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.

1. a. b. c.

Enactment This includes three stages: Seeking information, Obtaining remedies, and Enacting solutions.

Diffusion of Innovation Model The Diffusion of Innovation Model looks at how new ideas are communicated to, and accepted by, members of a group or population. The three major components of this theory are 1. 2. Communication Channels for dispensing an innovative or new message. Opinion Leaders visible, respected people who can assist in dispensing the message.

3. Time and Process required to reach community or group. People receive/accept messages at different time intervals. 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. 1. 2. 3. 4. Perceived susceptibility personally vulnerable to the condition. Perceived severity belief that harm can be done by the condition. Perceived benefits of performing a behavior what they are going to get out of the change. Perceived barriers of performing the behavior what keeps them from changing.

Social Cognitive Theory The Social Cognitive Theory maintains that behavior changes are dynamic and influenced by personal and environmental factors. People learn new behaviors through direct experience or modeling after others by observation. 1. Outcome expectations - the extent the person values the expected outcome of a specific behavior. Will it lead to a positive or negative outcome? 2. Self efficacy a persons belief about his/her ability and confidence in performing behaviors.

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. The six stages are: 1. Pre-contemplation no intention to change behavior; not aware of risk. 2. Contemplation - recognizes behavior puts them at risk and is thinking about changing their behavior, but not committed to the behavior change. 3. Preparation the person intends to change the behavior sometime soon and is actively preparing.

4. Action - person has changed risky behavior recently (within the past six months). 5. Maintenance person has maintained behavior change for a period longer than six months. 6. Termination individuals are presumed to have no intention to relapse and possess a complete sense of selfefficacy concerning their ability to maintain healthy behavior. Theory of Reasoned Action The Theory of Reasoned Action maintains a person must have an intention to change. Intentions are influenced by two major factors. 1. a. b. 2. a. b. Attitudes towards the behavior. Belief in performing the behavior is based on positive or negative outcomes. Evaluation of consequences to performing behavior. Subjective norms about the behavior. What significant other thinks about performing the behavior. Motivation to perform behavior based on subjective norms.

Empowerment Theory The Empowerment Theory maintains people change through a process of coming together to share experiences, understand social influences, and develop solutions to problems. Three core elements of this theory are: 1. Populations for change individual/group level. 2. Participatory education listening, participatory dialogue and action. 3. Focus group strategies gathering information and finding solutions with the community.

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. Theories used in HIV prevention are drawn from several disciplines, including psychology, sociology and anthropology. A theory becomes formalized when it is carefully tested with the results repeatable in a number of different settings, and generalizable to various communities. Both formal and informal (or implicit) theories first begin with an individuals observation about a person or phenomenon. Informal theoriesthose conceived by service providers are not usually tested, 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. Theories can help providers frame interventions and design evaluation. When designing or choosing an intervention, theory can show what factors should be targeted and where to focus interventions. Theories can help define the expected outcome of an intervention for evaluation purposes. Also, basing programs on a tested theory gives it scientific support, especially if the program hasnt been evaluated.

HIV prevention providers are frequently required to use theory in the development of prevention interventions. Its common, though, for providers to pick a theory based on their intervention. Because many providers are not trained or supported in using theory, they can miss the opportunity to use it as a process for thinking critically about a community in the development of programs. 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. Theories of behavior change usually address one or more these levels and include individual, interpersonal, community, and structural and environmental factors. Many researchers and providers use a combination of factors from several theories to guide their programs. Following are select theories and models and examples of programs that use them. Structural and policy level These theories look at societal and environmental influences on health, including laws, policies, customs, economic conditions and social inequalities (e.g. racism, classism, sexism). Social Disorganization Theory states that where social institutions, norms and values are no longer functioning, high rates of violence, drug abuse, poverty and disease occur. Theory of Gender and Power views the differences in labor, power dynamics, and relationship-investment between women and men as structures that can produce inequalities for women and increase womens 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, NY. Designed to address a broad range of social issues, the program seeks to foster strong relationships in a community with high rates of violence, drug abuse and HIV infection, thus influencing the social determinants of individual risk behavior. Community level Empowerment Education Theory, based on Paulo Freires popular education model, engages groups to identify and discuss problems. Once the issue is fully understood by community members, solutions are jointly proposed, agreed, and acted upon. This seeks to promote health by increasing peoples feelings of power and control over their lives. Diffusion of Innovation helps understand how new ideas or behaviors are introduced to, and are spread into and then accepted by a community. Voices of Women of Color Against HIV/AIDS (VOW) in New York City, 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. Women

