Modeling and Reinforcement to Combat HIV: The MARCH Approach to Behavior Change

Abstract: "Theory and research suggest that behavioral interventions to prevent HIV/AIDS may be most effective when they are personalized and affectively compelling, when they provide models of desired behaviors, and when they are linked to social and cultural narratives. Effective strategies must also take into account the opportunities and obstacles present in the local environment. The Modeling and Reinforcement to Combat HIV (MARCH) projects combine key aspects of individual behavior change with efforts to change social norms.

There are 2 main components to the program: entertainment as a vehicle for education (long-running serialized dramas on radio or television portray role models evolving toward the adoption of positive behaviors) and interpersonal reinforcement at the community level (support from friends, family members, and others can help people initiate behavior changes; support through changes in social norms is necessary for behavioral effects to be sustained over time). Both media and interpersonal intervention activities should be linked to existing resources in the community and, wherever possible, provide increased access to preventive services, supplies, and other supporting elements."

This article describes in detail a theory-based approach used by the Global AIDS Program, initiated by the US Centers for Disease Control and Prevention (CDC). The strategy, called MARCH, is designed to help people vulnerable to HIV/AIDS in sub-Saharan Africa rewrite the dominant societal narrative according to which early marriage, unprotected sexual contact, unplanned birth, and HIV infection are deemed inevitable. This process is based on a framework according to which behavioural change is accomplished only when broad factors influencing behaviour -- on the individual, cultural, and societal levels -- are addressed. The MARCH approach, however, differs from other programmes that have incorporated reward-based motivation for carrying out behavioural change in that self-efficacy is a key focus. That is, the conditions must be in place so that individuals sense that they are empowered to change their behaviour.

The authors go on to detail the two components of the MARCH approach (described in the abstract, above) that draw on this theoretical framework. Key to the entertainment-education component, they contend, is the use of role models in the context of a storyline to provide information about change, to motivate the viewer, and to enhance a sense of self-efficacy. That is, an emphasis on narrative that is aligned with the norms of the particular culture allows people "to understand the origins, meanings, and significance of [their] difficulties, and to do so in a way that makes change conceivable and attainable". The second component involves reinforcing the message through interpersonal strategies like printed materials (like brochures) delivered by members of the affected community as well as increased availability of condoms and kits designed to clean needles.

A progress report follows. The authors note that extensive preparation, careful coordination, and ongoing evaluation must be in place if the strategy described is to succeed. Following discussion of these and other factors, a concluding section lays out the ways in which the MARCH approach is distinct from other programmes that include an entertainment-education component for behavioural change. Namely, first, "the approach focuses as much on enabling men and women to enact and maintain new cognitive and behavioral patterns as on promoting the behaviors themselves"; second, the goal is long-term change in "personal, social, and cultural views of sexual and reproductive health behavior, as well as the behaviors themselves"; and, third, "MARCH has a theory-refining objective" that focuses on the question of "how identification with role models in the media really works to influence behavior".