Using Health Promotion Models to Aid Behaviour Change

Information taken from a variety of sources; see Bibliography for full listing.

You are now going to consider the behaviour change models that have been most consistently used in HIV, STI and Viral Hepatitis prevention programmes. Follow along and it may help to make notes on interventions that you know about or have developed that use any of the behaviour change models that are covered.

After you have finished reading, identify the models used in an intervention aimed at MSM that you are familiar with. See if you can identify how that intervention and others are linked and if you are interested, see where they fit in a final overarching model at the end of the module.

Harm reduction

Harm Reduction is the attempt to reduce or mitigate the harm from a particular behaviour through a process of behavioural change. It is a strategy, service or product that is designed to modify causes, consumption and/or consequences of risky behaviour.

It was developed for and used mainly and extensively in Drug Treatment programmes where harm reduction measures include needle exchanges, drug replacement and drug withdrawal.

Sexual Harm Reduction is an offshoot of this methodology and seeks to reduce the risk of HIV transmission during sexual encounters.

Some principles of Harm Reduction Practice, amended from harmreduction.org:

• Accepts, for better and or worse, that risk behaviours form part of our world and chooses to work to minimize harmful effects rather than simply ignore or condemn them.
• Understands behaviour as a complex, multi-faceted phenomenon that encompasses a continuum of behaviours, and acknowledges that some ways of behaving are clearly safer than others.
• Establishes quality of individual and community life and well-being–not necessarily cessation of all potentially harmful behaviour–as the criteria for successful interventions and policies.
• Calls for the non-judgmental, non-coercive provision of services and resources to people at risk from harmful behaviours and the communities in which they live in order to assist them in reducing attendant harm.
• Ensures that the communities the work is aimed at routinely have a real voice in the creation of programs and policies designed to serve them.
• Affirms the people at risk from harmful behaviours as the primary agents of reducing the harms of their behaviour/s, and seeks to empower them to share information and support each other in strategies which meet their actual needs.
• Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with risk behaviours.

A Harm Reduction strategy around condoms could involve their use with people who you do not know well and do not know their HIV status, at the same time as having condomless sex with people who’s status you know to be the same as your own.

Harm Reduction is different to Harm Elimination, which is an attempt, usually imposed upon a person or group of people, to eliminate harm from their behaviours. Attempting to eliminate harm rather than reduce harm could lead to interventions such as; suggesting changing sexual behaviour by abstaining from sex altogether, separating out ‘infected’ people from ‘uninfected’ and segregating them or making certain behaviours or activities illegal and imprisoning people who engage in those behaviours. 

Harm Reduction measures attempt to persuade people to reduce harm by providing strategies or tools to help enable safer behaviours to be enacted. Harm Elimination measures attempt to eliminate the behaviour by measures that restrict peoples in that behaviour, many times by using legal restrictions and separation policies (imprisoning positive people who have sex with negative people). As such they disable people rather than enabling them to be safer in their choices and behaviours.

Health belief model

“The Health belief model, developed in the 1950s, holds that health behaviour is a function of individual’s socio-demographic characteristics, knowledge and attitudes. According to this model, a person must hold the following beliefs in order to be able to change behaviour:

• Perceived susceptibility to a particular health problem: “Am I at risk for HIV?”
• Perceived seriousness of the condition: “How serious is AIDS; how hard would my life be if I got it?”
• Belief in effectiveness of the new behaviour: “Condoms are effective against HIV transmission”
• Cues to action: “Witnessing the illness or death of a close friend or relative due to AIDS”
• Perceived benefits of preventive action: “If I start using condoms, I can avoid HIV infection”
• Barriers to taking action: “I don’t like using condoms”

In this model, promoting action to change behaviour includes changing individual personal beliefs. Individuals weigh the benefits against the perceived costs and barriers to change. For change to occur, benefits must outweigh costs. With respect to HIV, interventions often target perception of risk, beliefs in severity of AIDS (“there is no cure”), beliefs in effectiveness of condom use and benefits of condom use or delaying onset of sexual relations.”

Theory of reasoned action and theory of planned behaviour 

“The theory of reasoned action, advanced in the mid-1960s by Fishbein and Ajzen, is based on the assumptions that human beings are usually quite rational and make systematic use of the information available to them.

People consider the implications of their actions in a given context at a given time before they decide to engage or not engage in a given behaviour, and that most actions of social relevance are under volitional control (Ajzen, 1980).

The theory of reasoned action is conceptually similar to the health belief model but adds the construct of behavioural intention as a determinant of health behaviour. Both theories focus on perceived susceptibility, perceived benefits and constraints to changing behaviour. 

The theory of reasoned action specifically focuses on the role of personal intention in determining whether a behaviour will occur. A person’s intention is a function of 2 basic determinants:

• Their attitude toward the behaviour, and
• The prevailing ‘subjective norms’, i.e. any social influence upon them

‘Normative’ beliefs play a central role in the theory, and generally focus on what an individual believes other people, especially influential people, would expect him/her to do. 

For example, for a person to start using condoms, their attitude might be “having sex with condoms is just as good as having sex without condoms” and subjective norms (or the normative belief) could be “most of my peers are using condoms, they would expect me to do so as well”. 

