July 19, 2007
I’ve noticed that what has been interesting me most in the documents I’ve been working with here at UNICEF is what the development field likes to call “behavior change communication:” the idea that if you somehow say the right thing in the right way, a person will actually start to act differently. The question of behavior change comes up a lot in work with HIV/AIDS, because seemingly the vast majority of interventions focus on educating people. If people don’t know that they can get HIV from oral sex or from a person who appears healthy, clearly they can’t protect themselves well. From the opposite perspective therefore, it is presumed or assumed that if a person does know that even if you do it say, in the ocean, sexual intercourse can still transmit HIV, that they will stop having unsafe sex. Though this seems perfectly logical, it really isn’t true. In some parts of the world, and this region, people are still painfully and dangerously ignorant of HIV, AIDS and methods of transmission and prevention. And reproductive health education is imperative to halting the spread of the disease. But in many places in this region where the epidemic is spreading and becoming generalized, young people have a pretty decent grasp of how they can catch HIV/AIDS. And even if they don’t know all the nitty gritty details, they do know that the best way not to get infected is to use a condom. Yet many still don’t.
So we come to the question that fascinates me: why not? It seems like in order to answer it, those working in the field of behavior change and AIDS education programs need to take a step closer, outside of the academic and institutional perspective we know and love. Pretty much my favorite document I’ve read from any of the country offices so far was a study in Barbados trying to answer this question of ‘why?’ They conducted focus groups and interviews with ‘at risk’ teenage girls in several public schools, talking with them about their relationships, their general social environment, their understanding of safe sex, their knowledge of HIV/AIDS, and their actual actions in terms of protection during sexual activities. The report includes many quotes from the girls, and through their words this ‘gap’ between education and action starts to make much more sense. Because though prevention programs and public health strategies take a purely epidemiologically perspective of all STDs and HIV in particular, as I read somewhere recently, the old, very un-PC, label of “social diseases” instead of “Sexually Transmitted Infections” does say something important because it addresses the social context. This is important because the means of contracting HIV are rooted in relationships with other people. Of course this is difficult to change, and much more complicated than informing people that if they always use condoms they will be protected.
Sex is involved in all sorts of negotiations of power, status, appearances, peer pressure, machismo, and curiosity even before you consider any of the complications often added into the mix by material exchanges. And social decisions are rarely made in a straightforward, perfectly logical fashion. After all we are talking about love, passion, happiness, beauty and popularity, not something practical or definable. But what I think it’s easy to forget when you talk about changing people’s behavior is that people always do what they think is best for themselves. As my friend Jesus said last weekend when I continued blabbering about this topic far away from the office, everything people do is a cost benefit analysis. And as they tell me in economics class, each person is the best judge for themselves as to what will benefit them and what will hurt them. This is, supposedly, also the problem with communism. But I think I’m a little off topic. What I’m trying to say is that we seem to forget that we, the readers and writers of endless analyses and diagnostics are not particularly different from the people who are reported on. They, like us, are human beings. We often do things that are vaguely stupid and against our ‘better interest.’ But if you ask us to explain why we do them, we have reasons.
During the Global Orientation for Junior Professional Officers in the beginning of my time here, my boss gave the standard Children and HIV/AIDS in Latin America power point presentation, explaining the situation in our region, the differences from the epidemic in Africa, the unique problems, etc. All very interesting but completely predictable until she pulled out male and female condoms and a dildo in order to give us a sex-ed class. She told us you can’t talk about AIDS if you’re going to be a prude about it. Not only were we all very shy to go up and demonstrate proper usage of a condom, it seemed that many people in the room had never heard of a female condom. And certainly no one had any idea how to use one. None of us were going to leave that room after that ten minute lesson and start using one either. Yet we are constantly expecting that people will do just that.
You have to change more than just a person’s knowledge. You need to try to change the environment in which they are making their decisions, to change which way will seem to offer the most costs and which the most benefits. However, this insight of mine, even if it is right, is less than a magic bullet. Changing the whole environment quickly becomes a completely impossible task (‘development’) which has to be broken down into more manageable chunks. Like improving sex education perhaps. When it comes down to it, a person who doesn’t know how to protect themselves from HIV just can’t, even if some who do know how to avoid infection still insist on “at risk” behaviors.
