How to Influence Larger Systems Change in Hiv Art

INTRODUCTION

Attempts to ho-hum the HIV epidemic worldwide have led to a clearer understanding that the battle is not simply about using condoms or adherence to medication. Rather, HIV risk and AIDS care involve complex behaviors influenced from multiple levels, from an private'southward cognition, attitudes, emotions, and take chances perception, to ability dynamics between partners, accessibility of services, economic inequalities, criminalization of vulnerable groups, and policies that brand HIV a priority wellness issue.^one–3 Although there accept been some calls to be more inclusive of multi-level factors beyond the individual level (e.g., at the interpersonal, network, institutional, or structural levels),^4,five testify addressing a more holistic arroyo to changing HIV-related behaviors is limited. Among such models, ecological models are a family of approaches seeking to depict the multiple levels of influence on individual beliefs in the interest of creating environments conducive to wellness promotion.⁶ Although there seems to exist fiddling disagreement that ecological approaches are more comprehensive and potentially more explanatory and effective than frameworks or models merely taking ane level into account,⁷ such frameworks have received relatively little inquiry attention, for at least three reasons.

Commencement, assessing impact at multiple levels is oftentimes viewed as too difficult or expensive. For example, an intervention in a low-income setting with the objective of increasing HIV counseling and testing may need to address (i) the stigma of being tested and/or of testing positive; (2) the quality of patient–counselor interactions; (three) facility capacity, supplies, and environment; and (4) admission to those facilities by infrastructure, such as good roads and public transportation. Addressing all of those factors and measuring improvements of each is extremely ambitious for any one research project. Even in an individual-focused intervention, addressing multi-level factors has its challenges.

Second, multi-level interventions are diverse and often context specific,⁸ and thus, it is not easy, or even appropriate, to replicate them. Nor do they easily support generalizations across contexts.⁹ For instance, a "structural" intervention for people who inject drugs in Ukraine (eg, needle commutation programs) would seem to accept little in mutual with a structural intervention for poor women in Federal democratic republic of ethiopia whose fiscal dependence on men often results in transactional or cantankerous-generational sex (eg, cash transfer).

Finally, with randomized controlled trials (RCTs) still viewed as the "aureate standard" in wellness research, interventions addressing factors at multiple levels are often not attempted considering an RCT is not feasible or even appropriate.^x Furthermore, combining individual-level and structural-level factors in one written report is not straightforward. For instance, Kippax¹⁰ argued that structural influences, such equally political will to implement harm reduction strategies or funding for mass media to lead public discussions virtually sensitive HIV-related topics, have a determining impact on HIV transmission and the likelihood that private- or interpersonal-level interventions will succeed. But political will and vibrant mass media are rarely amenable to evaluation through an RCT, as the meta-analysis by Lacroix et al.^eleven in this special issue documents.

Multi-level approaches, thus, are in many ways at odds with contemporary HIV-related policy, which often favors brief, replicable, and easily disseminated interventions. Individual-level or interpersonal-level interventions are nearly amenable to such constraints. All the same, this commodity is guided by the current literature and theory, rather than by policy constraints. Indeed, it is in line with simultaneous policy shifts (contradictory to the accent on brevity and replicability) in favor of structural interventions. Although the field of behavior change research in HIV seems to accept that alter ways going across the individual level,⁴ there is all the same only a pocket-size literature on models taking multi-level approaches. This article aims to contribute to the shift to a more than holistic approach by synthesizing and making sense of a complex literature, leading us to outline the next steps required equally clearly as possible. Specifically, nosotros (i) list potentially relevant variables/factors related to beliefs alter at all levels of the individual–structural spectrum, (2) identify characteristics of important contempo multi-level models and compare them, (three) identify challenges in using such models, and (4) identify next steps and make actionable recommendations.

