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4 Facilitating Change in Health Behaviors
Pages 259-315

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From page 259...
... There has been little useful evaluation of the few major intervention programs that have been undertaken, and there have been even fewer studies that compared the efficacy of alternative interventions (Office of Technology Assessment, 1988~. Consequently, the committee has had to rely on a more basic analysis of intervention strategies, using principles of human behavior established through empirical research in the social and behavioral sciences, to suggest useful programs to prevent the spread of HIV infection.
From page 260...
... By focusing on facilitating change in risk-associated behavior, the committee does not wish to impute a diminished importance to maintaining those behaviors that are not associated with risk. Clearly, the best way to prevent IV cirug-associated HTV transmission is to prevent the use of drugs.
From page 261...
... of HIV infection. A wealth of research on health behavior indicates that indivicluals are certainly capable of undertaking changes in important areas of conduct; indeecI, substantial changes in individual behavior have already been reported among homosexual men and IV drug users in response to the AIDS epidemic (Becker and Joseph, 1988; Office of Technology Assessment, 1988~.
From page 262...
... In this section, the committee reviews the role of education programs in preventing HIV infection, including the behavioral mollifications that increased knowledge can reasonably be expected to accomplish. The remainder of the section focuses on three aspects of such programs that have- particular relevance for AIDS prevention: (1)
From page 263...
... Print and broadcast media offer the economy of reaching many people with a unified message. However, face-to-face communication for hard-to-reach inclividuals (e.g., {V drug users)
From page 264...
... Some IV drug users, for example, still believe that water is sufficient for sterilizing injection equipment; others believe infected individuals can be identified by their appearance. Moreover, homosexual men who believed they had successfully "fought off" the virus (as one would fight off the flu- by mounting an antibody response)
From page 265...
... multimillion-(lollar cooperative agreements with the 50 states, 5 territories, and 4 other locales to support community task forces, hot lines, and antibody testing and counseling; and . community demonstration projects to disseminate information, promote change in social norms and riskassociated behavior, and provide antibody testing anct counseling.
From page 266...
... Similar tactics have been used in programs to prevent AIDS. (For example, such messages as "Bang Bang You're Dead" have been used to call attention to the fatal consequences of sexually transmitted HIV infection.)
From page 267...
... Job (1988) has proposed five prescriptions for the role of fear in health education messages: 1.
From page 268...
... and the Presidential Commission on the Human Immunodeficiency Virus Epidemic (1988~; both of these bodies found that the gravity of HIV infection calls for an expanded use of the media in educational activities. Because of a lack of evaluation of AIDS media campaigns in the United States, little can be said about their impact on riskassociated behaviors.
From page 269...
... For example, the media are not a scientific institution; they have to popularize news topics to make them appeal to a mainstream audience. Nevertheless, despite the somewhat constrained role of the mass media, they have made significant contributions to efforts to prevent the spread of HIV infection.
From page 270...
... Several community-based programs, including the San Fiancisco AIDS Foundation program, have used such approaches for AIDS prevention campaigns. In the San Ffancisco case, an advertising agency was hired to conduct focus groups and prepare newspaper advertisements promoting safer sex among gay men.
From page 271...
... feasible) to assist in preventing the further spread of HIV infection.
From page 272...
... Thus, the awareness of HIV infection in a local {V drug-using population may increase the perception of risk among drug users and therefore the likelihood of appropriate action. However, it should be noted that very high rates of local infection could reinforce the notion that a single episode of sharing would inevitably lead to infection.
From page 273...
... . For instance, it may be so difficult for men who engage in same-gender sex to recognize it as gay or homosexual behavior that they deny the HIVassociated risks.
From page 274...
... If alternative approaches are available, the one that is most consistent with ongoing, accepted practices in a group should be emphasized. If no alternatives exist, steps should be taken to modify any negative perceptions of the proposed strategy on the parts of opinion leaders and the target audience.
From page 275...
... Communication problems, cultural ant! religious barriers, poor access to health resources and prevention services, community-level embarrassment, apathy, and misunderstanding have all contributed to the spread of HIV infection among some groups, especially minorities.6 The tragic increase in the prevalence of infection within minority groups illustrates some of the problems that are associates!
From page 276...
... . The committee-recommends that innovative approaches to AIDS prevention programs be introclucec} in a planned manner that reflects wel]
From page 277...
... In the sections that follow, the committee reviews some of the factors that motivate behavioral change to reduce the risk of HIV infection, inclucling perceived self-efficacy, altruistic motives, and knowledge of antibody status. Because HIV infection is a fatal threat for which there is no biomedical "magic bullet," it will be necessary to maintain behavioral changes for an indefinite period, perhaps for a lifetime.
