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

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          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.

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          The longitudinal course of marital quality and stability: a review of theory, method, and research.

          Although much has been learned from cross-sectional research on marriage, an understanding of how marriages develop, succeed, and fail is best achieved with longitudinal data. In view of growing interest in longitudinal research on marriage, the authors reviewed and evaluated the literature on how the quality and stability of marriages change over time. First, prevailing theoretical perspectives are examined for their ability to explain change in marital quality and stability. Second, the methods and findings of 115 longitudinal studies--representing over 45,000 marriages--are summarized and evaluated, yielding specific suggestions for improving this research, Finally, a model is outlined that integrates the strengths of previous theories of marriage, accounts for established findings, and indicates new directions for research on how marriages change.
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            Towards an improved investment approach for an effective response to HIV/AIDS.

            Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. We propose a strategic investment framework that is intended to support better management of national and international HIV/AIDS responses than exists with the present system. Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV/AIDS. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion. Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29·4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone. Copyright © 2011 Elsevier Ltd. All rights reserved.
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              Intervening within and across levels: a multilevel approach to stigma and public health.

              This article uses a multilevel approach to review the literature on interventions with promise to reduce social stigma and its consequences for population health. Three levels of an ecological system are discussed. The intrapersonal level describes interventions directed at individuals, to either enhance coping strategies of people who belong to stigmatized groups or change attitudes and behaviors of the non-stigmatized. The interpersonal level describes interventions that target dyadic or small group interactions. The structural level describes interventions directed at the social-political environment, such as laws and policies. These intervention levels are related and they reciprocally affect one another. In this article we review the literature within each level. We suggest that interventions at any level have the potential to affect other levels of an ecological system through a process of mutually reinforcing reciprocal processes. We discuss research priorities, in particular longitudinal research that incorporates multiple outcomes across a system. Copyright © 2013 Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                J Acquir Immune Defic Syndr
                J. Acquir. Immune Defic. Syndr
                qai
                Journal of Acquired Immune Deficiency Syndromes (1999)
                JAIDS Journal of Acquired Immune Deficiency Syndromes
                1525-4135
                1944-7884
                15 August 2014
                11 July 2015
                : 66
                : Suppl 3
                : S250-S258
                Affiliations
                [* ]Johns Hopkins University Bloomberg School of Public Health, Center for Communication Programs, Baltimore, MD;
                []Department of Methodology, London School of Economics and Political Science, London, UK;
                []University of Missouri—St. Louis, College of Nursing; and
                [§ ]Department of Psychology, University of Connecticut and Center for Health, Intervention, and Prevention, Storrs CT.
                Author notes
                Correspondence to: Michelle R. Kaufman, PhD, Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD 21212 (e-mail: MichelleKaufman@ 123456jhu.edu ).
                Article
                QAIV14370 00003
                10.1097/QAI.0000000000000236
                4536982
                25007194
                55d6ebb3-8f30-45ea-83c3-6121b5094bee
                Copyright © 2014 by Lippincott Williams & Wilkins

                This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial No Derivative 3.0 License, which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially.

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                behavior change,hiv,socio-ecological model,factors,multi-level

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