Saturday, May 8, 2010

Assessment on the effectiveness of the AIDS Risk Reduction Model - Paolo Chanes-Mora

The AIDS Risk Reduction Model (ARRM), an approach to reducing AIDS, is one of several social and behavioral models to reduce the ever growing impact of HIV/AIDS. ARRM is grounded in several health behavior theories including the, Theory of Planned Behavior, Health Belief Model and the Transtheoretical Model. These three theories are flawed because they treat problems as if they existed in a vacuum when in reality they are complex and multidimensional. As a result of being based on these three models ARRM suffers similar weaknesses. ARRM does not take into account that individuals will not change just because they are shown their susceptibility, and severity, of a health issue, that fact that planning to change a behavior does not always translate to behavior change, and it heavily depends of the use of arbitrary stages of change. ARRM is a weak model to target the HIV/AIDS population and several adjustments and changes would benefit this model.
The Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) have created a pandemic that takes approximately 2 million lives a year, with nearly 3 million new infections yearly (1). HIV/AIDS impacts many demographic areas and it is important to develop a specific approach to truly make an impact in risk reduction. College campuses, state health officials, and grassroots programs are investing time and resources to implement effective models that will reduce the infections of HIV/AIDS. There are multiple available models, interventions and approaches to decrease HIV infections and improve awareness, some of which have been proven to work better than others. ARRM is one several models that can benefit from change in order to have a greater impact.
ARRM focuses on reducing the spread of AIDS. It aims to explain and predict the behavior change of individuals in relation to the sexual transmission of HIV/AIDS (2). The approach is based on the Health Belief Model (HBM), Theory of Planned Behavior (TPB) and the Transtheoretical Model (TTM). It is composed of three stages: 1) recognition and labeling of one's behavior as high risk, 2) making a commitment to reduce high-risk sexual contacts and to increase low-risk activities, and 3) taking action. The last stage, taking action, is broken into three more steps: 1) information seeking, 2) obtaining remedies and 3) enacting solutions (2).
In stage one of ARRM, the individual is supposed understand susceptibility through education about the severity of sexual activities associated with HIV transmission, believe that he/she is personally susceptible to contracting HIV, believe that having AIDS is undesirable and learn about social norms and networking (2).
Stage two examines the cost and benefits of risky behavior. It takes into consideration enjoyment, response efficacy, self-efficacy, knowledge of the value of good health and enjoyability of a sexual practice, as well as social factors (2).
Lastly, in stage three social networks and problem-solving choices come into play. It includes prior experiences with problems and solutions, level of self-esteem; resource requirements of acquiring help, ability to communicate verbally with sexual partners, and sexual partner's beliefs and behaviors (2).
The Health Belief Model is the fundamental theory driving the three stages of ARRM. The HBM, one of the oldest and most commonly used models in public health, is one of several individual based theories (3). It relies on perceived susceptibility, severity, benefits and actions, and barriers to taking the action. Also, It takes into consideration the degree to which a person feels at risk for a health problem, the degree to which a person believes the consequences of the health problem will be severe, the positive outcomes a person believes will result from the action, the negative outcomes from the action, an external event that motivates a person to act, and a person’s belief in his or her ability to take action (3). Exactly because of several of these approaches in the HBM, that exists in ARRM, make ARRM weak because not everyone who is aware of their risk to HIV/AIDS will want to change their behavior
The TPB is also a core theory of ARRM. Like the HBM, TPB focuses on rational decision-making, and planned behavior. This theory believes that a person’s attitude towards a specific behavior, and their perception of the subjective norms associated with that behavior are the driving force to initiating, or not initiating, a new behavior (4). The TPB extends on the HBM to include social norms and acceptance by others due to the change, or lack of change, in the behavior. Though, this theory is also not strong enough to make ARRM change a behavior and move from planning to actions. The TPB still does not allow for ARRM to be a successful approach to risk reduction due to that fact that planning to change a behavior does not always translate to behavior change.
The TTM proposes that individuals move through a series of motivational stages before achieving the desired behavior. For ARRM the desired behavior change is the risky behavior (5). The five stages of change are precontemplation, in which an individual shows no intention to adopt the health behavior; contemplation, in which an individual shows awareness of personal risk and the need to change; preparation, in which an individual expresses intention to change; action, in which an individual has actively adopted the behavior for a period of less than six months; and maintenance, in which the behavior is sustained for more than six months. At each stage emotional, cognitive, and behavioral processes promote moving to the next stage. Behavioral change can be made by the use of intervention strategies customized to an individual’s stage of readiness to change (6). In addition, a person can move in various ways through this model and do not need to follow a linear transition (5). However, when this theory is applied to the ARRM risk reduction is less likely to work because people don’t always directly fall into these categorized stages and would probably benefit more from individualized approaches
Stage one of ARRM which follows closely the beliefs of the HBM, require a person to understand knowledge of sexual activities associated with HIV transmission, believe that one is personally susceptible to contracting HIV, believe that having AIDS is undesirable and learn about social norms and networking. While in theory this knowledge would lead a person into stage two, weigh the health costs and benefits, it does not always work this way. If a person has multiple partners and is at a much higher risk of contracting HIV/AIDS but enjoys having unprotected sex, they are unlikely to be willing to change their behavior by just someone exposing them to the information. Salazar, in his literature review agrees that in multiple studies perceived severity was of low significance, particularly as it related to preventive health behaviors (7). In addition, it has been stated the HBM, in which ARRM is grounded in, has contributed to the limited understanding and the devaluation of individuals which can easily be applied to those seeing risk reduction practices (8). If an ARRM practitioner believes that based on such implications, as just spreading knowledge to a person, the individual will want to stop risky behavior, it can be seen how indeed the model does add to the limited understanding and devaluating individuals. It is not that simple, the individuals the ARRM is targeting are dynamic, and ever changing, not static and predictable as it is proposed by the model.