Interventions using this theory to guide activities focus on attitudes about risk-reduction, response to social norms, and intentions to change risky behaviours.

The Theory of Planned Behaviour built further on this framework. Its design and dissemination followed Bandura’s work on self-efficacy and the publication of his Social Cognitive Theory in 1986 (Ajzen 1985, 1988). 

It is differentiated from the Theory of Reasoned Action, by the additional dimension of Perceived Behavioural Control (PBC), which is defined as the product of the control beliefs and self-efficacy. PBC is seen as acting as a determinant of intentions alongside subjective norms and behavioural attitude, and also as a direct influence on behaviour additional to intention.”

Stages of change model

“This model, developed early in the 1990s specifically for smoking cessation by Prochaska, DiClemente and colleagues, posits 6 stages that individuals or groups pass through when changing behaviour: 

• pre-contemplation,
• contemplation,
• preparation,
• action,
• maintenance and
• relapse.

With respect to condom use, the stages could be described as:

• pre-contemplation: has not considered using condoms
• contemplation: recognizes the need to use condoms
• preparation: thinking about using condoms in the next months
• action: using condoms consistently for less than 6 months
• maintenance: using condoms consistently for 6 months or more
• relapse: slipping-up with respect to consistent condom use

In order for an intervention to be successful it must target the appropriate stage of the individual or group. For example, awareness raising between stage one and two. Groups and individuals pass through all stages, but do not necessarily move in a linear fashion (Prochaska, 1992). As with previous theories, the stages of change model emphasizes the importance of cognitive processes and uses Bandura’s concept of self-efficacy. Movement between stages depends on cognitive-behavioural processes.”

Social cognitive (or learning) theory

“The premise of the social cognitive or social learning theory (SCT) states that new behaviours are learned either by modelling the behaviour of others or by direct experience. Social learning theory focuses on the important roles played by vicarious, symbolic, and self-regulatory processes in psychological functioning and looks at human behaviour as a continuous interaction between cognitive, behavioural and environmental determinants (Bandura, 1977). 

Central tenets of the social cognitive theory are:

• self-efficacy: the belief in the ability to implement the necessary behaviour: 

“I know I can insist on condom use with my partner”

• outcome expectancies: beliefs about outcomes: 

“I believe that if I use using condoms correctly that will prevent HIV infection.”

Programmes built on SCT integrate information and attitudinal change to enhance motivation and reinforcement of risk reduction skills and self-efficacy. Specifically, activities focus on the experience people have in talking to their partners about sex and condom use, the positive and negative beliefs about adopting condom use, and the types of environmental barriers to risk reduction.”

Now we will move on to look at models built on social interaction, and how people interact and could be influenced by those they come into contact with. They are:

Diffusion of innovation theory

“The diffusion of innovation theory (Rogers, 1983) describes the process of how an idea is disseminated throughout a community. According to the theory, there are four essential elements: the innovation, its communication, the social system and time. 

People’s exposure to a new idea, which takes place within a social network or through the media, will determine the rate at which various people adopt a new behaviour. The theory posits that people are most likely to adopt new behaviours based on favourable evaluations of the idea communicated to them by other members whom they respect (Kegeles, 1996).

Kelly explains that when the diffusion theory is applied to HIV risk reduction, normative and risk behavioural changes can be initiated when enough key opinion leaders adopt and endorse behavioural changes, influence others to do the same and eventually diffuse the new norm widely within peer networks. When beneficial prevention beliefs are instilled and widely held within one’s immediate social network, individuals’ behaviour is more likely to be consistent with the perceived social norms (Kelly, 1995).

Interventions using this theory generally investigate the best method to disperse messages within a community and who are the leaders able to act as role models to change community norms.

So if we look at this theory around condom use; at the start of the HIV epidemic condom use among gay and other MSM was low, they were viewed as something to stop pregnancy. As the leaders in the LGBTQI+ community identified that barrier methods were a probable protective method of avoiding infection community leaders began to use them and advocate their use with sexual partners. This grew to be a ‘norm’.

At the same time, community-based publications provided both evidence and information about condoms as protection against HIV infection to help spread the message, and community-based organisations began providing and distributing condoms via bars and other places gay and other MSM met for sex to enable men to access the ‘tools for safer sex’.”

Now that we have covered the most popular theories, here’s a table that shows how the models fit within the areas they change/affect, so read down the table to see where the models we’ve covered fit in.

Areas of change and the theories and models that underpin them

Areas of change	Theories or models
Theories that explain health behaviour and health behaviour change by focussing on the individual	Health Belief Model Theory of Reasoned Action Trans theoretical (stages of change) model Social Learning Theory
Theories that explain change in communities and community action for health	Community Mobilisation – Social Planning – Social Action – Community Development Diffusion of Innovation

Now that we have gone through the table, I’d like you to take some time to develop a small intervention of your choice that uses one of the models we’ve covered. If you’d prefer, try and identify a couple of interventions you have seen or worked on that use one or more of the models. See if you can identify separate interventions that have used models from the individual, the social and then the structural or environmental areas. 

You have about 15 minutes to complete the task/s.

How was that? Now that you maybe know more about the models, did it make it easier to think of or identify an intervention?

Next module: Useful settings for interventions aimed at MSM