Flora Cornish

Towards a fourth generation of approaches to HIV/AIDS management: creating contexts for effective community mobilisation

Abstract Many biomedical and behavioural HIV/AIDS programmes aimed at prevention, care and treatment have disappointing outcomes because of a lack of effective community mobilisation. But community mobilisation is notoriously difficult to bring about. We present a conceptual framework that maps out those dimensions of social context that are likely to support or undermine community mobilisation efforts, proposing that attention should be given to three dimensions of social context: the material, symbolic and relational. This paper has four parts. We begin by outlining why community mobilisation is regarded as a core dimension of effective HIV/AIDS management: it increases the “reach” and sustainability of programmes; it is a vital component of the wider “task shifting” agenda given the scarcity of health professionals in many HIV/AIDS-vulnerable contexts. Most importantly it facilitates those social psychological processes that we argue are vital preconditions for effective prevention, care and treatment. Secondly we map out three generations of approaches to behaviour change within the HIV/AIDS field: HIV-awareness, peer education and community mobilisation. We critically evaluate each approachs underlying assumptions about the drivers of behaviour change, to frame our understandings of the pathways between mobilisation and health, drawing on the concepts of social capital, dialogue and empowerment. Thirdly we refer to two well-documented case studies of community mobilisation in India and South Africa to illustrate our claim that community mobilisation is unlikely to succeed in the absence of supportive material, symbolic and relational contexts. Fourthly we provide a brief overview of how the papers in this special issue help us flesh out our conceptualisation of the “health enabling social environment”. We conclude by arguing for the urgent need for a ‘fourth generation’ of approaches in the theory and practice of HIV/AIDS management, one which pays far greater attention to the wider contextual influences on programme success.

The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa.

Peer education is a community-based intervention being implemented worldwide as an approach to HIV prevention. However, its results are inconsistent, with little consensus on why some projects succeed while others fail. Considering peer education as an ‘intervention-in-context’, we systematically compare the context and the implementation of two peer education interventions run by sex workers, one in India and one in South Africa, which produced contrasting outcomes. In so doing, we aim to identify key factors in the projects’ successes or failures that may inform future peer education efforts. The Indian project’s relative success was facilitated (1) by a more stable and supportive social, material and political context, and (2) by a community development ethos which devoted significant resources to sex workers’ involvement, ownership and empowerment, as opposed to a biomedical approach which marginalised sex workers’ concerns. We conclude with lessons learned and implications for current trends in peer education.

African-Caribbean interactions with mental health services in the UK: experiences and expectations of exclusion as (re)productive of health inequalities

In the context of current concerns about health inequalities among minority ethnic groups in the UK, this paper addresses perceptions of mental health services among members of an African-Caribbean community in a South England town. Efforts to reduce health inequalities must take account of the views of local community members on the sources of those inequalities and on local health services. The statistical existence of inequalities in diagnosis and treatment of African-Caribbeans in the UK is well-established, supported by sociological explanations of these inequalities which centre on social exclusion in a variety of forms: institutional, cultural and socio-economic. However, detailed studies of the perspectives of local communities on mental health issues and services have received less attention. In this case study of community perceptions of mental health services, we find that social exclusion comprises an explanatory framework which is repeatedly invoked by community members in describing their interaction with mental health services. Interviewees assert that experience and expectation of racist mis-treatment by mental health services are key factors discouraging early accessing of mental health services, and thereby perpetuating mental health inequalities. We conclude that participation and partnership are vital means by which to generate both the objective and subjective inclusion that are requirements for an accessible and appropriate health service.

A Pragmatist Approach to the Problem of Knowledge in Health Psychology

The multiplicity of forms of health-related knowledge, including biomedical knowledge, lay knowledge and critical constructionist knowledge, raises challenges for health researchers. On one hand, there is a demand for a pluralist acceptance of the variety of health-related knowledge. On the other, the need to improve health calls for action, and thus for choices between opposing forms of knowledge. The present article proposes a pragmatist approach to this epistemological problem. According to pragmatism, knowledge is a tool for action and as such it should be evaluated according to whether it serves our desired interests. We identify implications for research methodology and the choice of research goals.

How Can Community Health Programmes Build Enabling Environments for Transformative Communication? Experiences from India and South Africa

Much research has examined how to empower the poor to articulate demands for health-enabling living conditions. Less is known about creating receptive social environments where the powerful heed the voices of the poor. We explore the potential for ‘transformative communication’ between the poor and the powerful, through comparing two well-documented case studies of HIV/AIDS management. The Entabeni Project in South Africa sought to empower impoverished women to deliver home-based nursing to people with AIDS. It successfully provided short-term welfare, but did not achieve local leadership or sustainability. The Sonagachi Project in India, an HIV-prevention programme targeting female sex workers, became locally led and sustainable. We highlight the strategies through which Sonagachi, but not Entabeni, altered the material, symbolic and relational contexts of participants’ lives, enabling transformative communication and opportunities for sexual health-enabling social change.ResumenMucho se ha investigado acerca de cómo empoderar a personas en situación de pobreza para demandar condiciones de vida favorables a la salud. Sin embargo, existe un conocimiento limitado acerca de cómo crear entornos sociales receptivos donde los poderosos presten atención a las voces de los pobres. Exploramos aquí el potencial de la ‘comunicación transformadora’ entre personas en condición de pobreza y aquellas que se encuentran en posiciones de poder, a través de la comparación de dos estudios de caso acerca del manejo del VIH/SIDA. El Proyecto Entabeni en Sudáfrica buscó empoderar a mujeres empobrecidas para administrar cuidados domiciliarios a personas con SIDA. Éste suministró exitosamente bienestar a corto plazo, pero no consiguió desarrollar liderazgos locales ni sostenibilidad. El Proyecto Sonagachi en India, un programa de prevención del VIH dirigido a trabajadoras sexuales, logró ser liderado localmente y sostenible. Destacamos las estrategias a través de las cuales Sonagachi, contrario a Entabeni, modificó los contextos material, simbólico y relacional en las vidas de los participantes, permitiendo una comunicación transformadora y oportunidades para un cambio social favorable a la salud sexual.