Also tied to the BHM, ARRM’s first stage, as Kyung-Hee describes it, is a stage of labeling (9). The risk reduction is meant to occur by labeling the risky behavior with the new information that has been presented regarding the health benefits. However, labeling can be different from individual to individual. There is not a set standard, nor can there be an assumption, that with labeling an action based on presented information it will lead to the desired behavior change.
The assumption in the TPB that planning behavior change leads to the desired behavior change makes ARRM weak. It assumes that behavior is a result of rational decision-making, and that behavior is done in a mechanistic order (6). It does not take into consideration instincts of sudden emotion, habits, income, education level, and other demographic characteristics (6). ARRM assumes that one’s intentions are an immediate determinant of behavior (7).
Further explaining the TPB, Kyung-Hee studies the connection made by ARRM in planning and actually changing behavior in his studies of Asian males who have sex with males (MSM). The subjects who did not practice safe sex, was not because they didn’t plan to use a condom, nor because they didn’t know about their risky behavior. The reasons included, not wanting to show their sexual status in order to avoid community stigma, bringing shame to the family and disappointing parents. MSM is a very high risk population because as explained, they are led by sexual urges and seek sex in a quick way that does not always allow them to use protection even if planned on it before hand (9). ARRM doesn’t take into consideration these outside influences that need to be targeted in the model to actually have significant risk reduction.
Stage three of ARRM, based on the TTM, reduces a person’s behavioral change into steps and heavily relies on the transitional stages, which makes the ARRM an ineffective model. People don’t always progress nor desire to progress in a straight line, as proposed by the ARRM, and can evolve a cyclical pattern of trying to stop, stopping and then beginning at another stage for several cycles (6). In addition, it is difficult to develop an arbitrary set of criteria to measure stages such as contemplation vs. maintenance, or maintenance vs. termination. Categorical placing can result in focusing on trying to figure out what stage the person is in rather than trying to focus on the intervention they should get (6).
West, R, adds that besides creating arbitrary categories and classifying individuals, the transtheoretical model ARRM is grounded on, presupposes coherent and stable plans will be made by the individual (10). Prior to engaging in risky sexual behavior one does not schedule a place and a time. People, who have multiple sex partners, do not always leave their homes scheduling appointments to have sex, nor whether or not they will be practicing safe sex. Many times it is spontaneous, impulsive, and a result of outside uncontrollable factors, and the TTM and ARRM leave no room for non-coherent and unstable plans.
The TTM is also heavily criticized as a type of scientific assessment used to appear capable of developing an intervention based on the needs of the individual (10). It is critiqued on the “soft” results it acquires, for example, going from precontemplation to contemplation, which according to West has no proven value (10). ARRM attempts to bring risk reduction in matter that fits its possible beneficiaries into boxes—stages they will most often not fit into.
To find the effectiveness of ARRM, and at the same time assess the HBM, TPB, and TTM that support the risk reduction model, an evaluation was created for both high risk seekers and low risk seekers. Risk seeking individuals were described as having impulsivity, disinhibition and engagement in problem behaviors. The study associated high risk seeking individuals with lower condom use, having multiple sexual partners, and not knowing their HIV status (11). The subjects in the study were asked to rank from 1 (strong disagree) to 4 (strongly agree), and answer yes/no questions to assess their risk level. The four main types of ranking questions asked were about perceived infection risk, AIDS knowledge, peer norms—mainly related to the HBM. Then there were yes/no questions asked about self-efficacy and intention to use condoms—TTM (11).
The results of the study showed that ARRM worked well for predicting condom use in both high and low risk seekers in this specific group of individuals. The two risk level groups achieved different levels of success depending on the ARRM stages of the study. For the high risk group, the leverage points were “prior condom use” and “self-efficacy.” Meaning stage two of ARRM, based on TPB, was not as useful to them. However, for the low risk seekers the leverage points were “previous condom use” and” intention to condom use,” and were the most important factors in their risk reduction. The low risk seekers leverage point demonstrates the importance of stage two for these individuals, and also further emphasizes how ARRM is not suitable for individuals of all risk levels (11).
