How is theory used?
Whether or not it is stated, some form of theory is already the basis of prevention interventions. Prevention planners know their populations and have ideas about what determines client behaviors as well as their strengths and needs as individuals and as a community. This hands-on knowledge about what works is informal theory.
Formal theory is made up of principles and methods about prevention and behavior change that have already proven useful in some areas of disease prevention and behavior change. Theories can give HIV program planners a framework for the goals of an intervention, or help explain aspects of risk-taking behavior when working with a new population. Using theories to design HIV prevention interventions can help improve programs, saving valuable time and resources.(1)
What are some theories?
Theory is one of many tools that can have an important influence on HIV prevention programs. Some of the most widely-known theories are presented below. These theories are not mutually exclusive, but can work together to guide effective programs.
Health Belief Model proposes that an individual's actions are based on beliefs.(2) It identifies key elements of decision making such as the person's perception of susceptibility, perceived severity of the illness, and the perceived barriers to prevention.
Theory of Reasoned Action sees intention as the main influence on behavior.(3) Intentions are a combination of personal attitudes toward the behavior as well as the opinions of peers, both heavily influenced by the social milieu.
Social Cognitive Theory views learning as a social process influenced by interactions with other people.(4) In Social Cognitive Theory physical and social environments are influential in reinforcing and shaping the beliefs that determine behavior. A change in any of the three components-behavior, physical or social environments-influences the other two. Self-efficacy, an essential component of the theory, is the person's belief that s/he is capable of performing the new behavior in the proposed situation.
AIDS Risk Reduction Model suggests that in order to change behavior one must first label the behavior as risky, then make a commitment to reduce the behavior, and finally to take action to perform the desired change.(5) Factors influencing movement between these stages include fear/anxiety and social norms.
Diffusion of Innovation helps understand how new ideas or behaviors are introduced and become accepted by a community. People in the same community adopt new behaviors at different rates and respond to different methods of intervention.(6)
Stages of Change explains the process of behavior change, from not being aware of the negative effects of a behavior, to maintaining safer behaviors.(7) The five stages are: Precontemplation, Contemplation, Preparation, Action and Maintenance. Different stages exist in the same population. People do not necessarily pass through stages sequentially and may repeat stages.
Harm Reduction accepts that while harmful behaviors exist, the main goal is to reduce their negative effects.(8) HR examines behaviors and attitudes of the individual to offer ways to decrease the negative consequences of the targeted behavior.
Paulo Freire's ideas on Popular Education are based on the belief that teachers and students have different strengths, and should learn reciprocally from each other.(9) Group discussions examine problems and develop solutions to personally empower people to change their environment, thereby influencing their subsequent actions.
How is theory used in practice?
Just as people draw from a variety of influences for their actions, programs can be designed or modified using relevant parts of different theories.
A school-based program targeting African-American male adolescents in Philadelphia, PA used Reasoned Action and Social Cognitive theories. A five-hour session included discussion, games, role playing, videos, and other activities. The session targeted self-efficacy through role playing, and peer norms through a variety of exercises. Follow-up after three months showed less sexual risk-taking and higher maintenance of safer sex intentions since the intervention.(10)
Guided by Diffusion of Innovation, one mid-western project used bartenders at gay bars in several medium-sized towns to help identify the most popular people. These people were trained to deliver AIDS risk-reduction messages to their friends and acquaintances in the bars. Patrons encouraged by the role modeling of these popular community members were found to have fewer instances of unsafe sex.(11)
In a sexually-transmitted disease clinic in New York, a video-based educational intervention was planned through the use of the Theory of Reasoned Action and Social Cognitive Theory. The culturally sensitive videos were effective in increasing condom purchases among both men and women and even more effective with the addition of interactive group sessions following the videos (a 74% increase over the control group). The videos targeted norms, attitudes, and behaviors that were reducing the effectiveness of current sexually transmitted disease prevention efforts. The intervention was effective by providing information to overcome barriers to safe sex, discussing issues around condom use, and practicing condom negotiating skills.(12)
MenTalk, a program for gay men in Oregon, uses a Popular Education approach, gathering groups of gay men and a volunteer facilitator to discuss barriers and solutions to issues about HIV testing, safer-sex and community involvement. The program helped raise consciousness and encouraged the participants to make HIV prevention behavior changes at both the personal and the community level.(13)
Using the Harm Reduction model and the principles of Freirean empowerment, needle exchange programs across the country aim to decrease the transmission of HIV infection in injection drug users. Programs may offer clean needles, bleach, condoms, as well as referrals to treatment programs. By working with clients whether they intend to continue using drugs or not, these programs build trust and assist clients to decrease the risk of HIV infection.(14)
A program targeting recently released male and female parolees with a history of drug injection used Social Cognitive Theory to develop an AIDS prevention training. By using ideas of community building, individual responsibility, role models, and job training as outreach workers, the environment in which behaviors would be determined was modified. After one year, participants had significantly decreased certain sexual and drug risk taking and also improved their adjustment to the community.(15)
What needs to be done?
New theories arise from a variety of sources, often from the community that sees the need. Collaborations between service organizations and researchers need to be encouraged, so that programs move beyond learning through word of mouth. A comprehensive HIVprevention strategy uses multiple elements to protect as many of those at risk of HIV infection as possible. Using theory as a framework, planners can take a closer look at what works in prevention and design more effective programs and lay the groundwork for program evaluation. This synthesis can result in more effective programs which better reach people at risk, and can help save time, money and lives.
References:
Prepared by Tara Herlocher, Colleen Hoff, Pamela DeCarlo
Reproduction of this text is encouraged; however, copies may not be sold. The Center for AIDS
Prevention Studies at the University of California San Franciso is the source of this
information. For additional copies of this and other HIV Prevention Fact Sheets, please call the
National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may
be e-mailed to prevention_factsheets@quickmail.ucsf.edu. ©1996, University of California
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