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

3. Freeman A, Vogan S, Rietmeijer K, et al. Bridging theory and practice: a course on apply-ing behavioral theory to STD/HIV prevention. Presented at National HIV Prevention Conference, Atlanta, GA; 1999. Abst #263. 4. Elliott MA, Merrill FE. Social disorganization. New York, NY: Harper; 1961. 5. Wingood GM, DiClemente RJ. Application of the theory of gender and power to examine HIV-related exposures, risk factors and effective interventions for women. Health Education and Behavior. 2000;27:539-565. 6. Fullilove RE, Green L, Fullilove MT. The Family to Family pro-gram: a structural intervention with implications for the prevention of HIV/AIDS and other community epidemics. AIDS. 2000;14S1;S63-S67. 7. Wallerstein N. Powerlessness, empowerment and health: implications for health promotion programs. American Journal of Health Promotion. 1992;6:197-205. 8. Rogers EM. Diffusion of Innovations. Third edition. New York, NY: The Free Press:1983. 9. Elcock S, Goodman D. Women of color doing it for ourselves: HIV prevention policies. Presented at the National HIV Prevention Conference, Atlanta , GA. 1999, Abst. #443. 10. Bandura A. Social cognitive theory and exercise of control over HIV infection. In DiClemente RJ (ed) Preventing AIDS: Theories and Methods of Behavioral Interventions. New York, NY: Plenum Press; 1994. 11. Glanz K, Marcus Lewis F, Rimer BK, Eds. Health Behavior and Health Education: Theory, Research and Practice. 2nd Edition. San Francisco: Jossey-Bass, Inc. 1997. 12. Buitron M, Corby N, Rhodes F. Creating a culturally appropriate behavioral prevention intervention for Spanish speaking gay men from an existing risk-reduction program. Presented at the International Conference on AIDS, Geneva, Switzerland, 1998. Abst # 335553. 13. Rosenstock IM, Strecher VJ, Becker MH. The health belief model and HIV risk behavior change. In DiClemente RJ (ed) Preventing AIDS: Theories and Methods of Behavioral Interventions. New York, NY: Plenum Press; 1994. 14. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. American Psychologist. 1992;47:1102-1114. 15. Fishbein M, Middlestadt SE. Using the theory of reasoned action as a framework for under-standing and changing AIDS-related behaviors. In Wasserheit JN (ed) Primary Prevention of AIDS: Psychological Approaches. 1989. 16. Smith MU, DiClemente RJ. STAND: A peer educator training curriculum for sexual risk reduction in the rural South. Preventive Medicine. 2000;30:441-449. 17. Brettle RP. HIV and harm reduction for injection drug users. AIDS. 1991;5:125-136. 18. Community organizing and community building for health. M Minkler, ed. New Brunswick, NJ: Rutgers University Press. 1997. - See more at: http://caps.ucsf.edu/factsheets/theory/#sthash.2NjRU71k.dpuf Teaching Tip Sheet: Attitudes and Behavior Change Social Psychology Courses Important Issues or Topic in Psychology

