990). Jaccard.g. This fact notwithstanding. many of the conceptual theories that social scientists frequently apply to HIV/AIDS prevention behaviors are based on individualistic. gay men (Cochran. Despite the applicability of the Theory of Reasoned Action to HIV/AIDS-related attitudes and behaviors. suggesting that other variables sometimes may be more predictive of behavioral change than attitudes. and HIV/AIDS risk reduction behaviors. attitudes. 1994). & Minkoff. 1996. Krahe & Reiss. racially and ethnically diverse groups of women (Gomez & VanOss-Marin. and Hispanic and White heterosexual men and women (VanOss-Marin. and condom use). 1993). Similar findings have held for adolescents (Barling & Moore. Teaching Strategies There are several teaching strategies that psychologists who teach the study of attitudes can use to update and enhance their courses to reflect what social scientists have learned from HIV/AIDS-related research. . 1993). The important lesson that these studies have provided is that attitudes alone are insufficient predictors of behavior. Wood. and African-American women (Jemmott & Jemmott. Chan. Caruso. Ask students to compare and analyze how peoples' attitudes about their general health and well-being influence health behaviors across domains (e. The following teaching strategies may be used in class discussions or may be assigned as course papers. a city with a large and visible gay community had greater intentions to engage in safer sex than gay men who lived in Albany where the gay community was much smaller and more invisible. (1992) study demonstrated that gay men's attitudes about safer sex behaviors were the most important determinant of intentions to perform HIV/AIDS protective behaviors. middle-class. O'Reilly. 1995). Proctor & Bonati. Mays.. Endias. subjective norms varied by city. 1992. exercise. & Cohn. social scientists have found that attitudes about condoms. critics have argued that this theory and other psychosocial models of HIV/AIDS prevention behavior generally have failed to consider how social contextual factors influence HIV/AIDS risk behaviors among women (Amaro.

E.. J. A. and condom use). S. heterosexual women. & Mays. & Gallilos. 14(3). and must perceive that the severity of the condition is such that it is worth avoiding. NY: Springer Publishing Co.. HIV/AIDS is an excellent topic for exploring issues relevant to diverse populations such as gay and bisexual men.. Using information to change sexually transmitted diseaserelated behaviors: An analysis based on the theory of reasoned action.. O. 142-154. Ajdukovic and Prislin's (1992) study's findings that attitudes about AIDS were poor predictors of young people's HIV/AIDS behavior changes is useful for this topic... D. S. A review of research on sexual and AIDS -related attitudes and behaviors. In D. 499-501. C. the Theory of Reasoned Action and the Health Belief Model). Key References Cochran. Gallios & M. & Hitchcock. Peterson (Eds.. & Rye. Chan. P. American Journal of Public Health. Ross.The theory of reasoned action: Its application to AIDS-preventive behavior.. & Albrecht. injection drug users. C. 6178). W.). The Cochran and Mays (1993) article is useful for this topic. Oxford. J. Applying social psychological models to predicting HIV-related sexual risk behaviors among African Americans.. B. R. C. (1989). Journal of Black Psychology. 79. The health-belief model This model (and the similar protection-motivation model) attempts to explain how individuals will take action to avoid ill health. (1995). J. (1993). G. D.).. AIDS in an aging society: What we need to know (pp. 39-59). Fisher. Zablotsky (Eds.. . Fishbein. Proctor. F. McLaws. (1994).J. (1992). L. A. W. Inc. mammography. Middlestadt. V. V. O'Reilly.. Journal of Applied Social Psychology. The Adjukovic. Schnell.. New York. Have students analyze the circumstances under which attitudes predict HIV/AIDS protective behaviors. Fisher.. AIDS prevention and mental health (pp. D... & Bonati. Understanding and promoting AIDS-preventive behavior: Insights from the Theory of Reasoned Action. M.). England: Pergammon Press. and when other variables are more significant. 255-264. Arena. 999-1011. individuals must recognise that they are susceptible to a particular condition (‘at risk’). McCamish (Eds. (1989).. A. Levy. 19 (2). J. The relationship between women's attitudes about condoms and their use: Implications for condom promotion programs. D. exercise.. Ask students to examine and analyze how social and contextual factors may mediate the attitude-behavior change link. M. (1994). Ory & D.G. Attitudes toward condoms and the theory or reasoned action. M. Beeker. K. L. In R. and low income communities to name just a few. First. New York.g. D. D. & Cohn. Fishbein. 