A Menu of Behavior Change Factors

Effigy 1 provides a carte of the diverse influences on behavior change at each level of the socio-ecological framework based on our review of existing literature on behavior alter interventions related to HIV prevention, treatment, and care. The individual level includes factors comprising the micro-level, such every bit individual perceptions, beliefs, or emotions. The interpersonal/network level includes dyadic or family unit influences, such as human relationship satisfaction or social support. The community level includes influences at a larger group level, such every bit social upper-case letter or community norms. The institutional level focuses on factors within the health system, such as quality of service providers, confidentiality, or sufficient resource. Finally, the structural level includes the well-nigh macro-level factors affecting behavior, such as the economy, political climate, enforcement of policies and laws, or funding environment. Some structural factors may be more removed from individual control than others. For instance, wars, famines, or droughts are important structural factors further removed from the individual than, for instance, the availability of transport to admission a clinic or income-generating opportunities in a particular customs. Moreover, although we distinguish between "levels," they are highly interactive, with processes ranging between micro and macro. Structural influences function just with the cooperation of individuals and their interpersonal relationships, and vice versa.

Figure ane:

Factors influencing HIV-related beliefs and/or behavior alter at each level of the socio-ecological model.

Many of these factors accept been extensively researched and incorporated into successful interventions (eg, cocky-efficacy, behavioral skills, stigma reduction) while others accept been discussed as important factors without much evidence to engagement on how they can be leveraged for beliefs change (eg, emotions, sexual relationship ability, community mobilization). The effigy provides citations to key articles evidencing or arguing for each factor, where available.

The purpose of this figure is to provide an overview of the diverse influences relating to HIV risk or AIDS care. The effigy does not represent a theory of the relationships amongst the variables at the unlike levels of analyses, nor tin it be used to determine which variables might be most of import to address in a particular intervention. Yet, information technology does highlight some variables that take but recently been investigated, such as emotions,^12,13 social networks/coalitions/capital,¹⁴ and relationship investment.¹⁵ Moreover, in recent years, theoretical models accept begun to conceptualize how these variables and levels are linked together.

Recent Theoretical Frameworks Addressing Multi-Level Factors

Many individual-level theories have played prominent roles in past behavioral interventions focused on HIV prevention and AIDS intendance, including especially Social Cognitive Theory,^xvi,17 the Theories of Reasoned Action^xviii and Planned Behavior,¹⁹ the Transtheoretical Model,^20,21 and the Information, Motivation, Behavioral Skills Model²² (Table 1). Although these models primarily focus on the private level, they have been associated with pregnant beliefs change beyond a range of groups with varying risk levels (eg, men who have sex with men, adolescents, people living with HIV/AIDS, African Americans^23–28). Nonetheless, reviews of such models have concluded that, because they practice non explicitly consider loftier-level connections, their success is constrained.²⁹ Of note, meta-analyses of behavioral intervention trials routinely detect that inconsistencies in report outcomes cannot be explained solely on the ground of moderators stemming from individual-level theories²³⁻²⁸; until recently, these meta-analyses have rarely considered factors outside the intervention itself in efforts to explain heterogeneity.

Tabular array ane:

Synopsis of Selected Individual HIV Prevention Models on Primal Considerations

Several recent models have taken upwards the challenge of expanding from individual-level features to be inclusive of college levels. The Multiple Domain Model (MDM)³⁰ proposes that in that location are multiple domains of influence on health behavior, with situational/contextual variables beingness the about proximal to behavior, followed by preparatory behaviors, behavioral intentions, normative, attitudinal, and self-efficacy beliefs, personality and social environmental factors, and finally social structural variables. Substantially, the MDM starts with the Theory of Planned Behavior, replacing perceived behavioral control with cocky-efficacy. It so adds structural factors in the sociological sense (race, gender, age, social course) and variables that address personality, the social environment (school connectedness or family relationships), and social situational variables (substance use, human relationship status, or hormonal contraceptive use). The MDM allows each of these to have direct (not merely indirect) relationships with behavior. Hence, factors outside of the individual are explicitly modeled as factors shaping one'due south beliefs.