As the results of Connor’s studies show, individuals in the ARRM do not always perfectly fit into the three stages of the model. Therefore, while a model might appear to be overall effective, it needs to be further analyzed and developed to find the stages that are relevant to the desired population. In ARRM specifically, and the three health belief theories need to be further developed to understand that knowledge of severity and susceptibility does not lead to behavior change, planning behaviors change does not always lead to action of the desired behavior change, and lastly that a person’s progress which is reduced into steps and heavily relies on the TTM stages might not apply and be effective to all people.
To improve these three main flaws in the health belief theories, and as a result in ARRM, there should be three major changes. First, the assumption in the HBM that perceived susceptibility and severity leads to behavior change needs to be dismissed. Rather, a new approach that show the benefits of engaging in good sexual practices needs to be developed; scare tactics usually don’t work. Second, environmental factors that can lead a person to change planned behavior, which are not included in the TPB, need to be addressed. Problems like not having access to condoms, cultural beliefs, income, and education level need to be addressed. Thirdly, a model that includes motivational progress, not one that will set a person in boxes as the TTM, will be most beneficial.
To dismiss the belief ARRM has that perceived susceptibility and severity leads to behavior change, safer sex practices should be made fun. For example, showing the individual who is about to engage in risky behavior and does not have a condom that there are multiple ways to still receive pleasure from a sexual activity that is less risky. Oral sex and several other methods of foreplay that do not involve sexual intercourse, and are still pleasurable, can reduce their risk level for contracting HIV/AIDS.
In addition to foreplay there are several “toys” such as dice, cards, and fun condoms that can be used in a campaign, or new approach, to show high risk users that being safe, even when caught in unprepared moments, can still be arousing and very pleasurable. This method of showing the positives will greatly steer away from ARRM’s way of showing scary statistics and information to try to show severity and individual’s susceptibility. As discussed in class with the childhood obesity campaign, showing parents the issue won’t change much. Better tactics are to show the positive outcome of the wanted behavior change.
In addition, by focusing on the positive results of safe sex practices, a new approach to stage one of ARRM, and the HBM, should be developed. The new approach should highlight that those who engage in low risk behavior have better communication skills. Partners who get tested for HIV prior to having intercourse, who talk about condoms usage, sexual transmitted diseases (STDs) and sexually transmitted infections (STIs) are able to have a healthier sexual relationship. These are the positive aspects risk reduction models like ARRM should focus on.
Secondly, as ARRM and the TPB wrongly assumes, planning behavior does not lead to change in risk reduction practices. A new successful approach would be to provide risk reduction opportunities. These opportunities should include established outreach programs that provide information about lubes, condoms, sexual health. Also the new approach to risk reduction should provide free HIV testing for couples and individuals who want to know their HIV status, and free STD/STI screenings.
Referrals to centers where women, and men, who want to engage in safer sex but are experiencing domestic violence, should also be available. Providing a support system will lead to higher chances of engaging in safer sex practices that will decrease their vulnerability to risky behavior. In addition, counseling should be provided for these individuals who do not have a say in the risky behavior they are involved in. If they need to leave an abusive partner temporary housing such as shelters should be available.
For individuals like the MSM discussed in Kyung-Hee’s study who were scared of their loved ones realizing their sexual conduct, there should be tactics such as group therapy to help them learn how to express their sexuality openly. Seminars and workshops to help those who have decided to change their behavior achieve it by providing the necessary skills to accomplish them would be a great environmentally inclusive as well as productive approach.
Lastly, to further be inclusive of environmental factors that can result in an individual who has planned to change their behavior carry out the change, cultural awareness and norms need to be considered. Since ARRM and the TPB do not consider these factors it has resulted in making them weak models. Cultural norms for many people define their behavior and if this important factor is ignored public health cannot expect planned behavior to result in actions that will reduce risky behavior.
To address the issue that ARRM, and the TTM, has with arbitrarily formed stages, new motivational and encouraging steps need to be formed. As mentioned by Edberg, people sometimes have a cyclical pattern, and can follow different steps in a non-sequential matter proposed by ARRM. Rather than trying to find what stage a person is in, ARRM and the TTM should develop a more individual approach to helping reduce risky behavior. Taking into consideration the environmental factors that make a person not follow through with their plans should be addressed. Another note made by West, is that “soft” results are not useful and steps such as precontemplation and contemplation need to be eliminated to develop an effective approach. Motivational and self-assessed changes are more successful than just trying to move someone from stage to stage (12).
These three recommendations would greatly benefit ARRM, and serve as a new approach to risk reduction. ARRM failed by being based on three models that were already flawed, that as a result made this risk reduction model even weaker. The model did not take into account that individuals participate in irrational behavior regardless of being shown the severity and susceptibility of the desired health change, that fact that planning to change a behavior does not always translate to behavior change, and it heavily depended on the use of the stages of change, which cannot be applied to all high risk individuals. HIV/AIDS interventions in general need to be more population and target specific and since HIV/AIDS does not occur in a vacuum and it involves relationships is should not solely be based on individual interventions. It is difficult to have strong model that tries to apply an approach surrounded only on the individual to a pandemic that is so complex. With a more population specific approach, a risk reduction program that includes the noted recommendations will be successful.


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