How Do You Change Behavior? AIDS, Behavioral Science and Structural Environment
By Fiorenzo Conte
While working in Kenya I attended a sport events during which the youths were asked to explain possible ways to prevent HIV transmission. Almost unanimously girls and boys were able to list the ABC (Abstinence Be Faithful Condom) components which are the pillars of most of HIV prevention messages in Sub-Saharan Africa. Later on in the day I sat to chat with some of the girls of one football team. After a while one of the girl who was around 14 asked me the following question: “so when the match is over do you want to go with any of us?”. This question needs to be read against the backdrop of the social prestige attached to having a relationship with a white men in rural and urban Kenya. A social prestige which is a colonial legacy and the result of a reality where the wealth is concentrated in white hands. What this question makes clear is how the ABC messages is received and perceived not to be applicable to the personal lives of the intended audience. Why does this happen?
According to some experts of the Centre for Disease Control (CDC) people might have a very good understanding of why they should change their behavior yet they could have very little insights in how such change should be achieved. The result is that very little of such educational messages is translated into practices. To bridge this gap between education and behavior they have tapped into behavioral science and argued that dramas featuring a role model can be an effective way to present to the audience how the change could take place. In this fashion the spectators can in fact identify themselves with a character whose life models the challenges and experience faced in that specific cultural, social and economic context.
To understand how this works take the story of Anita from Do Kay in Haiti. Anita’s family had experienced of period of acute poverty as a result of a forced displacement of their community. When Anita’s mother died, the worsening material deprivation caused her dad to become more aggressive and abusive. This was the spark that tipped Anita into running away to town (Port au Prince). Anita moved to one of the slums of the capital where she settled in a routine of “water, clothes, food”. While living in the slum her aunt introduced her to Vincent, one of the few man who had a job (in the tourist industry) and therefore enjoyed a style of life relatively better when compared with other inhabitants of the slum. Given the problems she had gone through, she felt she had little choice other than getting married with Vincent: this marriage in her view would have guaranteed a decent living that she had never had before. She did not know however that her first and only sexual union would have caused her to contract HIV. Now imagine one wants to come up with how Anita could have avoided this outcome to happen e.g. through protected sex with Vincent. Such role model would have the purpose to structure the motivation of young women like Anita to not enter unprotected sexual relationship and to show possible ways to overcome the barriers facing Anita in making this choice.
Firstly, the choices facing Anita should be feasible given the specifc context in which she finds herself. One could say that once Anita realizes the risk factors in the city she could decide to go back to the village. This however would not be feasible given the specific social and environmental forces which set the possibilities and limitations of Anita. She fled the village because of unbearable familiar situation and she entered the relationship with Vincent as a mean to secure a decent living. Secondly, our role model should engage in a behavior whose outcome can serve as incentive rather than as disincentive to assume the desired behavior. So if the decision to force the husband to use condoms during sexual relationship would lead Vincent to leave Anita, this would be a disincentive in that it would undermine the decent living which was Anita’s goal. Contrarily, if the outcome associated with protected sex is a positive outcome such as improved health this would serve as incentive. Thirdly, as Anita faces initial opposition by Vincent she would try different avenues to convince him to use condoms; in this way she would increase the confidence in her ability to assume a certain behavior. As this self-efficacy increases, Anita would be more willing to attempt changes and to persist in the behavior. Lastly, Anita’s story presented to the audience should depict her process of going from not thinking about changing the behavior to the moment when action is taken to change it and maintain it over time. The passage from one stage of change to another is not unilinear or unidirectional and in fact Anita would face a lot of setback. What her story should show is how one can overcome such setbacks and proceed in the pathway to change, given the possibilities and limitations dictated by the external environment.
Such attempt to link Anita’s story to the social and environmental context she belongs to, to outline positive outcome which can increase expectation, to increase self efficacy of her own actions, and to show how to overcome the different drawbacks in the pathway to change constitutes an important contribution of behavioral science to better tailor public health messages aiming at changing dangerous behaviors. Behavioral principles built in role models can in other words help to link healthier behavior to private and personal aspirations while showing the social costs of risky behaviors thus causing the accepted norms to shift.
There is however a caveat: for behavioral change to happen the structural environment – i.e. social and economic barriers – has to shift too. The poverty of Anita’s family pushed her to flee to the urban slums and to enter a relationship with a man she did not know at the age of 15, simply because he had a job (which remains the exception rather than the rule in Haiti). The absence of an exit option (the situation back home was even direr) leaves Anita with very little bargaining power in case Vincent would continuously refuse to use condoms . This underlying factor of material deprivation which limits the agency of Anita and leads to define AIDS as disease of poverty is much more persistent and goes beyond the reach of behavioral science.
 The experts at the CDC have formalized their approach in what is called Modeling and Reinforcement to combat HIV/AIDS (MARCH) and now they have founded the NGO Global Health Communication with the goal to implement such tool.
 This story is taken by Paul Farmer’s book “ AIDS & Accusation” and the discussion which follows draws upon some of the key messages of the book.
 This discussion draws upon two academic papers “Applying Behavioral Science to Behavior Change Communication: The Pathways to Change Tools” Joseph Petraglia, Christine Galavotti, Nicola Harford, Katina A. Pappas-DeLuca and Maungo Mooki Health Promot Pract 2007 8: 384 and “Narrative Intervention in Behavior and Public Health” Joseph Petraglia, Journal of Health Communication, 12:493–505, 2007