3 recent efforts embraced ecological frameworks as an overarching theme. First, the Network-Individual-Resource Model (NIRM) recognizes and addresses the noun reciprocal ties of individuals and of import social networks across their lifespans—ties that have their footing in the tangible and mental resources individuals and networks possess.²⁹ 2nd, the Dynamic Social Systems Model (DSSM)³¹ conceptualizes resource, science and technology, formal social control, informal social influences and control, social interconnectedness, and settings as aspects that dynamically intersect to create structural realities ranging from micro- to meso- to macro-levels. Third, the Manual Reduction Intervention Project (TRIP)³² rests explicitly on the fact that HIV transmission requires trunk fluid exchange and is spread through community sexual and injection networks. Electric current expositions related to TRIP emphasize the need to simultaneously arbitrate at higher levels than the individual (eg, care providers) and rectify power imbalances (eg, ensure they sympathise patients' social and economic realities).

All iv multi-level approaches concur that factors outside the private chronicle to take chances and the ability to change beliefs. For example, a great deal of recent research confirms that social stigma creates health risks and worsens health care.^33,34 The DSSM, TRIP, and NIRM hold in focusing on resources as disquisitional for sustaining beliefs alter; they also emphasize power dynamics betwixt individuals and surrounding social forces. The DSSM and NIRM also agree in focusing on the dynamic coaction between levels, although the quondam focuses only on the structures people face and the latter implies reciprocal interactions betwixt individuals and realities constructed by networks. To the NIRM, networks cannot exist without individuals and vice versa. The MDM and the NIRM agree in emphasizing social environmental factors directly influencing behavior, even when the individual may wish to human activity differently.

The NIRM is the only 1 of these 4 models directly addressing development across the lifespan, which characterizes both individuals and networks. Thus, the NIRM holds that prevention needs, and gamble itself, depend importantly on the life stage and circumstances. Individuals with nifty needs or little autonomous power (eg, infants and children) are vulnerable to others' influence and can exist positively (eg, sustenance from caregivers) or negatively afflicted (eg, harmed by poor intendance). In parallel, networks that might improve health gain strength when more individuals actively participate in them and promote their goals.

Finally, of these models, TRIP and the NIRM most embrace the perspective that individuals must notice ways to cope with stressors. In short, one reason beliefs change efforts may fail is because those addressed by an intervention live in circumstances filled with stressors such as demanding concrete environments or stigmas associated with minority status, HIV-positive status, or both. Reid et al³⁵ recently showed that both residential segregation and prejudice levels of majority members toward minorities interfered with the success of behavioral interventions meant to decrease sexual risk behaviors. Logically, the stress created by unfriendly social environments—in this instance addressed at the U.S. county level—interfered with individuals' power to improve habits. Understanding how to promote positive coping with ecology stressors and how to brand communities more than supportive would thus offer considerable hope for larger behavior modify furnishings.

Table 1 compares recent behavior alter models and how they attempt to address factors beyond the individual. Because individual and structural elements conspicuously are relevant to HIV take chances and manual prevention, a forcefulness of the NIRM is that it recognizes the linkage betwixt levels, where micro connotes processes or variables solely within individuals, and macro implies linkages between individuals and others.³⁶ Thus, the NIRM recognizes that individuals (micro) enact risk behaviors with those to whom they are linked in networks (macro). In contrast, individual-level HIV prevention theories either have no explicit linkage to macro-levels or practice so only indirectly. Finally, the individual-level models have little ability to explain structural influences, whereas the other 4 models at least permit a directly influence of such factors on chance beliefs. The NIRM and TRIP recognize that networks or organizations possess resources that conduct on risk beliefs; the NIRM explicitly addresses how networks create structural realities that interplay with gamble. Although addressing these high-level factors creates challenges for brevity and replicability, doing and then is more probable to result in sustainable behavior alter.