The study of attitudes has had a long and preeminent history in the field of social psychology (Eagly, 1992; Eagly & Chaiken, 1993). The topic of attitudes is intrinsically appealing to psychologists and non-psychologists alike; we all hold attitudes about many different abstract (e.g., ideologies such as democracy and liberalism) and concrete (e.g., people, places, and things) attitude objects. Attitudes are "psychological tendenc[ies] that [are] expressed by evaluating a particular entity with some degree of favor or disfavor" (Eagly & Chaiken, 1993, p. 1). Although research on attitudes is dispersed among many topics such as the measurement of attitudes, the structures of attitudes and beliefs, and theories of attitude formation and change, 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, 1993). Intuitively, the association between a person's attitudes and her or his behavior makes sense. However, 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; and when a single attitude is related to a single attitude-relevant behavior (Eagly & Chaiken, 1993). In the context of HIV/AIDS research, an aggregation of condom-relevant behaviors (e.g., using condoms, carrying condoms, purchasing condoms, etc.) 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.g., attitudes about the preventive efficacy of condoms, the ease of use of condoms, attitudes about the enjoyment of condoms, the availability of condoms, etc.). Because HIV infection is transmitted primarily through behaviors such as unprotected sex and injection drug use, 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. Since the beginning of the epidemic, social scientists have examined how attitudes about a variety of HIV/AIDS related topics (e.g., attitudes towards sex, condoms, the perceived consequences of contracting HIV, etc.) predict or correlate with HIV/AIDS protective behaviors (e.g., using condoms, carrying condoms, changing risky sexual practices, reducing the number of sexual partners, being more selective about sexual partners, etc.). Since most of the cases of HIV/AIDS in the United States have been sexually transmitted, researchers have focused most of their attention on the attitudes and behaviors relevant to condom use. In general, 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. Rather, these studies have often included measures of respondents' attitudes about HIV/AIDS-related topics along with other variables such as knowledge about HIV/AIDS, risk perception, or self-efficacy. Nonetheless, 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 addition to the aforementioned studies, many studies have applied conceptual models of health-related behavior change to the study of HIV/AIDS risk behaviors. Attitudes toward a specific behavior are a cornerstone of the Theory of Reasoned Action (Fishbein & Azjen, 1975). Other conceptual models such as the Health Belief Model (Becker & Joseph, 1988; Kirscht & Joseph, 1989) often include some attitudinal component. For example, in addition to people's perceptions of the severity of the health threat and their susceptibility to it, the Health Belief Model also focuses on attitudes about behaviors that will reduce the health threat. 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. This section will focus on research on attitudes and behavior relevant to condom use. In 1993, the Centers for Disease Control and Prevention (CDC) declared that (male) condoms when consistently and correctly used, are the most effective way to prevent the sexual transmission of HIV. Even before the federal agency's announcement, many social scientists had already begun examining whether people's attitudes about condoms influence condom use. In general, many of these studies have yielded fairly consistent findings

about the condom attitude-behavior link. Specifically, 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, current or future (Valdiserri, Arena, Proctor & Bonati, 1988). Similar findings have held for adolescents (Barling & Moore, 1990); racially and ethnically diverse groups of women (Gomez & VanOss-Marin, 1996; Wilson, Jaccard, Endias, & Minkoff, 1993); and Hispanic and White heterosexual men and women (VanOss-Marin, Tschann, Gomez & Kegeles, 1993). 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. This fact notwithstanding, other studies have found no or weak links between attitudes and HIV/AIDS protective behaviors (Adjukovic, Ajdukovic & Prislin, 1992), suggesting that other variables sometimes may be more predictive of behavioral change than attitudes. Although the Theory of Reasoned Action is not an HIV/AIDS specific theory, it has emerged as a one of the most successfully applied models of HIV/AIDS-related attitudes and behaviors. Fishbein and Azjen (1975) designed the theory to explain the psychological processes that mediate peoples' attitudes and behaviors. The theory posits that an individual's intention to engage in a certain behavior is the best predictor of that behavior. The theory is composed of three determinants: intention, attitudes, and subjective norms. Using this theory, social scientists have found that attitudes about condoms, in combination with subjective norms, have strongly predicted intentions to use condoms in populations such as adolescents (Basen-Enquist & Parcel, 1992; Krahe & Reiss, 1995); sexually active heterosexuals (Zimmerman & Olson, 1994); gay men (Cochran, Mays, Ciarletta, Caruso, & Mallon, 1992; Fishbein, Chan, O'Reilly, Shnell, Wood, Beeker, & Cohn, 1992); and African-American women (Jemmott & Jemmott, 1991). The important lesson that these studies have provided is that attitudes alone are insufficient predictors of behavior; subjective norms are also important. For example, although the Fishbein et al. (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, subjective norms varied by city. Specifically, gay men who lived in Seattle, 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. Despite the applicability of the Theory of Reasoned Action to HIV/AIDS-related attitudes and behaviors, 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, 1995) and people who are poor or members of racial and ethnic minority groups (Cochran & Mays, 1993). According to Cochran and Mays (1993), many of the conceptual theories that social scientists frequently apply to HIV/AIDS prevention behaviors are based on individualistic, middle-class, 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. In reality however, socialcontextual factors such as poverty and gender roles may mediate the relationship between attitudes about HIV/AIDS prevention practices, and HIV/AIDS risk reduction behaviors. 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. The following teaching strategies may be used in class discussions or may be assigned as course papers. 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. Ask students to compare and analyze how peoples' attitudes about their general health and well-being influence health behaviors across domains (e.g., smoking-cessation or avoidance, exercise, and condom use). This exercise is useful for demonstrating how attitude-behavior correlations are influenced by the aggregation of attitude-relevant behaviors.