From page 278...
... Programs that focus on self-efficacy help individuals change their behavior by building their sense of competency and by teaching them the necessary skills. Strategies based on self-efficacy were originally designed to prevent the use of tobacco and have been adapted to drug-use prevention; they are now being applied to AIDS education efforts.
From page 279...
... . Similar altruism has been demonstrated among {V drug users: some of the behavioral changes among {V drug users have been made to protect sexual partners and trusted needIe-sharing partners (Des Jariais, 1987~.
From page 280...
... More is known about the effects of testing among homosexual and bisexual men than about its effects among IV drug users, adolescents, or women at high risk of HIV infection. In general, studies have found positive behavioral effects associated with antibody testing among homosexual men in the United States, Canada, and Europe (Farthing et al., 1987; Fox et al., 1987b; Go~frie(1 et al., 1987; Willoughby et al., 1987; Coates et al., l98Sa; McCusker et al., 1988~.
From page 281...
... In one small study of 15 seropositive {V drug users recruited from methadone clinics in New York City, learning of a positive antibody status was not associated with serious psychological sequelIae (Casadonte et al., 1988~. A separate study of 66 pregnant women from the New York City area (Cancellieri et al., 1988)
From page 282...
... Clearly, it will be important to ascertain the extent and direction of self-selection bias in future studies. In no case, however, will testing be a panacea to prevent the spread of HIV infection, and it should not be the centerpiece of a health education program.
From page 283...
... High relapse rates have been reported in studies of a variety of health behaviors, although a critical review of experimental studies and their methodologies indicates that the problem of relapse has sometimes been overstated (Green et al., 1986~. For chronic health threats (e.g., HIV infection)
From page 284...
... Drug treatment programs are obvious points for reaching IV drug users at risk of HIV infection and are effective in decreasing the frequency of infection, thus decreasing the likelihood of spreading AIDS. It is obvious, however, that an {V drug user must first have access to treatment if treatment is to have an effect.
From page 285...
... Both the individual and the environment in which he or she lives are dynamic. The grave consequences of HIV infection require continued efforts to facilitate change in those behaviors associated with risk and to support change that has already occurred.
From page 286...
... of HIV infection within a community, thereby decreasing the likelihood that a risk-taking person will encounter an infected individual? Unfortunately, there is limited information available on the distribution of sexual and cirug-use behaviors (see Chapters 2 and 3)
From page 287...
... among IV drug users, albeit with variation across locations. A sample of IV drug users recruited through methadone maintenance programs in New York City in 1984 reported behavioral change to reduce the risk of contracting AIDS: approximately 30 percent reported the increased use of clean or new injection equipment and reduced needle-sharing (Friedman et al., 1986~.
From page 288...
... When men who "always" used condoms for insertive anal intercourse were compared with men who "never" used them, nonusers tended to be younger, less educated, less concerned about risk, less convinced of condom efficacy in preventing the spread of HIV, and more likely to have used alcohol or other drugs during sex (Valdiserri et al., 1988~. Indeed, the health education literature is replete with examples of motivated individuals who nevertheless do not undertake
From page 289...
... Unfortunately, there is virtually no scientific data on the failure rate of condoms as used by humans. Last April, the FDA wrote condom manufacturers explaining that, as a result of HIV infection, "it has become very important that users be fully aware that latex condoms provide protection, but do not guarantee it, and that protection is lost if condoms are not used properly." Properly used or not, a defective condom is, of course, worthless.
From page 290...
... Focusing on the risk of condom failure in this way can lead to feelings of hopelessness and frustration, which in turn can lead to unprotected intercourse. Indeed, messages that stress the failure of condoms rather than their capacity to protect have been shown to clissuacle young adults from believing that condoms are an effective means of preventing HIV infection.9 It is clear, however, that protected intercourse, although not perfectly safe, is still safer than unprotected intercourse.
From page 291...
... In the early days of the AIDS epidemic, for instance, gay men turned to their communities for information about the disease and for an interpretation of relevant information. Yet social support for health behavior goes beyond the provision and interpretation of information, and this broader definition implies the need for aciclitional resources and the possibility of other problems.
From page 292...
... It is logical, therefore, to consider peer approval as a potential strategy to reinforce risk-reducing behaviors. Indeed, data from one study in New York City indicated that the participation of friends in risk-reducing activities was the strongest predictor of behavioral change among IV drug users (FYiedman et al., 1987~.
From page 293...