Considering these multi-level models are all relatively new, in that location have not been extensive empirical studies evaluating their assumptions. Some other consideration in our give-and-take is that various versions of socio-ecological models accept typically been discussed as organizing frameworks rather than every bit testable (ie, falsifiable) empirical models. Indeed, at this writing, of the broader, relatively new models we discuss here, we are enlightened of research supporting predictions simply of the MDM and the NIRM. MDM inquiry so far has generally shown that situational and preparatory behaviors add significant predictive power for behavior across attitudes, norms, intentions, and self-efficacy. The MDM research also suggests that social–structural variables (eg, gender, age, socioeconomic status) seem to have primarily indirect effects on behavior through attitudinal and situational factors.^28,37,38 NIRM-related meta-analyses have supported its hypotheses: (1) individual resources are crucial to the success of interventions (eg, interventions were more successful if they as well reduced depression³⁹) and (2) the structural dimensions of economic resources and community support in the locales where individuals are targeted by health promotion chronicle to the success of these efforts.^{xi,35,forty,41} Simply time volition tell whether DSSM and TRIP function more than every bit organizing frameworks or begin to exist tested empirically. Finally, we have also noted that evaluating multi-level theories is routinely more than circuitous than evaluating individual-level theories.

DISCUSSION

The Fine art and Science of Understanding Health Behavior

In this article, nosotros have sought to map out the state of the art and science of theorizing the contextual shaping of health beliefs. The summary of variables presented in Figure one is intended equally a useful source to aid aggrandize the details of more abstract models when it comes to applying them to intervention pattern relevant inquiry. One of the lessons to sally from the growing movement to embrace multi-level and ecological models of HIV-related beliefs is their complication and context specificity. For this reason, coupled with the paucity of show directly comparison the influence of the variables in question, we refrain from endorsing any particular unmarried comprehensive model and from producing another. Instead, we believe that information technology is better to offer a variety of options.

Effigy 1, consonant with the bulk of the ecological literature, maps out a very wide range of variables at multiple levels, serving as a useful heuristic but one that is oversimplified. Separating out factors into distinct levels can obscure the mechanisms linking the structural, institutional, community, interpersonal, and private in dynamic systems of influence.^10,42 For instance, laws criminalizing injecting drugs or same-sex behavior may make health care institutions inaccessible considering people fear discrimination or abort. They may touch on the capacity of communities to organize, as members fearfulness identification as groups breaking the police force. They may affect stigma at the community and interpersonal levels and affect perceived control at the individual level.⁴³ Similarly, economic inequalities at the macro-social scale may carve up communities, encourage transactional sex, and introduce vast interpersonal power inequalities in the negotiation of safer sex.⁴⁴ The benefit of using "levels" to describe explicit attending to the macro-social and community-level influences on wellness beliefs comes at the cost of obscuring some of the mechanisms through which these levels are interlinked (Table 1).

One of the strengths of the theoretical models reviewed is that they explain links between individual behavior and social structures. The NIRM and TRIP emphasize the networks in which individuals are embedded and link them in relationships with others and thereby to ability dynamics and resources. Such models also highlight the complexity of modeling the social–structural shaping of health. While individual-level models pinpoint a relatively few psychological mechanisms to be targeted by interventions, multi-level interventions seem to differ. As the DSSM argues, HIV-related beliefs is contextual and dynamic, and the identification of the near relevant dimensions and variables for whatsoever one intervention rests on assessment of the local context.

Different aspects of the ecology of influences on beliefs may exist relevant in dissimilar settings or at different times,^v,45,46 which complicates the challenges of making policy recommendations, designing interventions, and planning evaluations. It implies all these activities may demand to be undertaken in a way that is increasingly flexible and responsive to local weather. Such flexibility and context-specificity raises challenges to the current modus operandi for HIV policy, which often strives for universal statements of policy goals and evaluation standards.

Implications

The foregoing word suggests several means researchers and practitioners can accelerate in agreement behavior related to HIV prevention and intendance and incorporate these multi-level approaches into behavior change interventions.

