Monday, May 20, 2013

The Failure of One-dimensional Approached to Behavior Change: A Call for Community-Level Interventions among IV Drug Users - Sarah Mackin

It has been thirty-two years since the HIV was discovered in the United States, and twenty-six years since President Ronald Reagan first publicly said the word “AIDS.”  Since the beginning of the AIDS epidemic in the 1980s, over a half a million people have died in the U.S.--roughly equivalent to the entire population of Las Vegas.  [1] While dramatic gains in biomedicine and public health have succeeded in slowing the spread of the epidemic, significant challenges remain. On average, over 50,000 Americans are infected with HIV each year, or one every nine and a half minutes. [2]
After nearly three decades without a cohesive, comprehensive national strategy in the U.S., the Obama administration unveiled the first National AIDS Strategy in July of 2010. Two of the central goals of the strategy are lowering the number of annual new infections by 25%, and reducing HIV transmission by 30%. Intravenous drug users (IDUs) have been identified as “vulnerable populations” since the onset of the HIV epidemic, with intravenous drug use recognized as a direct route of transmission of the virus. In light of the Obama administration’s goals, IDUs have been identified as the “face” of the HIV epidemic and continue to be disproportionately impacted by the epidemic today, accounting for 9% of all new HIV infections in the US in 2009. [3]

Approaches to HIV Prevention among Intravenous Drug Users
One of the key ways in which public health responded to high rates of HIV among IDUs was through the introduction of structural interventions such as needle exchange and syringe access programs. However, beyond these structural interventions, behavioral interventions aimed at reducing risk behaviors associated with HIV transmission have long played a critical role in the fight against HIV. With biomedical solutions, such as an HIV vaccine, still in the distant future, behavioral interventions continue to be an integral part of prevention efforts with active substance users.
Many of these interventions are founded in cognitive-behavioral theory, which seeks to change risk behavior at the individual level. While general prevention efforts with active drug users have succeeded in drastically lowering rates of HIV transmission among IDUs, these individual level interventions have inherent, severe limitations in effectively preventing new HIV infections among IDU populations [4]. The vast majority of these behavioral interventions are grounded in the underlying assumption that if individuals increase knowledge of their risks, and are adequately “motivated,” then they will take action to change their risky behavior.  These theories do not address the macro-social and structural constructs of injection drug use such as poverty, violence, and a multitude of other societal and fundamental factors. While research supports the claim that these behavioral interventions, at least in the short term, increase knowledge of risk and inspire changes in attitudes, there is a lack of evidence and research that shows these modalities as effective in reducing the number of new HIV infections. [5]
One of the most widely implemented behavioral interventions, used with both injection and non-injection drug users, is Safety Counts. This intervention aims to reduce high-risk drug use and sexual behaviors, and is founded in cognitive-behavioral theory. Comprising seven core sessions, held over the course of four months, Safety Counts incorporates both group and individual level behavioral health interventions.
The seven core components of Safety Counts consist of two group sessions, one or more individual counseling sessions, two or more social events, and two or more follow up contacts. A behavioral health counselor facilitates group sessions, in which individuals share personal accounts of risk reduction stories. The Stages of Change Model (Prochaska) serves as the structural foundation for both the group and individual level sessions, with participants assessing their own readiness to change risky behavior, and then identifying personal behavior goals. In following sessions, participants share personal stories of how they have successfully implemented risk reduction in their own lives. By listening to how peers have overcome barriers to behavior change, and by understanding how these changes led to ultimately desirable outcomes, individuals in Safety Counts develop their own belief in their individual ability to modify unhealthy behaviors.
With an end goal of long-term behavioral change in all participants, Safety Counts relies on the Health Belief Model, Social Cognitive Theory, and the Transtheoretical Model as its foundation. [21] While there is evidence that interventions based in these theories and models achieve short-term changes in behavior, there is no evidentiary basis upon which Safety Counts  can claim that their participants will achieve successful behavior modification in the long-term. [13]