... Community-I,eve} Intervention Programs Community-leve] approaches to prevent HIV infection provide information, skills training, and a social environment that supports and sustains individual behavioral changes.
From page 294...
... statement that "change may require ideas ant! technology from the outside, but adoption, maintenance, and adaptation require the explicit colIaboration of individuals and agencies from within the community." The committee recommencis that, to the extent possible, community-level interventions to prevent the spread of HIV infection address simultaneously information, motivational factors, skills, prevailing norms, and methods for diffusing innovation.
From page 295...
... The Women's AIDS Network and the California Prostitutes Education Project are addressing the needs of women at high risk of HIV infection. Another part of the San Fiancisco community-level program provided AIDS
From page 296...
... research documenting baseline levels of high-risk behavior and behavioral change, noting, where possible, the factors related to a failure to change (Communication Technologies, 1987~. In the case of AIDS, fostering community norms that allow those at risk to avail themselves of help is critical in controlling the spread of HIV infection.
From page 297...
... of HIV infection. This exaggerated sense of difference between oneself or one's group (in-group)
From page 298...
... IVDrugUsers An example of this hopelessness is the public's perception that IV drug users are unable to alter their drug and sexual behaviors to
From page 299...
... It is clear, however, that many IV drug users want to and can change some of their behavior, and the social barriers to such change should be removed. Female Prostitutes Considerable concern has also been expressed about the role that female prostitutes may play in spreading HIV infection.
From page 300...
... Rather, there is a need to interact with the group to determine what these goals are. Innovative ant} Controversial Approaches to Behavioral Change In its recent report, the IOM/NAS AIDS cot ttee concluded that "the HIV epidemic should prompt a reexamination of the fiscal and institutional barriers that impede effective public health efforts in all program areas related to the control of HIV infection" (IOM/NAS, 1988:62~.
From page 301...
... are needed to determine the effectiveness of these strategies in preventing disease. Sterile Needle Programs There is no controversy about whether sterile needles help to prevent the spread of AIDS among {V drug users.
From page 302...
... As discussed in the previous chapter, data from Amsterdam (Buning, 1987) , where neecIle exchange programs have been in place for several years and the sale of injection equipment is legal, indicated no increase in the number of {V drug users; they clip indicate an increase in the demand for treatment.
From page 303...
... If teenagers have not learned about sex, the argument goes, then they will not engage in it. Does sex education precipitate or encourage sexual behavior?
From page 304...
... The specter of HIV infection may increase the aIrea(ly high proportion of parents wishing to have sex education in the schools. In a recent national survey by Harris, virtually all parents (94 percent)
From page 305...
... In high school, more information would be added, including HIV transmission by homosexual and heterosexual behaviors, skills training and decision making, and the effective use of contraceptive methods (DiClemente et al., 1987~. The committee supports school-based AIDS education efforts for adolescents that encompass planned program variations and evaluation to provide information on educating youths more effectively about the risks posed by HIV infection.
From page 306...
... Nevertheless, the committee recognizes that the majority of school-based AIDS education takes place outside these venues and that joint efforts involving the schools and communities may hold the greatest promise for preventing HIV infection, other STDs, and unintended pregnancies (Vincent et al., 1987~. The CDC Guidelines for Effective School Health Education to Prevent the Spread of AIDS (CDC, l98Sb)
From page 307...
... Unfortunately, such data do not exist. There are self-reported data on relevant behavioral change: some {V drug users report changes in neecIlesharing practices and increased sterilization of injection equipment, while some homosexual men report less unprotected anal intercourse.
From page 308...
... Creating and sustaining behavioral changes in people have many aspects: producing an awareness of threat and the motivation to change while providing people with alternative ways of behaving; involving the relevant community or communities in such efforts; ant! creating economic, political, and social environments that support the new behaviors.
From page 309...
... (1988) Preventing HIV infection and AIDS in children and adolescents: Behavioral research and intervention strategies.
From page 310...
... (1988a) AIDS antibody testing: Will it stop the AIDS epidemic?
From page 311...
... (1987) HIV infection among intravenous drug users: Epidemiology and risk reduction (editorial review)
From page 312...
... (1986) AIDS health education for intravenous drug users.
From page 313...
... (1987) Prevention of HIV Infection Among Gay and Bisexual Men: Two Longitudinal Studies.
From page 314...
... (1985) Evaluation of family health education to build social support for long-term control of high blood pressure.
From page 315...
... (1987) Preventing Human Immunodeficiency Virus Contagion Among Intravenous Drug Users: The Impact of Street-Based Education on Risk Behavior.


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