22(13). M. Riley. NY: Plenum Press. L. Terry. Health Psychology. G. R. Preventing AIDS: Theories and methods of behavioral interventions. Attitudinal and normative factors as determinants of gay men's intentions to perform AIDS-related sexual behaviors: A Multisite analysis. communities of color.Neubauer's (1989) findings of a weak link between people's attitudes about HIV/AIDS protective behaviors and other preventive behaviors such as wearing seat-belts and avoiding smoking is a useful article for this topic. Next. In M. W. G. J. Valdiserri. C. students can discuss the benefits and drawbacks of applying these models to different health behaviors (e. Have students compare and contrast the strengths and limitations of conceptual models that include measures of attitudes and behaviors (e. K.. Wood. M. DiClemente & J. M.g. Inc.

Plenum Press.They must also perceive that the benefits of avoidance are worth the effort of changing their behaviour and the possible adverse effects of the change (e. References 1. critics have argued that it makes no reference to the pressures from peers or partners that may encourage risky behaviour. believe it to constitute a serious health problem and believe that the threat could be reduced by changing their behaviour at an acceptable psychological cost. etc. (Self-efficacy is ‘functional self-confidence’: it is a person’s confidence that they will accomplish a specific task. 119. 1996 2.) Cues to action are considered important in assisting all stages of change in this model. Rosenstock1 argues: “Programs to deal with a health problem should be based in part on knowledge of how many and which members of a target population feel susceptible to AIDS. One earlier meta-analysis2 found that there was no association between a person’s perceived vulnerability to HIV and the care they took to have safer sex. It does not offer much insight into long–term sustenance of behaviour change. The social learning model discussed immediately below grew out of the health-belief model during the 1970s and 1980s as educators began to appreciate its limitations for explaining how and why people change their behaviour. In particular. A cue for action could be a poster. 390-409.g. the model is strongly biased towards explaining the success of information-giving. New York. And. and allows sexual and drug-using behaviour to be framed in terms of ‘relapse’ if it does not conform to the model of behaviour change offered to the target audience. which can be more fully explained by the ‘reasoned action’ model discussed below. Rosenstock IM et al. Rosenstock argues that behaviour change is most likely to occur in circumstances where severity and susceptibility are rated highly by individuals. However.) to change their behaviour. an alcoholic losing friends when they stop drinking). they must perceive that they have the self–efficacy (in terms of skills. For example. The notion of relapse assumes that behaviour change is a once-and-for-all event rather than an evolution which requires ‘sustenance’ and support. DiClemente RJ & Peterson JL (Eds). The Health belief model and HIV risk behaviour change in Preventing AIDS: theories and models of behavioural interventions. and does not take into account new situations in which previous learning will be inappropriate. and the need for concentrating on the development of skills or cognitive techniques. Gerrard M et al. as seen above. and measuring its impact through knowledge and attitudes surveys. The model does offer some useful tools for questioning assumptions embedded in HIV prevention. assertiveness. a face–to–face encounter with an outreach worker or a conversation with a friend. 1996 ← . Relation between perceived vulnerability to HIV and precautionary sexual behavior. Finally. it can often come as a surprise to those involved in HIV prevention to discover that members of the target audience consider the consequences of HIV infection to be less serious than other outcomes (such as demonstrating a lack of trust in a partner or a loss of sexual pleasure from condom use).Psychological Bulletin. interventions that attempted to reinforce the threat of HIV were generally counter-productive. The health-belief model of individual behaviour change has been criticised for its lack of reference to the social and interactive context in which individuals come to judge their susceptibility to risks. An example might be the decision to abandon condom use in a relationship.” The attraction of this model is that responses to cues to action at each of the theorised stages are easily measurable by surveys of knowledge and attitudes and of self–reported behaviour.