Critique 1: Health Belief Model/Health Promotion
One of the theories on which Safety Counts relies is the Health Belief Model (Rosenstock), which involves a balancing act between a patient’s perceived benefits of a behavior versus their perceived costs. The Health Belief Model relies on an individual’s perceived personal threat in order to alter behavior. [22] Safety Counts, in confluence with the Health Belief Model, assumes that with increased knowledge of the risks and dangers of their behavior, IDUs will rationally modify their behavior in order to avoid HIV infection and transmission.
However, the Health Belief Model in inherently flawed in its reliance on this assumption of rationality. It has been shown that people will do irrational, extreme things to prevent experiencing loss. Once a person owns something, whether it is something physical or intangible like a habit or behavior, that person will value it very highly and won’t let it go. As humans, behavior is a part of who we are, so asking IDUs to change their health behaviors based solely on assumed rationality is asking them to willingly give up a part of themselves.
Along with the flawed assumption of rationality, the Health Belief Model does not take into account behavior-modifying influences that surround IDUs. Behaviors are deeply influenced by environmental, social, and cultural factors; improvement in knowledge is not necessarily concurrent with a positive change in an individual’s behavior. Perceived risk of HIV acquisition, and even knowledge of the severity of the disease, is often not enough to override competing priorities and interests. For example, there are habits, rituals and expectations within IDU subculture that at times include social expectations around needle sharing. Regardless of increased knowledge, social norms within IDU networks may cause a drug user to fear consequences among his or her peers upon refusal to share injection equipment. [12]

Critique #2: Social Cognitive Theory

Another key tenet of the Safety Counts intervention model is based in Social Cognitive Theory, which is built upon two concepts: self-efficacy and social modeling. By determining the beliefs that an individual has about their own ability to affect situations and be successful, and coupling that self-efficacy with models of good behavior to imitate, Social Cognitive Theory seeks to address both individual behaviors and the impact of societal factors on an individual. One key aspect of this theory is social modeling. The assumption behind modeling is that people act by observing the behavior around them, and model the behaviors they see. Therefore, Social Cognitive Theory is not solely reliant on assumed rationality.
However, Social Cognitive Theory does not account for the fact that relapse into risky behaviors is an impulsive decision. Also missing from the theory is the acknowledgement of ‘visceral factors’ [20], such as thirst, hunger, sexual desire, or cravings, and how these factors mitigate the regulation of behavior. In addition to the critical oversight of these two factors, it is important to note that they are inextricably linked; impulsivity increases as these visceral factors intensify. So for IDUs, as withdrawal, trauma, and other emotional crises increase, so also increases the likelihood of relapse. The more intense withdrawal becomes for an IDU, regardless of the level of self-efficacy or modeled behavior modifications, the more apt the IDU is to use a borrowed needle, or engage in other high-risk behaviors.
Social Cognitive Theory is severely limited by the assumption that changes in an individual’s environment automatically changes behavior. For example, in the case of Safety Counts, the environment that the intervention is changing is limited to a loosely affiliated group of participants involved in the intervention. The modification does not extend to personal networks, close interpersonal ties, and other important elements of IDUs’ lives. [9]
In order for an intervention based in Social Cognitive Theory to be effective, it must be based in the reality of the IDUs it serves. The inherent artificiality of the groups within Safety Counts automatically limits the intervention’s effectiveness, because changes, triggers, and other factors from the individuals’ environment are completely unaccounted for.

Critique #3: Transtheoretical Model

While Safety Counts is theoretically based in both Social Cognitive Theory and Health Belief Model Theory, the group and individual level sessions are modeled on the Stages of Change, also known as the Transtheoretical Model. The Transtheoretical Model (TTM) is based on the assumption that behavioral change does not occur in a moment, but is an ongoing, cyclical process. [21]
The TTM is grounded in the belief that every individual moves through six stages in order to achieve change: precontemplation, contemplation, preparation, action, maintenance, and termination. The TTM is not a theory in and of itself, and different behavioral theories and intervention strategies are most effective at each stage in moving an individual through the model. In the TTM, several cognitive, affective, and evaluative processes are applied to progress individuals through the stages of change; these processes range from increasing awareness to rewarding positive behavior and from committing to change to substituting healthy behaviors for unhealthy ones.
While the TTM is one of the most dominant models of behavior change in healthcare, and it is the model upon which Safety Counts is based, it has serious limitations when it comes to working with IDU populations, and affecting long-term behavioral change in general. The first major issue with the TTM is a lack of consistency and transparency within the model itself. [3]There is no determined timeline for how long an individual should take in each stage; neither is there a timeline for how long an individual should remain in each stage of change. In addition, there is no standardization among assessments used to determine which stage an individual should be assigned to, and these assignments are often arbitrary. Without a standardized set of criteria to determine an individual’s stage of change and without a timeline for an individual’s planned rate of change, the TTM becomes an organized form of guesswork for healthcare intervention providers. [3] Alongside its lack of accountability, standardization, and validation, the TTM also fails in its core assumption of rationality. Much like Social Cognitive Theory, the TTM’s design is rooted in the belief that an individual will make and follow coherent and logical steps in their decision-making and behavioral processes. An inherent flaw in the TTM is its failure to address the social and environmental contexts in which individuals make behavioral decisions. IDUs, like all individuals, have a variety of environmental factors that influence behavior on a daily basis. [3,11]The TTM disregards these factors, and claims that the process for behavioral change is uniform across all individuals.
Drug use is a complex behavioral issue, stemming from a multitude of environmental, mental, physiological, and emotional concerns. Applying generic, arbitrary stages of change to complex behavior such as drug use [3] is ineffective and problematic. Multiple researchers have emphasized that with complex behavioral challenges, such as drug use, a more objective assessment of an individual’s behavior is essential for effective intervention.


