Rethinking Conceptual Approaches to Behaviour Change: The Importance of Context

Published by the Centre for AIDS Development, Research and Evaluation (CADRE), this 6-page article reviews the concept of behaviour change as it has been applied to individual behaviour in relation to HIV/AIDS. It notes the limits of cognitive approaches to behaviour change when applied within complex contexts and variations of risk to HIV/AIDS infection. "With regard to communication, there is a need to move beyond top-down approaches and to incorporate horizontal and participatory approaches. These include recognising and resourcing the role of civil society responses to HIV/AIDS."

"The concept of behaviour change has long been the rallying cry of HIV/AIDS prevention interventions and campaigns. Behaviour change approaches have predominantly been grounded in cognitive theories and models of health behaviour including the health belief model, the theory of reasoned action, the AIDS risk reduction model, and theories of social learning amongst others.

A review of HIV/AIDS behaviour change communication interventions by Airhihenbuwa et al (1999) concluded that these theories and models do not provide an adequate framework for bringing about behavioural change especially when applied to the contexts of Africa, Asia, Latin America and the Caribbean."

The paper states that over the past two decades, millions of dollars have been invested in behavioural interventions providing information, education and communication for behaviour change. Although many of these have made impacts on knowledge and awareness, and have contributed to overall HIV risk reduction, they have been insufficient to the task of ensuring the rapid changes necessary for containing the HIVAIDS epidemic in many countries. The paper concludes that behaviour change theories and interventions are limited by a range of conceptual and contextual factors. These factors do not negate the value of ‘choice-based’ behaviour change approaches, but recognition needs to be given to the broader milieu of risk and prevention. According to the author, in many instances, there has been an over-reliance and over-investment in ‘behaviour change communication’. In high prevalence contexts, there is little merit in separating prevention activities from the broader continuum of HIV response in relation to treatment, care, support, rights and social mobilisation, and there is evidence that such integration further contributes to prevention impacts.

The author further concludes that integration should also include broader development issues, and that the HIV/AIDS epidemic should be used to leverage attention and resources to some of the developmental issues that underpin the epidemic. With regard to communication interventions per se, recent developments have foregrounded the need to move beyond top-down communication (which has largely been employed by cognitive behaviour change theories) towards horizontal and participatory approaches. Such approaches incorporate the concept of addressing enabling environments and contextual factors and are framed by the concept of ‘communication for social change’. Elements of this framework include: moving away from people as objects of change, towards people and communities as agents of change; moving away from delivering messages, towards supporting dialogue and debate on key issues; moving away from a focus on individual behaviour, towards a focus on social norms, policies, culture and supportive environments; moving away from persuasion, towards negotiation and partnership; and finally moving away from external technical expertise, towards integrating communities in assessing issues of concern at local level.