But I still think this idea of understanding a person’s whole life in order to understand seemingly impossibly frustrating outcomes is important. And it comes up constantly when you are trying to get other people to do what you think is best for them. People who don’t take their medicine are probably not merely noncompliant because they are lazy, they would probably have to starve in order to pay for it. HIV positive mothers who breastfeed are probably not just careless with their child’s health, but are probably trying to protect them from the AIDS stigma that would come from using any sort of replacement feeding. Sometimes other things are just more important than what is best for us.
Certainly there are plenty of people at Brown, for example, who engage in at risk behaviors and they definitely understand the transmission of HIV. They just happen to be less likely to run into the consequences of their actions than some people are. And that ‘its not about me’ attitude is exactly one of the issues that comes up when you examine why people are not listening to the lessons they are being taught.
Women are the ones who are being infected at the fastest rate in Latin America. If prevention efforts aren’t dramatically more effective, the epidemic is on the brink of changing from a concentrated (in vulnerable populations such as gay men, intravenous drug users, and sex workers) to generalized epidemic. Yet everyone here still thinks of AIDS as something that happens to other people. Bad people, immoral people, people that look sick, people who are homosexuals, NOT people they might sleep with. The worst part is that it is just this invincible attitude that helps spread the disease and make everyone more at risk. So why don’t they believe it could happen to them? And why am I using the third person? It all comes from the same desire to assume that we know better, that the people we choose to associate with are clean and healthy and good. In terms of behavior change, for women who have never been with anyone besides their husbands, telling them that they should always use a condom is akin to telling them that their husbands are cheating on them, or cannot be trusted. And if they do suggest it, their husbands often accuse them of being the cheaters, because if they were being faithful they wouldn’t need to use protection.
An anecdote that I read in a report on a study on my “why” question among poor black women in New York City seemed particularly striking, important, enlightening, depressing. Take your pick of adjective. It was about a (white, middle class) volunteer giving a reproductive health workshop to a group of women who were patients at a free health clinic. While counseling women that they should always use a condom, she was explaining that it was important to get tested for HIV and other STDS so that you could know for sure that both partners are clean and healthy. She mentioned how she and her husband had just gotten tested and she was looking forward to getting the results back so that they would have to use condoms anymore. This, at the same time as telling these women that they should always insist on condom use, even with their husbands or boyfriends. What does this say about these women in comparison with herself? That their men are likely to be infected but hers is not. That their men are likely to be unfaithful, but hers is not. Not in my backyard…
Of course, you may note, that she is probably just unconsciously enforcing an unfortunate truth. That these women are more vulnerable to infection. But the point is, she is saying that she won’t use a condom because she has faith in her husband. And that is what the women she is ‘teaching’ would probably say too. Maybe if they don’t have faith that the husband isn’t cheating, they have faith that the husband uses a condom with the other women. So do we really expect to convince people in trusting, monogamous relationships to begin using condoms all the time? That seems like a tall order if you think about it as applied to the average population of the U.S. (who have a significantly higher level of education and health education than the average population in a developing country).
So is it hopeless? Can you never change people’s behavior? I still think you can. Anecdotally, I have to say that most of my friends and peers at Brown do seem to have been pretty well convinced about the need for condom usage at least outside of monogamous relationships. Be it fear of pregnancy or fear of AIDS, something seems to have clicked for our generation, at least those of us who have benefited from something besides abstinence only sex education. So somehow, it is possible to make that connection, and to force that shift away from condoms as a hypothetical to condoms as a given.
When you put it the wrong way, adolescents who don’t use condoms just seem careless, reckless, and in danger. But if you think of a girl who is in her first sexual relationship with a boy she loves, it makes a lot more sense that she would say that she doesn’t need to use one because she trusts him. Just because, as an outsider, one might be able to see that he could easily be infected with HIV doesn’t mean that in her situation we might not be swayed the same way. Understanding something like that doesn’t provide a magical solution as to how to convince her. But I do think without it you don’t have a chance.
Posted by Leona Rosenblum at July 19, 2007 02:01 PM
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