The majority of behavioral interventions used in vulnerable populations are implemented exclusively at the individual level, and are thus only able to address one small part of a complex epidemic, fundamentally undermining HIV prevention efforts. Without addressing macro-level factors, interventions that are solely psycho-socially based cannot have a lasting impact on behavior change, neither at the individual nor community level. [14]
An IDU’s behavior, and consequent behavior change, does not happen in a vacuum. Rather, there are interactive and dynamic relationships between the individual, and socio-economic, cultural and structural factors that surround him or her. [13] Safety Counts is a commonly used intervention with IDU populations, and its efficacy is hampered by the narrow lens through which it views and approaches behavior change. Although the intervention utilizes both group level and individual level activities, the community change that Safety Counts advocates is limited to the artificial community of the program participants. [19]
The creation of an artificial, temporal “peer network” in these group sessions is problematic, as participants are likely to have few ties or relationships outside the scope of the intervention itself. Since a central tenet of Social Cognitive Theory is to utilize social influence to reinforce behavior change, these group level sessions do not achieve this goal. Once the intervention is over, participants return to their own communities and reintegrate into their own social networks, where the norms and values may be different or even counteractive to the behavior changes learned in the Safety Counts intervention.
In order to effectively address the HIV epidemic, interventions must address both the individual and community levels. While individual-level interventions have been shown to produce short-term belief, attitude, and behavior changes, there is no evidence showing that they have any long-term effect. Social Network Theory posits that individuals are dynamically and fluidly a part of many different networks and groups, such as peers, co-workers, family members, and social circles. If individuals are to maintain long-term behavior change, community-level interventions must be implemented in order to change the norms and values of individuals’ social networks. [5]
By influencing positive change in participants’ social networks, Safety Counts could also address its intrinsic issues that stem from the use of Health Behavior Models. Because individual-based Health Behavior Models are founded in the assumed rationality that increased knowledge leads to behavior change, Safety Counts could mitigate the negative influences of the complex social and environmental factors surrounding IDUs by implementing broad, community-based interventions.
Adapting Social Cognitive Theory to a broader community-based intervention model will address several inherent flaws in Safety Counts’ theoretical framework. However, the program’s design basis on the TTM remains a fundamental flaw. Multiple researchers argue in favor of a more objective assessment system for the complex behavioral issues that accompany IDUs. By adopting more uniform, objective, and standardized criteria for assessing participants’ needs and projected timeline, Safety Counts would be more effective in attending to individual’s needs.
There are several CDC AIDS Community Demonstration Projects that have yielded promising results with the kind of community-based interventions that Safety Counts needs in order to be more effective Rather than applying social modeling theory to artificial groups of unrelated intervention participants, instead Safety Counts should adequately invest in capacity building and training for these individuals, in order to build cohorts of peer educators. These peer educators then can be sent out into the community to both live as role models of and advocate for reducing risky behaviors. With a growing cadre of influential peer educators, Safety Counts could begin to change the norms of the IDU social networks and affect lasting behavior change.


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[11] Observations by five Commentators on the paper by Adams, J. and White, M. (2004) Why don’t stage-based activity promotion interventions work
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[20] LOEWENSTEIN Out of Control: Visceral Influences on Behavior ORGANIZATIONAL BEHAVIOR AND HUMAN DECISION PROCESSES Vol. 65, No. 3, March, pp. 272–292, 1996

 [22] Rosenstock, I. M.; Strecher, V. J., Becker, M. H. (1 January 1988). "Social Learning Theory and the Health Belief Model". Health Education & Behavior 15 (2): 175–183.

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