Prevention: Why and how does it work? Considerations to strengthen HIV behavioural prevention John BF de Wit
Guiding thoughts <ul><li>Prevention is cost-effective way to promote health and regained centre stage in HIV response </li...
Outline of the presentation <ul><li>Different traditions, aims and tools in prevention </li></ul><ul><li>Continued role fo...
Different traditions, aims and tools in prevention
Distinct traditions provide multiple tools <ul><li>Public health approach </li></ul><ul><ul><ul><li>Diagnosis and treatmen...
Complementary philosophies and aims <ul><li>Biomedical </li></ul><ul><ul><li>making available effective and acceptable se...
Highly active combination prevention
Continued role for behaviour change <ul><li>Individual counselling (e.g., VCT) </li></ul><ul><li>Small group work (e.g., p...
Strengthening behavioural prevention of HIV
Behavior change skepticism <ul><li>Behaviour change approaches are reductionist and do not take into account the environme...
Behaviour change can be effective <ul><li>Mass communication campaigns </li></ul><ul><li>Computer-mediated program deliver...
Health promotion criticism <ul><li>Are proven behavioral interventions being implemented? </li></ul><ul><ul><ul><li>Accept...
Art and science of prevention <ul><li>Behavioral prevention programs and science can do better in ways that support partne...
Reflective innovation cycle Theory Research Practice Evaluation
Some comments about theory, content and evaluation
Selecting behavioural theory <ul><li>Behaviour is influenced by myriad factors at different levels, including individual, ...
Ecological perspective <ul><li>Multiple levels of influence on behaviour </li></ul><ul><ul><li>Individual </li></ul></ul><...
Dual-systems perspective <ul><li>A paradigm shift has occurred in psychology, behavioural decision-making and consumer beh...
Content matters, a lot <ul><li>Focus on key processes rather than shotgun approach </li></ul><ul><li>Employing powerful st...
Program evaluation <ul><li>Formative evaluation </li></ul><ul><ul><ul><li>Factors that shape behaviour or environment for ...
Let’s not demonise the RCT <ul><li>The randomised controlled trial is not perfect, but that doesn’t mean it’s useless; eve...
Concluding remarks
No quick fix but sophisticated mix <ul><li>HIV behavioral prevention can be effective </li></ul><ul><ul><ul><li>Theory-bas...
Systematic development of prevention <ul><li>Adequate understanding of the health problem </li></ul><ul><ul><ul><li>Epidem...
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Prevention: Why and how does it work? Considerations to strengthen HIV behavioural prevention - John BF de Wit

Presentation from the AFAO National Symposium on Prevention, held in Sydney, Thursday 27 May, 2010.
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Prevention: Why and how does it work? Considerations to strengthen HIV behavioural prevention - John BF de Wit

  • 1. Prevention: Why and how does it work? Considerations to strengthen HIV behavioural prevention John BF de Wit
  • 2. Guiding thoughts <ul><li>Prevention is cost-effective way to promote health and regained centre stage in HIV response </li></ul><ul><li>Different philosophical approaches are mostly complementary rather than competing </li></ul><ul><li>Behaviour change perspective continues to play a key role in health promotion and HIV prevention </li></ul><ul><li>Criticisms that have been levelled point to a need to strengthen behavioural prevention </li></ul><ul><li>This can be achieved through a stronger link between theory and practice through research and evaluation </li></ul><ul><li>Reflection on national prevention strategic directions and HIV prevention practices and understandings </li></ul>
  • 3. Outline of the presentation <ul><li>Different traditions, aims and tools in prevention </li></ul><ul><li>Continued role for behaviour change that works </li></ul><ul><li>Strengthening behavioural prevention of HIV </li></ul><ul><li>Some comments about theory, content and evaluation </li></ul><ul><li>Concluding remarks </li></ul>
  • 4. Different traditions, aims and tools in prevention
  • 5. Distinct traditions provide multiple tools <ul><li>Public health approach </li></ul><ul><ul><ul><li>Diagnosis and treatment; inoculation; harm reduction </li></ul></ul></ul><ul><ul><ul><li>NSPs; STI clinics and alternative testing sites; voluntary counseling and testing facilities; PEP, PMTCT, circumcision and other (future) biomedical prevention methods </li></ul></ul></ul><ul><li>Health education, communication and social marketing </li></ul><ul><ul><ul><li>Primary prevention through promoting behavior change; lifestyle </li></ul></ul></ul><ul><ul><ul><li>Campaigns; comprehensive sexuality/life skills education </li></ul></ul></ul><ul><li>Health promotion perspective </li></ul><ul><ul><ul><li>Also address wider economic, social, cultural, physical, legal, policy and health services environment </li></ul></ul></ul><ul><ul><ul><li>Partnerships, empowerment, advocacy, service provision and legal and policy reforms </li></ul></ul></ul>
