Health Promotion and HIV

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Health Promotion and HIV

• Dr Graham Brown

WA Centre for Health Promotion Research
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Health Promotion
Dahlgren, G and Whitehead, M. 1991. Policies and
strategies to promote social equity in health,
Institute of Future Studies,.Stockholm
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Organis - ational and systemic change
Community and social influence
Gay status non specific
HIV / HepC known
heterosexual men and women
Individual and group focused
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Organis -ational and systemic change
Marketing information to promote health
Community and social influence
Individual and group focused
Heterosexual men and women
Gay status non specific
HIV known
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Challenge of behaviour theory and risk practice
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Use of theory for multi level interventions
Examples of strategies
Ecological level
Useful theories / models
Change strategies
Change the environment
Change peoples behaviour
Adapted from Theory at a glance-National
Institutes for Health, USA
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Meanings of risk in HIV and health promotion

• Inaccurate and blunt use of models has often led
  to an individualist and rationalistic view of
  behaviour change.
• This has been damaging to the HIV and HepC
  response
• Most behaviour that places people at risk is not
  people setting out to take a risk.

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Risk Behaviour vs Practice

• People act with reference to meaning.
• For example..
• They do not engage in sexual behaviours eg
  penis-in-anus,
• they enact sexual practices they make love or
  have a one-night-stand or get their rocks
  off.

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Risk Behaviour vs Practice

• Sexual behaviour or injecting behaviour may be
  reasonably similar across time and place.
• Sexual or injecting practice is more fluid it
  takes on a number of forms.
• social and cultural - produced within a
  particular time and place.
• different in Australia from European or Asian
  contexts.
• it was different before HIV or HepC compared to
  now

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Risk Behaviour vs Practice

• Risk behaviour is modifiable and is open to
  intervention.
• But we modify it by engaging with practices

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Risk Behaviour vs Practice

• We may be looking at reported sexual behaviour or
  injecting behaviour as a measurable outcome but
  it is the broader practices that we try and
  engage / influence.
• Requires a broad integrated approach that
  understands and engages with the social /
  cultural meaning
• This is why active and genuine community
  participation is so critical

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Role and need for genuine participation
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Community development and organisation in health
promotion

• HIV brought a revolution in the way affected
  communities participated at all levels of public
  health initiatives
• Built on a range of human rights, gender rights
  and social justice movements in the 60s and 70s.

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The Jakarta Declaration 1997

• Re-affirmed Ottawa Charter
• Equity
• Partnerships
• Settings
• Sustainability
• Participation

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The Jakarta Declaration 1997

• Participation is essential to sustaining efforts.
  
• People have to be at the centre of health
  promotion action and decision-making processes
  for them to be effective.
• The challenge for the coming years will be to
  unlock the potential for health promotion
  inherent in local communities and society.
• Capacity building and partnerships for
  participation

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Greater Involvement of PLWHA (GIPA)

• In 1983, The Denver Principles
• a national AIDS conference was held in Denver,
  USA. Positive activists announced a set of
  principles that would revolutionise the way the
  world responds to an epidemic.
• standards for human rights and self-empowerment
  in a health crisis.
• 1994 Paris AIDS Summit Declaration
• Central role of people living with HIV in AIDS
  education and care, and in the design and
  implementation of policies and programs towards a
  successful response to HIV/AIDS
• Developed and debated further at a range of
  international forums and events.
• 1999 - From Principle to Practice Greater
  Involvement of People Living with or Affected by
  HIV/AIDS (GIPA)

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1st Australian HIV/AIDS Strategy

• Firmly based within principle of the Ottawa
  Charter
• Some have argued this has been watered down to
  some extent in subsequent strategies
• Participation and community ownership in
  particular

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Community participation

• The process of enabling individuals and
  communities, in partnership with health
  professionals, to participate in defining their
  health problems and shaping solutions to those
  problems.
• (Rifkin et al., Wallerstein, Minkler, Roberstson
  and Minkler, in Shediac-Rizkallah and Bone, 1998)
• It provides the opportunity for ownership,
  empowerment and self-determination those
  difficult-to-measure intangibles that can make
  the difference between long-term success and
  failure
• (Green and Kreuter 2005)

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Community organising and community development

• Community Development facilitate, encourage and
  sustain a level of community action. Decision
  making control is invested in the community, and
  is driven from a ground up approach.
• Community Organising has a more centralised, set
  agenda approach, where the community is involved
  in an already set health objective.

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A continuum of community participation
Rothmans model
Lower level of participation
Higher level of participation
Participation levels can vary throughout the
stages of program planning, implementation and
evaluation
COMMUNITY ORGANISATION
COMMUNITY DEVELOPMENT
top down approach
bottom up approach
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Organising vs development

• Community Organising (Social Planning)
• attempts to solve community problems within
  existing power structures
• assumes that complex community change must be
  guided by trained planners
• tends to be task-orientated and expert-driven
• traditionally delivered by govt and non govt
  agencies for the benefit of the community

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Organising vs development

• Community Development (Locality Development)
• community change is pursued through participation
  of a wide range of people in determining their
  own local goals and action
• health promotion practitioner is more of a
  facilitator, aiming to empower community members
  (Egger et al, 1999)

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Organising vs development

• It is important to achieve the right balance
  between the two, less initiatives become
  irrelevant to the lives of the communities they
  are for.
• As the program is implemented, there is good
  potential for a change in emphasis and approach

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Overall comments

• Clear need for
• effective evaluation and development with genuine
  participation
• sharing of evaluation at the project and
  programmatic level across jurisdictions
• Evidence informed practice and practice informed
  evidence

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Overall comments

• Community response to HIV has played a major role
  in the development of Health Promotion and New
  Public Health.
• Demonstration that an integrated, participatory,
  pragmatic and community driven response does
  work, and works better.
• Sustaining this is critical to the improved
  health of PLWHA, PLWHepC and reduction of
  transmission.
• Also relevant to broader communities of health
  and development, who often look to HIV to provide
  leadership