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

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.g. an alcoholic losing friends when they stop drinking). Finally, they must perceive that they have the selfefficacy (in terms of skills, assertiveness, etc.) to change their behaviour. (Self-efficacy is functional self-confidence: it is a persons confidence that they will accomplish a specific task.) Cues to action are considered important in assisting all stages of change in this model. A cue for action could be a poster, a facetoface encounter with an outreach worker or a conversation with a friend. 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, 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. 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 selfreported behaviour. However, the model is strongly biased towards explaining the success of information-giving, and measuring its impact through knowledge and attitudes surveys. It does not offer much insight into longterm sustenance of behaviour change, 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. The notion of relapse assumes that behaviour change is a once-and-for-all event rather than an evolution which requires sustenance and support, and does not take into account new situations in which previous learning will be inappropriate. An example might be the decision to abandon condom use in a relationship, which can be more fully explained by the reasoned action model discussed below. The model does offer some useful tools for questioning assumptions embedded in HIV prevention. For example, 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). Rosenstock argues that behaviour change is most likely to occur in circumstances where severity and susceptibility are rated highly by individuals. 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. In particular, critics have argued that it makes no reference to the pressures from peers or partners that may encourage risky behaviour. 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, and the need for concentrating on the development of skills or cognitive techniques. One earlier meta-analysis2 found that there was no association between a persons perceived vulnerability to HIV and the care they took to have safer sex. And, as seen above, interventions that attempted to reinforce the threat of HIV were generally counter-productive. References 1. Rosenstock IM et al. The Health belief model and HIV risk behaviour change in Preventing AIDS: theories and models of behavioural interventions. DiClemente RJ & Peterson JL (Eds), Plenum Press, New York, 1996 2. Gerrard M et al. Relation between perceived vulnerability to HIV and precautionary sexual behavior.Psychological Bulletin, 119, 390-409, 1996

Reasoned action model The reasoned action model1 assumes that most forms of human behaviour are a matter of choice. Thus, the most immediate determinant of any given behaviour is an individual's intention about whether or not to perform that behaviour. This in turn is influenced by the degree to which the person has a positive attitude towards the behaviour, and the degree to which they expect that important others will think that they should perform the behaviour. For example, if someone is told not to do something by someone they respect, they are more likely to act on that warning, according to the reasoned action model. This model is strongly biased towards changing subjective beliefs, but does not prescribe a particular methodology for doing so. There are very few evaluations of interventions aiming to alter beliefs and intentions amongst people at risk of HIV infection, despite the strength of association demonstrated between intention and behaviour in such areas as smoking control, alcoholism treatment, contraceptive behaviour and weight loss. References 1. Fishbein M Using information to change STDrelated behaviours in Preventing AIDS: theories and models of behavioural interventions. DiClemente RJ & Peterson JL Eds, Plenum Press, New York, 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. 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, regardless of the underlying drivers of that change. This model is particularly associated with notions of relapse behaviour, and has been used widely in the treatment of alcoholism and smoking. It divides behaviour change into the following stages:

pre-contemplation lack of awareness of risk, 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, environment or cognitive experience to overcome the problem maintenance the stabilisation of the new behaviour and avoidance of relapse.

This model was used as the basis for the US AIDS Community Demonstration Projects, which targeted five at-risk populations in five US cities. Messages were developed from the experiences of community members to model behaviour-change steps, and messages were developed to target people considered to be at each of these five stages. A similar model is Catanias AIDS Risk Reduction Model,2 which divides behavioural change into three stages, each with several influencing factors. Both theories attempt to define a sequence of stages that go from behaviour initiation to adoption to maintenance. Successful interventions should be the ones that focus on the particular stage of change the individual is experiencing and facilitate forward progression.