  • 6. Complementary philosophies and aims <ul><li>Biomedical </li></ul><ul><ul><li>making available effective and acceptable services </li></ul></ul><ul><li>Behavioural </li></ul><ul><ul><li>knowledge and skills to support changes in practices </li></ul></ul><ul><li>Structural </li></ul><ul><ul><li>enabling environment and removal of barriers </li></ul></ul><ul><li>Pragmatic tools, proximal factors and distal drivers </li></ul><ul><li>Range of disciplines produce complementary approaches </li></ul>
  • 7. Highly active combination prevention
  • 8. Continued role for behaviour change <ul><li>Individual counselling (e.g., VCT) </li></ul><ul><li>Small group work (e.g., post-seroconversion) </li></ul><ul><li>Peer education and outreach services </li></ul><ul><li>Health education, communication and social marketing </li></ul><ul><li>Targeting general population, vulnerable groups (e.g., young people) and most affected communities (e.g., gay and other MSM) </li></ul><ul><li>Promotion of a range of risk reduction practices, biomedical prevention and structural interventions </li></ul>
  • 9. Strengthening behavioural prevention of HIV
  • 10. Behavior change skepticism <ul><li>Behaviour change approaches are reductionist and do not take into account the environment in which people live and the contexts that shape practices and provide meaning </li></ul><ul><ul><ul><li>Ideally, behaviour change is embedded in a broader response and good education and counseling adopt a holistic approach </li></ul></ul></ul><ul><ul><ul><li>Comprehensive approach leaves unaddressed why programs work and what components are necessary and sufficient. This may result in over-use of resources and unnecessary burden. </li></ul></ul></ul><ul><li>Behaviour change approach does not work, does not work anymore, does not work in specific contexts, only works for the motivated or has limited/slow impact </li></ul><ul><ul><ul><li>Meta-analyses continue to document that HIV prevention is effective across a range of communities and approaches </li></ul></ul></ul><ul><ul><ul><li>Significant reductions in risk-taking have been found, effect sizes generally are moderate to large </li></ul></ul></ul>
  • 11. Behaviour change can be effective <ul><li>Mass communication campaigns </li></ul><ul><li>Computer-mediated program delivery </li></ul><ul><li>Curriculum-based sex education </li></ul><ul><li>Eroticising safer sex </li></ul><ul><li>Heterosexual adults and sexually experienced adolescents </li></ul><ul><li>Sexual behaviors and harm reduction in IDU </li></ul><ul><li>Prevention in people living with HIV </li></ul><ul><li>Individual, group and community programs in MSM </li></ul><ul><li>Peer education for diverse communities </li></ul><ul><li>Voluntary counselling and testing </li></ul>
  • 12. Health promotion criticism <ul><li>Are proven behavioral interventions being implemented? </li></ul><ul><ul><ul><li>Acceptability and feasibility for community and professionals </li></ul></ul></ul><ul><ul><ul><li>Supporting dissemination, adaptation and implementation </li></ul></ul></ul><ul><li>What is the evidence and reach of current interventions? </li></ul><ul><ul><ul><li>Evaluating and disseminating community interventions </li></ul></ul></ul><ul><ul><ul><li>Using novel delivery methods to ensure reach and appeal </li></ul></ul></ul><ul><li>Main factors that promote intervention efficacy </li></ul><ul><ul><ul><li>Sound conceptual basis, supported by strong empirical evidence </li></ul></ul></ul><ul><ul><ul><li>Addressing (evolving) community needs through participation </li></ul></ul></ul>
  • 13. Art and science of prevention <ul><li>Behavioral prevention programs and science can do better in ways that support partnership, build capacity and bridge the gap between practice and research </li></ul><ul><li>Researching theory-based factors that shape practices; identifying or developing effective methods and appropriate delivery strategies to address these factors through attractive and acceptable prevention programs </li></ul><ul><li>Evaluation of programs that focuses on outcomes and processes and can illuminate active ingredients in prevention programs </li></ul>
  • 14. Reflective innovation cycle Theory Research Practice Evaluation
  • 15. Some comments about theory, content and evaluation
  • 16. Selecting behavioural theory <ul><li>Behaviour is influenced by myriad factors at different levels, including individual, relationships, organisations, community, culture and society </li></ul><ul><li>No generally agreed, philosophical perspective or theoretical model, but range of approaches </li></ul><ul><li>Any theory should provide testable hypotheses related to clear, specific mechanisms of change that can be addressed in an intervention </li></ul><ul><li>Hypothesized processes should ideally be supported by appropriate empirical evidence pertinent to the audience of the intervention </li></ul>
  • 17. Ecological perspective <ul><li>Multiple levels of influence on behaviour </li></ul><ul><ul><li>Individual </li></ul></ul><ul><ul><li>Social relationship </li></ul></ul><ul><ul><li>Organisations </li></ul></ul><ul><ul><li>Communities </li></ul></ul><ul><ul><li>Society </li></ul></ul><ul><li>Resonates well with social, holistic perspective </li></ul><ul><li>Myriad factors interrelated in complex ways </li></ul><ul><li>Processes of influence not well understood </li></ul><ul><li>Promising, but little evidence and tools </li></ul>
