The Centrality of Behavioral Change

Purpose and Rationale

Effective responses depend upon the capacity of people to change the behaviours that place them at risk of infection. Information alone rarely produces such change. Sustainable behaviour change results, in part, from interaction between individuals, families, and communities. Community standards and social and cultural values may also have to change. Voluntary, confidential counselling and testing services need to be made available and accessible and the legal environment needs to protect and respect human rights, especially those of the most vulnerable populations: women, young people, orphaned children, sex workers, men who have sex with men, injecting drug users, the poor and unemployed.

Programming for behaviour change must be community-based. The role of government is to provide the enabling policy, legal and ethical environment, and to ensure that the required prevention technology and care services are affordable and available to persons living with HIV or AIDS.

This exercise is intended to deepen understanding of the central role of behavioural and attitudinal change in developing effective strategies, of the process of behaviour change and the conditions under which it occurs.

Procedure

Explain that we all take risks in our lives. Some smoke cigarettes and some drink too much, others gamble or drive too fast without wearing safety gear. Many more have unprotected sexual intercourse with more than one partner.

Divide into small groups and invite each participant to:

Review their recent past and identify a time when they experienced a significant change (not necessarily negative or associated with health risks).

Request volunteers to share with the rest of the small group a brief description of their experience.

When all participants have described their changes, the small group should reflect on the reasons and factors which contributed to this change. One participant should summarise and report back to plenary without identifying individual group members, and the whole group should then identify the most relevant lessons learned.

Materials:
Time: 30 minutes

Behavior Change Continuum

• The person is not aware of the problem and therefore does not see the need to change.


• The person vaguely perceives the problem, but does not feel identified with the issue.


• The person acknowledges that there is a problem, but does not know if he/she can do something to solve it.


• The person acknowledges the problem but does not feel ready to act upon it.


• The person acknowledges that there is a problem, but does not want to complicate life.


• The person acknowledges that there is a problem and wants to know what he/she can do to help.


• The person acknowledges that there is a problem and is ready to act upon it.


• The person acknowledges that there is a problem, acts upon it and wants to share with others what they did.


• The person engages in change but is unable to sustain the change, reverting to old behaviour.


• The person engages in change but fails, ceases action, feels discouraged and reverts to previous behaviour.


• The person wants to change, feels ready to change, but the environment obstructs the decision to change.


• The person acts to change, is successful and feels stimulated by their progress. Peers - who have already experienced the benefits of change- provide support and the change process is shared and mutually sustained.

The Life cycle

Purpose and Rationale

The life cycle continuum is a programming tool designed to assist in identifying appropriate times and contexts for effective interventions. The tool is intended to facilitate a comprehensive programming process.

Procedure

Present the model and lead a discussion.

Divide participants into small groups. Ask them to use the table and make a list of all interventions under each of the 3 columns (Prevention, Care, Support) linked in turn to intermediate objectives as these relate to each segment of the Life Cycle (for instance, - between birth and the onset of sexual activity to delay first sexual intercourse until biological maturity is reached).

Ask participants to consider how they would conduct a needs assessment for each segment of the life cycle, and how they would consider what needs to be done before transforming needs into effective interventions.

Materials:
Time: 45 minutes

The Life Cycle Chart

Cross Impact Analysis

Purpose and Rationale

The complexity of the epidemic requires a multisectoral approach. This in turn needs to take account of the fact that many socio-economic and cultural factors determine the spatial, gender, age and social pattern of HIV in the population. Such factors also play a role in the impact of HIV and AIDS on individuals, families, communities and productive activities.

An effective national response to the epidemic will be based on an understanding of the ways in which HIV and AIDS effects social and economic activity over time, given that the impact will differ between sectors and will also intensify as the epidemic deepens.

In order to prioritize the national and sectoral response to the epidemic it is important to identify the following:-

· Which economic and social sectors are likely to be most affected by the epidemic?

· Given the estimated impact on a specific individual sector, what are likely to be effects on other social and economic sectors with which it has social and economic linkages?

· What are the implications for Policy and Programming of the cross-sectoral impacts?

Procedure

For this exercise it is necessary to identify initially the part(s) of the economic and social system under consideration in order to then undertake 3 separate but linked analyses in response to the questions noted above.

Step 1

· Define the parts of the system being analysed (nation, region, community....)
· Identify the major components of the system being analysed (economic, social, political...)
· Select those components of the identified system where the effects of the HIV epidemic are thought to be most relevant for policy and programming

For example,

System - the nation
Component - the economy
Area - productive sectors of the economy

· Construct a matrix with as many cells as the components that have been selected (see example)

· Through a process of group discussion, and taking account of epidemiological, social and economic information reach a consensus on the impact of HIV and AIDS on each of the components of the area that has been selected

· Rank the impact of the epidemic on each of the components of the area using the following scale

0 - no effects
1 - minimal effects
2 - weak effects

3 - significant effects
4 - substantial effects
5 - strong & persistent effects

See Example 1

Completing this part of the exercise provides some guidance for establishing priorities for policy and programming within a multisectoral programme. It identifies those sectors, and within those sectors, the ones which are likely to be most affected by the HIV epidemic.

Review the outcomes of this part of the exercise and summarise its implications for developing a multisectoral programme.

The purpose of this part of the exercise is to identify the linkages between the areas and their components, and to then establish how important the impact of the epidemic on any selected component is likely to be on other components within a given area.

This part of the exercise repeats the process above under Step 1 and utilises information derived from it, but in this step the matrix will list both vertically and horizontally the components of the areas selected.

Using the same scale as in Step 1 the group should identify for each of the components listed vertically the size of the expected impact on each of the other components listed horizontally.

An example: - The vertical component is Transport and the impact of the HIV epidemic is expected to be great (a scale score of 5 from Step 1 of the exercise). The group decides that what happens to Transport will have a significant impact on the Tourism sector listed horizontally, then a scale score of 4 might be agreed as appropriate.

The Group should allocate to each of the cells in the matrix, their estimate of the probable impact of each of the components listed vertically on other selected components within the area, using the scale noted above.

Completing this process helps identify the links between the different parts of the social and economic system and the ways in which effects of HIV and AIDS on one sector have implications for other related sectors. It follows that a comprehensive set of policies and programmes will need to address not just the direct impacts of the epidemic but also those that are indirect.

Step 3

The Group should discuss the policy and programming implications of the exercise for a multisectoral response to the epidemic and report back to plenary.

Materials: Examples 1 and 2.
Time: 60 minutes

AREAS	Impact of HIV and AIDS On Identified Components
1. Economy 1.1 Agriculture 1.2 Tourism 1.3 Energy 1.4 Transport
2. Social 2.1 Health 2.2 Education
3. Political 3.1 Human Rights 3.2 Governance

Difficult Issues
Horizontal table

Impact of Sectors listed vertically on other sect