Presumably, knowledge of HIV/AIDS or more general risk perceptions may serve to prompt change when people are not yet performing the behaviour, but may not elicit movement beyond the initial stage. Similarly, inducing favourable attitudes may be important at the very initial stages, but not when people are already performing the behaviour and are aware of its outcomes. People who have already adopted the idea of change and begun to perform the behaviour may then need new skills to foster complete success. This finding should give some cheer to the developers of mass-media and prevention-information campaigns. They imply that although behavioural-skills training is generally a necessary part of an effective HIV-prevention programme, the provision of information, although it does not effect change in itself, can prompt people to think about changing and can help them maintain safer behaviour when they have made changes. References 1. Prochaska JO et al. In search of how people change: applications to addictive behaviours. Am Psychol 47 pp11021114, 1992 2. Catania JA et al. Towards an Understanding of Risk Behaviour: an AIDS Risk Reduction Model (ARRM).Health Education Quarterly,17, 53-72, 1990 Social diffusion models Innovations are diffused through social networks over time by well-established rules; health-related behaviours are no exception.

A body of social theory called social diffusion theory1 has studied the diffusion of innovations in fields such as agriculture, international development and marketing. More than 4500 studies have been published on the diffusion of innovations.

Diffusion of innovations theory has been adopted for the study of the adoption of behaviour intended to avoid HIV infection. Diffusion theorists argue that a behaviour or innovation will be adopted if it is judged to have a high degree of utility, and if it is compatible with how individuals already think and act.

However, an innovation will only be considered if it is known about, 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. The taboo status of much discussion about HIV makes it difficult for individuals to judge the utility of an innovation such as condom use, because frank discussion of condom use is impossible on television.

Diffusion research has also observed that innovations will tend to be adopted in a population according to a distribution that follows an Sshaped curve: that is, few at first, then an increasing proportion, and a few late adopters. Diffusion researchers have been very interested to define the characteristics of who adopts early, and who influences those who adopt an innovation later. They discovered that rates of adoption varied according to the homogeneity of the group, with innovations diffusing more rapidly in groups which were relatively homogenous. Change agents who modelled a new innovation or disseminated information about it were most likely to be successful if they came from that group.

Two other factors cited as important in the diffusion of innovations have particular relevance to HIV prevention. 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.

References Dearing JW et al. Diffusion theory and HIV risk behaviour change in Preventing AIDS: theories and models of behavioural interventions. DiClemente RJ & Peterson JL Eds, Plenum Press, New York, 1994 Social/environmental change The final model assumes that there are broad structural factors which shape or constrain the behaviour of individuals. Without seeking to change the root causes or structures that affect individual risk and vulnerability to HIV, individually focused interventions will be unable to achieve real change. The model suggests that influencing social policy, the legal environment, economic structures and the medical infrastructure are some of the key routes to achieving change. This model proposes the necessity of working with social groups, not individuals, and is the theoretical underpinning for activism, advocacy and political lobbying. Friedman and Des Jarlais,1 amongst many others, 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. Numerous studies have found that various environmental factors are associated both with high levels of risk behaviour and high levels of HIV infection. These range from:

factors that could be influenced by economic improvement, such as the poverty that drives some women and men into sex work factors that could be influenced by legislative change, such as laws which criminalise needle exchange, sex work or sex between men factors that can be influenced by cultural change or education programmes, such as stigma against people with HIV in the general population or in bodies like the police.

Gupta and colleagues suggest2 that an analysis of how social, political, economic and environmental factors relate to risk is the starting point for planning interventions. For example, gender inequality may be theorised to increase unprotected sex through more than one causal chain - women are economically dependent on men, so feel unable to negotiate condom use because they fear being abandoned by their partner. In addition, fear of violence by men leads to women being unable to negotiate condom use. Interventions need not aim to achieve total change with regard to gender inequality, but can identify points in a causal pathway where change may be achieved. For example, interventions may aim to help women be more economically independent, uphold womens property rights in cases of domestic abuse, prosecute men who inflict violence or provide havens for women who have experienced violence.

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