  • 18. Dual-systems perspective <ul><li>A paradigm shift has occurred in psychology, behavioural decision-making and consumer behaviour </li></ul><ul><li>Behaviour as the joint result of reflective and reflexive processes that differ in strength for individuals and situations </li></ul><ul><li>Classic theme: individuals’ are not (always) rational and are (also) be guided by implicit influences in the environment </li></ul><ul><li>Strong evidence base, but limited uptake in health promotion </li></ul><ul><li>Practical strategies to address behaviour ‘in the heat of the moment’ through promotion of behavioural planning; promising change of environmental constraints and cues </li></ul>
  • 19. Content matters, a lot <ul><li>Focus on key processes rather than shotgun approach </li></ul><ul><li>Employing powerful strategies in personally relevant ways </li></ul><ul><li>Beyond ‘education’ and ‘facts’ or slogans and sleek design </li></ul><ul><li>Stop fuzzy references to established approaches </li></ul><ul><li>‘ Counselling’ </li></ul><ul><ul><li>Goal clarification, motivation, self-regulation and skills </li></ul></ul><ul><li>‘ Peer education’ </li></ul><ul><ul><li>Appropriate shared perspectives and support </li></ul></ul><ul><li>‘ Social marketing’ </li></ul><ul><ul><li>Attitude change and social influence theories </li></ul></ul>
  • 20. Program evaluation <ul><li>Formative evaluation </li></ul><ul><ul><ul><li>Factors that shape behaviour or environment for audience </li></ul></ul></ul><ul><li>Process evaluation </li></ul><ul><ul><ul><li>Reach/coverage, acceptability/suitability, delivery/implementation </li></ul></ul></ul><ul><li>Summative evaluation </li></ul><ul><ul><ul><li>Outcome: behaviour and shaping factors </li></ul></ul></ul><ul><ul><ul><li>Impact: infection rates and other health indicators </li></ul></ul></ul><ul><ul><ul><li>Economic: costs and benefits </li></ul></ul></ul><ul><li>Focal indicators for evaluation of behavioural prevention </li></ul><ul><ul><ul><li>Intended outcome and hypothesized change processes </li></ul></ul></ul><ul><ul><ul><li>Change in behaviour and in factors that shape behaviour </li></ul></ul></ul>
  • 21. Let’s not demonise the RCT <ul><li>The randomised controlled trial is not perfect, but that doesn’t mean it’s useless; every method is limited </li></ul><ul><li>Use of RCTs depends on the question to answer and for important questions it is an appropriate, powerful tool </li></ul><ul><li>RCT is NOT a biomedical invention but an epistemological tool long used in natural, social and behavioural sciences </li></ul><ul><li>An RCT is not by necessity superficial or limiting for programs, while users of RCTs can be </li></ul><ul><li>RCTs can be much more widely used (in adapted form) than sometimes assumed </li></ul><ul><li>Move beyond sometimes ill-informed rhetoric that can sanctify what are often less optimal practices </li></ul>
  • 22. Concluding remarks
  • 23. No quick fix but sophisticated mix <ul><li>HIV behavioral prevention can be effective </li></ul><ul><ul><ul><li>Theory-based and responsive to real community needs </li></ul></ul></ul><ul><ul><ul><li>Field is maturing, but limited knowledge of success factors </li></ul></ul></ul><ul><li>It is time to move beyond ideologies and debate </li></ul><ul><ul><ul><li>Systematic program development and matched investment </li></ul></ul></ul><ul><ul><ul><li>Comprehensive, sustainable prevention approaches </li></ul></ul></ul><ul><li>More than behavior change alone </li></ul><ul><ul><ul><li>Combination prevention; tailored prevention ‘menu’ </li></ul></ul></ul><ul><ul><ul><li>Biomedical, behavioral and structural approaches </li></ul></ul></ul><ul><li>Behavior change remains key in multiple ways </li></ul><ul><ul><ul><li>Proximal determinants; direct and substantial effects </li></ul></ul></ul><ul><ul><ul><li>Behavioral implications of biomedical and structural interventions </li></ul></ul></ul>
  • 24. Systematic development of prevention <ul><li>Adequate understanding of the health problem </li></ul><ul><ul><ul><li>Epidemiology and risk factors; ‘Knowing your epidemic’ </li></ul></ul></ul><ul><li>Sophisticated knowledge of factors that shape practices </li></ul><ul><ul><ul><li>Behavioral and social theory and research </li></ul></ul></ul><ul><li>Effective strategies to promote change at different levels </li></ul><ul><ul><ul><li>Theory, evidence and expertise from a range of disciplines </li></ul></ul></ul><ul><li>Appropriate and rigorous evaluation </li></ul><ul><ul><ul><li>Range of indicators and approaches; designs to match questions; understanding necessary and sufficient components </li></ul></ul></ul><ul><li>Collaborative partnership and flexible adaptation </li></ul><ul><ul><ul><li>Expertise, capacity, ownership, suitability and sustainability </li></ul></ul></ul>
  • 25. [email_address]

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