Health Behavior Change Models for HIV Prevention and AIDS Care: Practical Recommendations for a Multi-Level Approach

Abstract:Despite increasing recent emphasis on the social and structural determinants of HIV-related behavior, empirical research and interventions lag behind, partly because of the complexity of social–structural approaches. This article provides a comprehensive and practical review of the diverse literature on multi-level approaches to HIV-related behavior change in the interest of contributing to the ongoing shift to more holistic theory, research, and practice. It has the following specific aims: (1) to provide a comprehensive list of relevant variables/factors related to behavior change at all points on the individual–structural spectrum, (2) to map out and compare the characteristics of important recent multi-level models, (3) to reflect on the challenges of operating with such complex theoretical tools, and (4) to identify next steps and make actionable recommendations. Using a multi-level approach implies incorporating increasing numbers of variables and increasingly context-specific mechanisms, overall producing greater intricacies. We conclude with recommendations on how best to respond to this complexity, which include: using formative research and interdisciplinary collaboration to select the most appropriate levels and variables in a given context; measuring social and institutional variables at the appropriate level to ensure meaningful assessments of multiple levels are made; and conceptualizing intervention and research with reference to theoretical models and mechanisms to facilitate transferability, sustainability, and scalability.

Heeding the push from below: how do social movements persuade the rich to listen to the poor?

This article discusses three successful pro-poor social movements: the Brazilian Landless Workers’ Movement, the Indian wing of the People’s Health Movement and the South African Treatment Action Campaign. These have mobilized poor people to demand access to land, health services and life-saving medical treatment respectively. We show how each group has succeeded not only through building the ‘voice’ of the poor to make forceful demands, but also through facilitating the development of ‘receptive social environments’ in which the rich are willing to take these voices seriously. Community psychologists need to pay more attention to the latter challenge.

The Metaphor of the Triangle in Theories of Human Development

Developmental psychologists have a long history of using triangle metaphors to conceptualise the social constitution of psychological development. In this paper, we present a genealogy of triadic theories, to clarify their origins, distinctions between them, and to identify key themes for theoretical development. The analysis identifies three core triangle models in the developmental literature. Each theory relies on some combination of the terms subject, object, other and sign, and they can be distinguished by the core psychological dynamic which they entail. We distinguish an emotional triangle rooted in psycho-analysis, a mediational triangle rooted in the work of Vygotsky, and a sociocognitive triangle originating with Piaget. Despite their differences, the analysis reveals a common theme of the transformation from external mediation to internal mediation. Contemporary research and possible future directions are discussed in the light of the theoretical distinctions that our genealogy has revealed.

Making 'Context' concrete: a dialogical approach to the society-health relation.

To understand the role of context in constituting health is recognized as a key challenge facing contemporary health psychology. However, few models or theories are available which pinpoint the processes linking individual health with community or societal contexts. This article draws on dialogical and sociocultural psychological theory, to make context concrete by proposing the concepts of ‘mediating moments’ and ‘reflected mediating moments’. These concepts are further developed through their application to the empirical case of the constitution of condom use in sex-worker–client interactions in Calcutta. Interviews and group discussions with sex workers and other ‘red light area’ residents are interpreted to examine at what moments the societal phenomena of poverty and gender relations come to mediate condom use behaviour.

Social Capital, Participation and the Perpetuation of Health Inequalities: Obstacles to African‐Caribbean Participation in ‘Partnerships’ to Improve Mental Health

Objectives. There has recently been much emphasis on the role of ‘partnerships’ between local community ‘stakeholders’ in strategies to redress health inequalities. This paper examines obstacles to participation in such partnerships by African‐Caribbean lay people in local initiatives to improve mental health in a town in southern England. We present a ‘social psychology of participation’ which we use to interpret our data. Our work seeks to illustrate some of the micro‐social mechanisms through which social inequalities are perpetuated, using Bourdieus conceptualisation of the role played by various forms of capital (economic, social, cultural and symbolic) in perpetuating social inequalities. Design. Our empirical research consists of a qualitative case study of attitudes to participation in mental‐health‐related partnerships in a deprived community. In‐depth interviews and focus groups were conducted with 30 local community ‘stakeholders’, drawn from the statutory, voluntary, user and lay sectors. Results. While interviewees expressed enthusiasm about the principles of participation, severe obstacles to its effective implementation were evident. These included severe distrust between statutory and community sectors, and reported disillusionment and disempowerment within the African‐Caribbean community, as well as low levels of community capacity. Moreover, divergent understandings of the meaning of ‘partnership’ suggested that it would be difficult to satisfy both community and statutory sectors at once. Conclusions. We suggest that disadvantaged and socially excluded communities are often deprived of the social resources which would provide a solid basis for their participation in partnerships with state health services. In the absence of efforts to remove such obstacles, and to generate the necessary resources for participation, partnerships may be ‘set up to fail’, leaving social inequalities to prevail.