Discard flimsy logic to change behaviours
By Prem Misir
November 13, 2006
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Today, the HIV-1 pandemic has become the defining public-health crisis, possibly of all times. Outstanding researchers as David Ho, Vivianna Simon, and Quarraisha Karim continue to echo their concerns about the absence of an AIDS cure; with poor countries carrying a disproportionate burden and consequences of this pandemic.
Notwithstanding the fact that research has enhanced our knowledge of how the virus reproduces, controls, and hides in an infected person, and that prevention interventions have increased, a cure or protective vaccine continues to be indefinable.
Clearly, today, in advanced industrial countries, antiretroviral medication has changed AIDS into a chronic disease; but in resource-limited countries, this certainly is not the case, but really a case of rapidly rising morbidity and mortality.
The UNAIDS 2006 Report claims that globally, 38.6 million persons are living with HIV-1, with about 25 million deaths. If you take 2005 alone, UNAIDS reported that worldwide, 4.1 million persons became infected with HIV-1 and that 2.8 million persons died of AIDS-related diseases. And heterosexual transmission is responsible for about 85% of all HIV-1 infections worldwide.
Clearly, in the absence of a cure or protective vaccine, all we have left is prevention; but we must design scientific and theory-based interventions, not interventions based on flimsy logic.
People live and work in social groups; these groups are governed through behavioural, social, psychological, and cultural factors; facets enabling people to form attitudes, acquire beliefs, attain skills, and perform behaviours.
If we agree on this, then we would need some kind of method to identify the factors encouraging risky behaviours, that is, behaviours that place people at risk for contracting Sexually Transmitted Infections (STI)/Human Immunodeficiency Virus (HIV).
The people themselves engaging in risky behaviours will have to tell what their interests and needs are, that is, what factors encourage their risky behaviours; this is the formative study in action, if you will; and Ďexpertsí should not speculate on factors placing people at risk. Let the people tell their own story and not be pressured, however, subtly, to give half-truths.
The formative study uses ethnographic components to identify what produces high-risk behaviours. And the formative study eventually will produce a written account of cultures, developed from the viewpoint of the Ďinsiderí, the high-risk person; the insider telling us about the most significant factors supporting his/her risk behaviours.
Knowing these factors will help us to design appropriate theory-based behaviour change interventions; the health belief model, social cognitive theory, and the theory of reasoned action, are some theories among others, which may explain a personís intentions and behaviours, thus:
1. The personís belief that he/she is at risk of contracting a disease/illness.
2. The personís attitude, positive or negative, to engaging in high-risk behaviours.
3. The personís perception of the community, that is, whether others in the community are changing, and whether close peers are supportive of his/her effort to change.
4. The personís self-efficacy, referring to whether the person has a perception that he/she has the skills to control a high-risk situation under different conditions.
A formative study will tell us which one or a combination of these factors has the most important influence on a personís high-risk behaviour. The intervention to change behaviours would then target this critical influencing factor or factors.
So, prior to designing an intervention to change behaviours, it is necessary to conduct a formative study to first identify and understand the factors influencing high-risk behaviours, before we can even begin to intervene to change a specific behaviour.
In a country as Guyana with a relatively high prevalence rate, it is crucial that interventions are scientifically designed, incorporating findings from the formative process, to further reduce the spread of HIV by HIV-positive persons. And note that this formative perspective, solidly based on the ethnographic method, seriously addresses the issue of secondary prevention.
As we approach another World AIDS Day on December 1, let us focus on the fact that HIV infection is preventable, mainly via behaviour change.