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CHAPTER 2 LITERATURE REVIEW
INTRODUCTION
This chapter focuses on the following major thematic areas: selected theories related to the study; global, national and regional status of HIV and AIDS; origin of stigma, SAD, HIV and AIDS-related SAD, factors associated with HIV and AIDS-related SAD, experiences of HIV and AIDS-related SAD; impacts of HIV and AIDS-related SAD and HIV and AIDS-related SAD reduction-interventions in the health care settings. Besides, the Ethiopian health care system and HIV and AIDS policy and strategy were included in the chapter. The theoretical framework of the study will be presented in the first part of the chapter.
THEORETICAL FRAMEWORK
Conceptualisation of stigma
The term stigma was first coined by Greeks to refer to bodily signs that show the poor moral standards of a person. Goffman (1963) was the first person to conceptualise the concept of stigma (Andrewin & Chein 2008:897). He described it as an attribute that is deeply discrediting within a particular social interaction. He also indicated the associations between stigmatisations and discriminations, with the latter emanating from the former (Andrewin & Chein 2008:897; Armando 2010:20).
Stigma associated with illness has been a persistent problem among the societies for several years. According to Luis (2008:30), the term stigma has evolved and it now refers to physical disorders given to a person who was assumed to be bad or deeply discredited. The SAD associated with HIV and AIDS has come to appear with the emergence of HIV epidemic and found to be more devastating than the other types of illnesses (Armando 2010:20; Luis 2008:30).
PLWHA differ from other stigmatised groups in four ways (Molero et al 2011:610).
- In addition to the fact that HIV is an illness, it is an infection that is contagious, the fear of contagiousness leads to the avoidance of contacts with the PLWHA.
- HIV is stereotypically associated with marginalised and stigmatised groups in society like sex workers and injection drug users.
- People with HIV are mostly perceived as responsible for contracting the disease.
- PLWHA and those with AIDS consider themselves that they belong to the stigmatised group.
Parker and Aggleton (2002:898) indicated that HIV and AIDS-related SAD is complex social processes that are related to pre-existing SAD associated with, sexuality, gender, ethnicity and poverty. They also underline the need to understand these phenomena across different settings and cultural contexts (Andrewin & Chein 2008:898).
Importance of theories in behavioural interventions
HIV and AIDS-related SAD reduction-interventions are most likely effective if they are based upon thorough needs assessments, theory and evidence-based intervention strategies and collaborative planning. Studies have indicated that socio-psychological theories can be used as a guideline for development of HIV and AIDS-related SAD reduction-interventions at various contexts (Arjan, Herman & John 2008:452).
Though many theories have been applied to health-related behavioural research and designing of behavioural interventions, some argue that there is a limited number of variables that need to be considered in understanding and predicting any given behaviour. These variables are contained in three theories that have been used in health behaviour research and interventions (Fishbein & Marco 2003:165).
These are:
- The Health Belief Model
- The Theory of Reasoned Action
- The Social Cognitive Theory
- The Integrated Theoretical Model
The Health Belief Model
The Health Belief Model (HBM), states that for a person to perform the desired health behaviour, the person should first believe that she/he is at risk of contracting a severe negative health effect (e.g. HIV and AIDS). At the same time, the person must believe that the benefit of performing a recommended protective behaviour exceeds the cost of performing the behaviour (e.g. using condom to protect HIV and AIDS) (Fishbein & Marco 2003:165).
The Theory of Reasoned Action
This theory asserts that performance of a given behaviour is mainly determined by the strengths of a person’s intention to carry out that behaviour. The intention to perform a given behaviour is a function of two factors. These factors are the persons’ attitudes towards performing the behaviour and/or the person’s subjective norm regarding the behaviour (Fishbein & Marco 2003:165).
The Social Cognitive Theory
According to the Social Cognitive Theory (SCT) (Bandura 1989), there are two primary factors that determine the adoption of health-protective behaviour. First, the person must believe that the positive outcomes or benefits of performing the behaviour must surpass the negative outcomes. Second, the person must believe that she/he can perform the desired behaviour even in the time of various conditions or barriers that hinder that performance of that behaviour (Fishbein & Marco 2003:165).
The social cognitive theory provides a conceptual framework for elucidating the psychological mechanisms through which socio-structural factors are associated with organisational performance. Moreover, the theory of cognitive theory provides correct guidelines about how to equip people with competencies, the self-regulatory capabilities and the sense of efficacy (Wood & Bandura 1989:380).
Altogether, the above-mentioned three theories identify a limited number of variables that serve as determinants of any given behaviour. Though there is empirical evidence for the role of attitudes, perceived norms and self-efficacy as determinants of intention and behaviour, the support for the role of perceived risk is inconsistent. While the methodological and conceptual drawbacks in research of perceived risk may be attributable for this inconsistency, current evidence suggests that perceived risk is the best predictor of intention and behaviour. Hence, most behavioural theories recommend three major determinants of a person’s intentions and behaviours (Wood & Bandura 1989:166). These are: (a) the person’s attitudes towards performing the behaviour, which depends on one’s beliefs about the positive and negative effects of performing the behaviour;r (b) perceived norms, which comprise the perception that those with whom the individual interacts most closely support the person’s adoption of the behaviour and that others in the community are accomplishing the behaviour; and (c) self-efficacy, involving the person’s perception that she/he can perform the behaviour under a variety of challenging conditions. These all variables have been incorporated in an integrative model of behavioural prediction (Fishbein & Marco 2003:166).
