Fact Sheet: Number 3 (1995)

Behavior Change Models For Reducing HIV/STD Risk

Individual practice of risk reduction behavior is the primary avenue for prevention of HIV/STD. Hence, the development of effective educational programs that will achieve this expected outcome is vital in societal efforts to control HIV/STD. Given the complex nature of many risky sexual and injecting drug behaviors, preventing and changing risk HIV/STD-related behavior represents a significant challenge to educators.

Studies have shown that increasing knowledge may not always change risky behaviors. Attention to other individual traits related to HIV/STD avoidance, such as perceptions of vulnerability to disease and peer norms, beliefs about the value of prevention behavior, recognition of high risk behavior, behavioral intention and self-efficacy are considered necessary. Several behavior change models have been suggested that incorporate components beyond HIV/STD knowledge. Some of the most promising models are briefly discussed here.

Alternative Behavior Change Models
The models are useful to program designers in that they suggest specific areas for educational intervention. Although presented separately here, they are not mutually exclusive and many may operate simultaneously in influencing behavior.

Health Belief Model. This model assumes that an individual's behavior is guided by expectations of consequences of adopting new practices. It has four concepts: (a) susceptibility: does the person perceive vulnerability to the specific disease?; (b) severity: does one perceive that getting the disease has negative consequences?; (c) benefits minus costs: what are the positive and negative effects of adopting a new practice?; and (d) health motive: does the individual have concern about the consequences of contracting the diseases? (1,2)

Social Cognitive Theory. According to this model, behavior is determined by expectations and incentives. Expectations include (a) beliefs about how environmental events are connected; (b) opinions about the consequences of one's own actions; and (c) expectations about one's own ability to perform the behavior needed to influence outcomes (self-efficacy). Incentive is the perceived value of a outcome, such as improved health status or approval of others. (3-5)

Theory of Reasoned Action. According to this model, behavior is substantially a reflection of behavioral intentions, the report of the probability that the person will perform the behavior. Behavioral intentions reflect attitudes toward performing the behavior (behavior will lead to certain outcomes) and perceived social norms (social pressure to perform or not to perform the behavior). (6) Research has shown that behavioral intentions correlate with actual behavior, and that attitudes and social norms predict behavioral intentions.

Theory of Planned Behavior. Like the theory of reasoned action, this theory postulates that behavior reflects behavioral intention. However, it includes another determinant of intention beyond attitude toward the behavior and subjective norm. This additional concept is perceived behavioral control, which refers to the perceived ease or difficulty of performing the behavior and reflects past experiences and anticipated obstacles.

Theory of Personal Investment. The basic proposition of this theory is that the subjective meaning of a behavior is the critical determinant of one's investment or engagement in the behavior. This theory contends that meaning has three interrelated facets: personal incentives associated with performing in a situation, thoughts about self, and perceived options available in a situation. (8)

Multi-component Stage Model. This model posits that there are discrete steps (stages) in the process of all intentional behavioral change, and that different learning and motivational processes are needed for each stage. The stages are precomtemplation, contemplation, preparation, action, and maintenance. (4,9)

AIDS Risk Reduction Model. Drawing from previously suggested behavior change theories and human sexuality studies, this model characterizes people's effort to change sexual behaviors related to HIV transmission. The model is comprised of three stages: (a) recognition and labeling of one's sexual behaviors as high risk for contracting HIV, (b) making a commitment to reduce high risk sexual contacts and increase low risk activities, and (c) seeking and enacting strategies to obtain these goals. (10)

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Information-Motivation-Behavioral Skills Model. This model contends that there are three fundamental determinants of AIDS-risk reduction: (a) information regarding AIDS transmission and prevention; (b) motivation to change AIDS-risk behavior; and (c) behavioral skills for performing specific AIDS-preventive acts. The authors state that review of studies indicate that interventions focusing on these three components are most impactful. Also, five skills are identified as necessary for the practice of AIDS prevention: (a) self-acceptance of sexuality; (b) acquisition of behaviorally relevant information; (c) negotiation of preventive behavior with partner; (d) performance of public prevention acts, such as condom purchase; and (e) consistent performance of prevention behavior. (2)

Choosing the Best Model
Research indicates that the most effective educational programs are based upon theoretical approaches derived from the behavioral change models. (11) Ideally, status assessment of the target population involving several of the model constructs should occur before constructing the intervention, although most program designers are unable to conduct extensive pretesting.

Program designers can, however, consider the fundamental concepts of the models and the research on their effectiveness, and then design interventions based on their best judgement. This process can involve several steps including:

• Specifying the specific target audience and the context in which the intervention will be administered.
• Identifying the desired behavioral expected outcome of the educational program.
• Examining how the constructs of the various models are related to the expected outcome and the target audience.
• Developing the intervention strategies and program based on the findings. (11,12)

Several alternative behavioral change models, such as identified here, can be utilized in developing the program. However, program designers may not want to limit the chosen strategies based on just one model. Several of the models may provide the most appropriate and effective approach. A program to increase HIV/STD prevention and risk reduction behavior in adolescents might, for example, (a) address perceived social norms and behavior, the severity of HIV/STD, the health value of performing prevention behavior, and perceived personal susceptibility; (b) increase knowledge of HIV/STD transmission and prevention and sources of help and support; (c) provide modeling and rehearsal of prevention-related skills to increase self-efficacy; (d) attempt to increase confidence in ability to perform prevention behavior; and (e) require the development of a personal HIV/STD prevention plan including promoting a commitment to adhere to the plan. Lastly, ongoing assessment can help determine if the chosen approach is effective.

Sources of Information

1. Hornik, R. (1991). Alternative models of behavior change. In J. N. Wasserheit, S. O. Aral, & K. K. Holmes (Eds.), Research issues in human behavior and sexually transmitted diseases in the AIDS era. Washington, DC: American Society for Microbiology.
2. Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS-Risk behavior. Psychological Bulletin. 111, 455-474.
3. Rosenstock, I., Strecher, V., & Becker, M. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15, 175-183.
4. Werch, C. E., & DiClemente, C. C. (1994). A multi-component stage model for matching drug prevention strategies and messages to youth stage of use. Health Education Research, 9, 37-46.
5. Bandura, A. (1986). Social foundations of thought & action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
6. Fishbein, M., Middlestadt, S. E., & Hitchcock, P. J. (1991). Using information to change sexually transmitted disease-related behaviors: An analysis based on the theory of reasoned action. In J. N. Wasserheit, S. O. Aral, & K. K. Holmes (Eds.), Research issues in human behavior and sexually transmitted diseases in the AIDS era. Washington, DC: American Society for Microbiology.
7. Ajzen, I. (1988). Attitudes, personality, and behavior. Chicago, IL: Dorsey Press.
8. Maehr, M. L. & Braskamp, L. A. (1986). The motivation factor: A theory of personal investment. Lexington, MA: Lexington Press.
9. Prochaska, J. O. & DiClemente, C. C. (1992). Stages of change in the modification of problem behaviors. Progress in Behavior Modification, 28, 183-218.
10. Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an understanding of risk behavior: An AIDS risk reduction model (ARRM). Health Education Quarterly, 17, 53-72.
11. Coyle, K. K., & Basen-Engquist, K. (1995). Key elements in HIV Prevention Programs. In M. Quackenbush, K Clark, & M. Nelson (Eds.), The HIV challenge: Prevention education for young people. Santa Cruz: ETR Associates.
12. Perry C. L., Baranowski, T., & Parcel, G. S. (1990). How individuals, en-vironment and health behavior interact: Social learning theory. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education: Theory, research and practice. San Francisco: Jossey-Bass.

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