For example. contraceptive behaviour and weight loss. This in turn is influenced by the degree to which the person has a positive attitude towards the behaviour. regardless of the underlying drivers of that change. or no intention to change risk behaviour contemplation – beginning to consider behaviour change without commitment to do anything immediately preparation – a definite intention to take preventive action in the near future action – modification of behaviour. Messages were developed from the experiences of community members to model behaviour-change steps. This model was used as the basis for the US AIDS Community Demonstration Projects. It is not so much a theory of how behaviour change happens as a ‘meta-theory’ of stages people go through in changing their behaviour. It divides behaviour change into the following stages:      pre-contemplation – lack of awareness of risk. This model is strongly biased towards changing subjective beliefs. Successful interventions should be the ones that focus on the particular stage of change the individual is experiencing and facilitate forward progression. Fishbein M Using information to change STD–related behaviours in Preventing AIDS: theories and models of behavioural interventions. if someone is told not to do something by someone they respect. There are very few evaluations of interventions aiming to alter beliefs and intentions amongst people at risk of HIV infection. according to the reasoned action model.Reasoned action model The reasoned action model1 assumes that most forms of human behaviour are a matter of choice. 1994 Stages of behaviour change models The behaviour-change-stage model1 offers an explanation of the stages through which an individual will progress during a change in health behaviour. environment or cognitive experience to overcome the problem maintenance – the stabilisation of the new behaviour and avoidance of relapse. Both theories attempt to define a sequence of stages that go from behaviour initiation to adoption to maintenance. . and the degree to which they expect that important others will think that they should perform the behaviour. alcoholism treatment. Plenum Press. and has been used widely in the treatment of alcoholism and smoking. DiClemente RJ & Peterson JL Eds. the most immediate determinant of any given behaviour is an individual's intention about whether or not to perform that behaviour. Thus. despite the strength of association demonstrated between intention and behaviour in such areas as smoking control. which targeted five at-risk populations in five US cities.2 which divides behavioural change into three stages. each with several influencing factors. but does not prescribe a particular methodology for doing so. A similar model is Catania’s AIDS Risk Reduction Model. This model is particularly associated with notions of ‘relapse’ behaviour. and messages were developed to target people considered to be at each of these five stages. References 1. they are more likely to act on that warning. New York.

few at first. Similarly. This finding should give some cheer to the developers of mass-media and prevention-information campaigns. but may not elicit movement beyond the initial stage. Diffusion theorists argue that a behaviour or innovation will be adopted if it is judged to have a high degree of utility. Prochaska JO et al. They imply that although behavioural-skills training is generally a necessary part of an effective HIV-prevention programme. Diffusion researchers have been very interested to define the characteristics of who adopts early. international development and marketing. However.Presumably. inducing favourable attitudes may be important at the very initial stages.Health Education Quarterly. and one of the major problems facing HIV educators is the difficulty of frank communication about HIV risk and how best to protect oneself and one's partners. but not when people are already performing the behaviour and are aware of its outcomes. A body of social theory called social diffusion theory1 has studied the diffusion of innovations in fields such as agriculture. knowledge of HIV/AIDS or more general risk perceptions may serve to prompt change when people are not yet performing the behaviour. . In search of how people change: applications to addictive behaviours. the provision of information. References 1. Diffusion of innovations theory has been adopted for the study of the adoption of behaviour intended to avoid HIV infection. More than 4500 studies have been published on the diffusion of innovations. Am Psychol 47 pp11021114. with innovations diffusing more rapidly in groups which were relatively homogenous. Catania JA et al. ‘Change agents’ who modelled a new innovation or disseminated information about it were most likely to be successful if they came from that group. They discovered that rates of adoption varied according to the homogeneity of the group. and if it is compatible with how individuals already think and act. an innovation will only be considered if it is known about. can prompt people to think about changing and can help them maintain safer behaviour when they have made changes. People who have already adopted the idea of change and begun to perform the behaviour may then need new skills to foster complete success. Diffusion research has also observed that innovations will tend to be adopted in a population according to a distribution that follows an S–shaped curve: that is. health-related behaviours are no exception. then an increasing proportion. 1990 Social diffusion models Innovations are diffused through social networks over time by well-established rules. and who influences those who adopt an innovation later. and a few late adopters. Towards an Understanding of Risk Behaviour: an AIDS Risk Reduction Model (ARRM). The taboo status of much discussion about HIV makes it difficult for individuals to judge the utility of an innovation such as condom use. 1992 2. because frank discussion of condom use is impossible on television. although it does not effect change in itself. 53-72.17.