The Integrated Theoretical Model
According to this model, any given behaviour is most likely to occur if one has strong intentions to perform the behaviour, required skills and abilities necessary to perform the behaviour and if there are no environmental constraints that prevent the behavioural performance (Fishbein & Marco 2003:166). If people have got the desired intention but are not performing it, the best intervention will be directed to either at skills building or at removing environmental barriers On the contrary, if strong intentions to perform a given behaviour have not been created, the model suggests that there are three major determinants of the intentions. These are attitudes toward performing the behaviour, perceived norms regarding performing the behaviour and one’s self-efficacy with regard to performing that behaviour (Fishbein & Marco 2003:167).
Application of the Integrated Model to behavioural change interventions
The primary implication in using the integrated model is indentifying the target for change (Fishbein & Marco 2003:168). Once the target is identified the model can be used to elucidate why some members of the target population are performing the behaviour and others are not (Fishbein & Marco 2003:169). It is recognised that the integrative model of behavioural prediction is especially important for interventions that aim at developing and strengthening the intentions to perform a desired behaviour. An appropriate application of the integrative model can identify the major determinants of a given behaviour and beliefs underlying these determinants (Fishbein & Marco 2003:180).
The integrative model of behavioural prediction states that people do not act upon their intentions either because they lack the skills to accomplish the behaviour or there are environmental constraints that hamper performance of the behaviour, or both. Thus, an intervention must aim at improving people’s skills or addressing barriers to performing the behaviour, or both. If the problems are related to skills, it is vital to train people to improve skills that will enable them to perform the intended behaviour. If the problems are related to environment, remove the barriers (Fishbein & Marco 2003:181).
In designing HIV and AIDS-related SAD reduction-intervention strategy in health care settings, the integrative model of behavioural prediction is considered as an appropriate theoretical framework because in designing the intervention strategy, the independent variables affecting the outcome variable are all contained in the selected theoretical model. Based on the theoretical model, the conceptual framework is developed, explicated as follows.
Conceptual framework
The root causes of HIV and AIDS-related SAD among HCPs are lack of awareness about HIV and AIDS, fear of transmission of HV infection and associating HIV and AIDS with improper behaviour.
Lack of awareness about HIV and AIDS
Awareness about HIV and AIDS can be associated with lack of knowledge and/or skills regarding HIV and AIDS. Knowledge about and skills of of dealing with HIV and AIDS can be considered as predisposing factors to attitudinal and behavioural change of individuals. The HCPs with different levels of qualifications need to have specialised knowledge and skills in areas of some specific health programmes like HIV and AIDS- related services. When they have adequate knowledge and skills they are more likely to have better attitudes and the desired behaviour towards the PLWHA and those with AIDS coming to health care settings. In the contrary, if the HCPs have low level of knowledge and skills, they are less likely to develop positive attitudes and practices towards the clients. To improve the knowledge and skills of the HCPs, there is a need to create awareness related to HIV and AIDS.
CHAPTER 1 ORIENTAION OF THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 STATEMENT OF THE PROBLEM
1.4 THE THEORETICAL FRAMEWORK
1.5 DEFINITONS OF KEY CONCEPTS
1.6 AIM OBJECTIVES AND RESEARCH QUESTIONS
1.7 METHODOLOGY
1.8 SIGNIFICANCE OF THE STUDY
1.9 ETHICAL CONSIDERATIONS
1.10 SCOPE THE STUDY
1.11 STRUCTURE OF THE THESIS
1.12 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 THEORETICAL FRAMEWORK
2.3 HIV AND AIDS
2.4 STIGMA AND DISCRIMANTION
2.5 FACTORS ASSOCIATED WITH HIV AND AIDS-RELATED SAD IN HEALTH CARE SETTINGS
2.6 EXPERIENCES OF HIV AND AIDS-RELATED SAD IN THE HEALTH CARE SETTINGS
2.7 IMPACT OF HIV AND AIDS-RELATED SAD IN THE HEALTH CARE SETTINGS
2.8 HIV AND AIDS-RELATED SAD-REDUCTION INTERVENTIONS
2.9 EFFECTIVE STRATEGIES TO REDUCE HIV AND AIDS-RELATED STIGMA AND DISCRIMINATION
2.10 THE ETHIOPIAN HEALTH CARE SYSTEM
2.11 CONCLUSION
CHAPTER 3 RESEARCH DESIGN AND METHODS
3.1 INTRODUCTION
3.2 RESEARCH DESIGN
3.3 APPROACHES USED IN THE STUDY
3.4 RESEARCH METHODS
3.5 BRIEF INTERVENTION
3.6 DATA QUALITY
3.7 ETHICAL CONSIDERATIONS
3.8 DISSEMINATION OF THE RESULTS
3.9 CONCLUSION
CHAPTER 4 FINDINGS OF THE STUDY
4.1 INTRODUCTION
4.2 FINDINGS OF THE QUALITATIVE PARADIGM
4.3 CONCLUSION
CHAPTER 5 BRIEF INTREVENTION
5.1 INTRODUCTION
5.2 CONCLUSION
CHAPTER 6 DISCUSSION
6.1 INTRODCTION
6.2 MAGNITUDE OF THE HIV AND AIDS-RELATED SAD IN THE HOSPITALS
6.3 EFFECTS OF THE INTERVENTION ON THE RESPONDENTS
6.4 DESIGNING HIV AND AIDS-RELATED SAD REDUCTION-INTERVENTION STRATEGY
6.5 CONCLUSION
CHAPTER 7 CONCLUSIONS AND RECOMMENDATIONS
7.1 INTRODUCTION
7.2 SUMMARY AND INTERPRETATION OF THE STUDY FINDINGS
7.3 CONCLUSIONS
7.4 RECOMMEDATIONS
7.5 CONTRIBUTION OF THE STUDY
7.6 LIMITATIONS OF THE STUDY
7.7 CONCLUSION
LIST OF REFERENCES
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