• 1. When trying to understand the process of beliefs alter or develop an intervention, consider all levels of influence and related variables from private to structural. Effigy one and Tabular array ane may assistance to identify potentially relevant variables.
• 2. Mapping out relevant variables is besides helped past interdisciplinary collaboration. Multi-level theorizing hinges on using perspectives spanning disciplines: private-level factors are commonly modeled using psychological and behavioral economical principles; interpersonal relationships need concepts from social psychology, anthropology, communication science, sociology, etc.; structural forces demand concepts from folklore, economic science, political science, geography, and engineering. Clearly, future scholarship needs to contain the richness multiple disciplines afford.
• 3. Based on the initial collaboration and mapping of potential variables, choose at least two levels to measure out, exam, and/or include in an intervention. Unless extensive resources are available, measuring or intervening at all levels will be too expensive and complex for comprehensive inquiry.
• 4. Early formative work can usefully inform the option of levels to measure and/or interventions to address. Such scoping might include exploratory research, review of existing data or reports on the population/customs, and consultations with local practitioners, patients, clients or subjects. Although at that place is a wealth of information at the individual level, work on higher levels will often likely require exploratory research, given the paucity of current prove.
• 5. Consider the straight and indirect levels of influence for the behavior(s) of focus. For example, sharing needles likely needs to include an understanding of social networks, prophylactic apply needs to include at least dyadic variables, medication adherence needs to include at least health practitioners and the patient, and all intervention efforts need to consider how difficult the environment is for the targeted populations. The lesson of multi-level theories of wellness behavior is that individuals and networks may have motivations in addition to those of expert health outcomes or interim safely in any particular fourth dimension and context.
• 6. Peculiarly at levels beyond the interpersonal, it is valuable to search for the mechanisms by which influences occur (Table ane). For instance, what is the mechanism whereby microfinance interventions may reduce risky sexual behavior (fiscal stability leading to work within a guild'south standard business organization model)? What is the machinery whereby girls who complete school engage in less sexual hazard-taking (empowerment, cocky-efficacy, a different view of gender roles)? Socio-ecological approaches are typically tested merely every bit lists of variables with little or no attempt to identify mechanisms (organizing frameworks). Understanding mechanisms is more probable to yield sustainable and replicable modify than but reporting associations between variables.⁴⁶
• seven. Mensurate variables at levels beyond the individual at the advisable level where possible rather than at the individual level. For example, social class should be measured at the family unit level rather than at the level of an individual adolescent; state, provincial, community, or national policy should be evaluated with an advisable and valid measure rather than researching perceptions of the policy.
• 8. Use analytic methods that attempt to look at relationships both within and between levels. At all-time, contemporary "tests" of socio-ecological approaches typically assess just the "proportion of variance" deemed for by variables at each level, normally measured at the individual level. But considering the linkage betwixt levels may be critical to a full agreement of mechanisms and long-term beliefs change.
• 9. Where possible, combine already existing theories at the various levels rather than creating brand new theories, until such time as the demand for a new theory is clearly indicated. Competing tests between elements of theories will, over fourth dimension, aid to clarify which factors deserve the most attending.
• 10. Apply theoretical models to inform considerations of scalability and sustainability of an intervention. To move toward "no new infections," national governments and international donors need research bear witness that is applicative on a big scale. Although the most important interventions and behaviors may be quite specific to a item community, transferability beyond settings can be gained by conceptualizing those interventions and behaviors as instances of more widely practical models.

Equally for hereafter inquiry, in addition to focusing on needed behaviors and content areas, methodological and theoretical piece of work is especially needed to aid understand how to select levels at which to work, how theories tin can exist combined beyond levels, and how processes tin can be best tested analytically both simultaneously and across various levels. Nosotros are beginning to brand progress in broadening our behavior change theories and models, but much piece of work remains to exist done. Much stands to be gained in improving HIV prevention and care if we consider more comprehensive models of beliefs change.

ACKNOWLEDGMENTS

The authors thank Samantha Tsang and Marina Smelyanskaya for their assistance with references.

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Keywords:

behavior change; HIV; socio-ecological model; factors; multi-level

© 2014 by Lippincott Williams & Wilkins

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Source: https://journals.lww.com/jaids/fulltext/2014/08151/health_behavior_change_models_for_hiv_prevention.3.aspx

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