Two other factors cited as important in the diffusion of innovations have particular relevance to HIV prevention. economic and environmental factors relate to risk is the starting point for planning interventions. uphold women’s property rights in cases of domestic abuse. individually focused interventions will be unable to achieve real change. prosecute men who inflict violence or provide havens for women who have experienced violence. In addition. so feel unable to negotiate condom use because they fear being abandoned by their partner. have argued that it is only by reference to social factors that we can understand differences in HIV prevalence amongst different ethnic groups of injecting drug users in the US. The model suggests that influencing social policy. Numerous studies have found that various environmental factors are associated both with high levels of risk behaviour and high levels of HIV infection. DiClemente RJ & Peterson JL Eds. political. For example. Without seeking to change the root causes or structures that affect individual risk and vulnerability to HIV. For example. such as stigma against people with HIV in the general population or in bodies like the police. but can identify points in a causal pathway where change may be achieved. These range from:  factors that could be influenced by economic improvement.   Gupta and colleagues suggest2 that an analysis of how social. economic structures and the medical infrastructure are some of the key routes to achieving change. New York. This model proposes the necessity of working with social groups. advocacy and political lobbying. interventions may aim to help women be more economically independent. 1994 Social/environmental change The final model assumes that there are broad structural factors which shape or constrain the behaviour of individuals. sex work or sex between men factors that can be influenced by cultural change or education programmes. and is the theoretical underpinning for activism. ‘Testability’ – opportunities for individuals to experiment with an innovation – and ‘visibility’ – the knowledge that others are already doing it – are crucial steps in the diffusion process.1 amongst many others. Diffusion theory and HIV risk behaviour change in Preventing AIDS: theories and models of behavioural interventions. References Dearing JW et al. such as the poverty that drives some women and men into sex work factors that could be influenced by legislative change. Interventions need not aim to achieve total change with regard to gender inequality. such as laws which criminalise needle exchange. fear of violence by men leads to women being unable to negotiate condom use. not individuals. the legal environment. gender inequality may be theorised to increase unprotected sex through more than one causal chain . Plenum Press.women are economically dependent on men. Friedman and Des Jarlais. .

Structural approaches to HIV prevention. decriminalising drug users or MSM may lead to more people adopting behaviours that risk HIV infection. Gupta GR et al. social change may not be sufficient in itself to produce a reduction in HIV incidence and may sometimes have paradoxical effects. Taking account of individual vulnerabilities and skills deficits will also continue to be an essential part of HIV prevention. with many intervening links. For example.It is beyond the remit of this book to investigate the social drivers of HIV in detail or action that has shown evidence of producing. is that there is a very long chain of causation between social changes being made and health outcomes. one of the problems with investigating social change as a driver of changes in HIV incidence. a reduction in HIV infections. New York. 1994 2. Moreover. References 1. as at least one of its outcomes. However. 2008 . The social-change model is influential in setting the agenda for HIV prevention and social change is regarded as essential as a prerequisite for tackling epidemics in certain populations. in DIClemente R & Peterson JL (Eds): Preventing AIDS: Theories and methods of behavioural interventions Plenum Press. Friedman S and Des Jarlais D Social models for changing health–relevant behaviour. The Lancet 372: 764-775. and devising studies to measure the efficacy of specific measures.