The ABCs and Beyond: Developing an Operations Research Agenda on Comprehensive Behavior Change Approaches for HIV Prevention

This 26-page report summarises a one-day technical meeting held in April 2003 to develop priorities for an operations research agenda to study effective behaviour change strategies for HIV risk reduction, particularly those that focus on what have been called the "ABC" behaviours: abstinence or delaying sex, being faithful or partner reduction, and condom use. Representatives from more than 20 organisations involved in prevention research and programming discussed epidemiological, behavioral, psychosocial, and structural factors that may help determine the effectiveness of promoting the ABCs and other types of prevention programmes.

The meeting began with an overview of theoretical perspectives, followed by a presentation by Dr. Julie Pulerwitz of Horizons/PATH. Dr. Pulerwitz described the ecological model of behaviour that shapes Horizons' research strategy, which "explicitly acknowledges that individuals are embedded in social and structural contexts that must also be addressed". To that end, Horizons studies examine behaviours within their social context and test behaviour change communication (BCC) strategies at multiple levels. This research may include evaluating:

• activities to increase information, skills, and economic opportunities at the individual level
• couple counseling or training for community "gatekeepers" (e.g., health care workers or teachers) at the interpersonal level
• community mobilisation
• the impact of different policies at the macro-environment level.

Stressing that "good formative research is needed to help develop specific messages and activities that are appropriate for different audiences", Dr. Pulerwitz cited the tailoring of behaviour change messages in HIV prevention programming in school settings in Mexico, South Africa, and Thailand as well as among migrant communities and sex workers.

Carol Larivee, associate director for behaviour change communications at the Institute for HIV/AIDS, Family Health International (FHI), then highlighted two projects implemented by FHI/IMPACT, one in Cambodia and another in Nigeria. She ended the presentation with a list of high-priority research questions, including:

• What is the impact of a comprehensive BCC approach coordinated with all stakeholders on individual and community behaviours?
• What is the impact of linking prevention, care, and support to individual and community behaviours?
• How extensive does the "target population research" need to be to develop the appropriate message mix?
• What is the appropriate mix and synergy of channels (interactivity among the mass media, community, and interpersonal channels) for the greatest effect on behaviour?
• What is the impact of participatory BCC strategy development on the adoption of new behaviours?
• How do community dialogue and discussion through existing community groups and structures affect behaviours?
• How important is accurate self-risk assessment in the behaviour change process?
• How do social norms affect personal choice in adopting behaviours?

Participants then highlighted key themes that they thought future operations research on prevention programming should address, including:

• Making a clearer distinction between ABC behaviours themselves and programmes to promote these behaviours, which may necessitate addressing prevention issues beyond ABC (such as building the negotiation skills and supportive social context required to enable young girls to handle sexual pressure from their peers and adults)
• Tailoring clear and consistent prevention messages to different audiences, as well as to the cultural and regional context
• Building comprehensive strategies - encompassing multiple messages, channels of
  information, and strategies - that can be coordinated across different partners and institutions. "On the other hand, using the 'ABC' paradigm as an umbrella term, with so many definitions of how the messages are used in practice, can become confusing or misleading."
• Closing the gap in knowledge about how best to promote partner reduction and faithfulness, in part by clarifying what people perceive when they hear partner reduction messages. "The challenge becomes promoting different partner reduction strategies without reinforcing stigma against those who have multiple partners."
• Improving messaging and programming for youth, including working with younger youth before they become sexually active (with the understanding that youth and their behaviours change over time) and acknowledging the role that family support can have on a young person's sexual choices
• Exploring the existing and potential role of faith-based organisations (FBOs) in collaborations to promote HIV risk reduction - researching the nature and impact of faith-based initiatives, exploring the role religious institutions can play in shaping group and broader social norms about HIV risk behaviour, and developing new models of partnership that include FBOs ("One suggestion was to coordinate ABC messages across different institutions, so that FBOs can focus on the abstinence and partner reduction messages and condom social marketing groups can focus on condom promotion, while also acknowledging the other options. In this way, groups with different approaches can concentrate on their strengths while not denying the value of other perspectives.")
• Evaluating the impact of prevention activities, including large BCC programmes, and assessing cost-effectiveness. "It was suggested that developing a tool to describe and compare interventions is essential. This tool would include such information as the types of activities employed, the topics covered, how each HIV risk reduction message is presented, and the length of the intervention. Gathering this information could lead to the development of indicators for program quality."

Partnership was also a key meeting theme. "During the meeting, specific opportunities for collaborations and areas of particular interest for each group were discussed, with the goal of permitting each organization to focus on its strengths while working together toward similar outcomes."