THE STEPS OF EDUCATION FOR BEHAVIOURAL CHANGE OF YOUNG PEOPLE ACCORDING TO GERARD EGAN: A TWENTY-YEAR EXPERIENCE IN AFRICA

Introduction

In the beginning of the AIDS pandemic, a great effort was made to ensure that all people had sufficient information about the disease to protect their lives and to prevent the spread of the virus.  There was a heavy emphasis on mass media messages, posters and input sessions.  All of this was necessary, however, just as with all public health Programmes, as the years have passed, it has become evident that information on its own is not enough to bring about behaviour change.

MORE IS NEEDED THAN SIMPLY INFORMATION

AND/ OR THE PRESENCE OF FEAR

This process, called “Education for Life”, is an attempt to provide that “more” and to assist those with information about AIDS to take the next important step.

The PREVENTION OF AIDS is a CALL TO LIFE, the life of the whole person.  This person is a sexual being, not just a person who has sex.  Thus, any effective preventative programme must take this into account and deal with the person’s whole life.  This life is dynamic, always changing.  It must change if the person is to grow.

“To change is to grow.  To grow is to change often.”

Change is normal; behaviour change is normal; change of sexual behaviour is normal.  It is a process of growing into the freedom of choice and intimacy; a process of becoming more fully

   However, Change in Human Behavior is difficult. Anyone who has ever made and broken a New Year’s Resolution can appreciate the difficulty of behavior change. Sustained Change in the desired behavior is rarely a simple process, and usually it involves a substantial commitment of time, effort, ability, triggers and motivation. Whether one wants to lose weight, stop smoking, prevent pleasurable but risky habits or even accomplish a minor goal, it is often met with resistance. Change might not come easy, but it is possible to change. Understanding the elements of change, the stages of change, and ways to work through each stage can help an individual to change and realize their desired goals.

EFL-Kenya Theory on Human Behaviour and Difficulty with Changing Behaviour

Human behaviour

This is not intended to be a complete review of the subject of behaviour change; however, to facilitate change in human behaviour, it is important to appreciate its complexity; be aware of possible motivations of current behaviour and reasons why human behaviour is difficult to change. The assumption made is that our current reality is by and large a function of our behaviour and those whose lives influence ours. The text below attempts to summarize and simplify some of the common schools of thought that explains human behaviour.

1. The African Traditional Heritage

2. The Faith Dimension

3. The School of Biology and Psychology

4. The Current Worldview

The various schools of thoughts above do have their strengths and weaknesses in explaining human behaviour.  The diagram below from: The Fifth Disciple by Peter Sanger called; “the Ladder of Inference”. Emphasize the complex nature of Human behaviour.

The Ladder of Inference

We live in a world of self-generating beliefs, which remain largely untested. Those beliefs are passed from one person to the other, one generation to the next or from one social group to another. Why is it so easy to adopt those beliefs? Because they are based on conclusions, which are inferred from what is observed plus the past experiences. This is strengthened by the feeling that;

· Our beliefs are the truth.

· The truth is obvious.

· Our beliefs are based on real data.

· The data we select are the real data.

The above creates a thought pattern that culminates to action.

Summary on Understanding Human Behaviour

From the various schools of thoughts and the illustration using the Ladder of inference, it is clear that most Human Behaviours are learnt or acquired. It is therefore true that such behaviours that are not life-giving can be unlearnt just as those that are life –giving can be reinforced. The above discussion about Human behaviour can be summed up using the below acronym. AVER (A: Activating agent, V: Vision (Attitude, Mindset), E: Emotional Reaction and R: Resultant Behaviour)

A--Activating Agent:

Behaviour does not take place in a vacuum, neither is one born with it, there has to be an object that activates it. Whatever object it will be, it will come through the five senses of the body i.e. sight, taste, hearing, touch and smell. The activating agents can include: Objects, people, events, sounds, things, etc. Nothing is in the mind that was not fist in the senses.

V--Vision/Mindset/Attitude/Perception:

We all have attitudes towards everything. It is as if we walk with our black boxes behind us where we fish for answers to our everyday realities. When one experiences a certain occurrence for a long time, he/she develops certain attitude. This takes advantage of the power of the mind to associate ideas. The mind and the senses mutually depend on each other. We have attitudes towards life, others, the world, God, sex, work etc. A sense without the mind is blind and the mind without the senses is empty. We do see the world as it is but as we are.

E--Emotional Reaction:

Feelings are behavioural tendencies. They often dictate our reaction. What people feel so strongly about, they tend to act on. Emotions are neither made nor created. They are innate. When one senses something, he/she generates emotions depending on his/her attitude towards the object. It is important to appreciate that feelings are just feelings, they are neither good nor bad, and it is what you do with them that is judged to be good or bad. Therefore the claim that you made me feel that way do not hold water because nobody can make you feel what you feel. Two people can experience the same reality and get different feelings about it.

R--Resultant Behaviour

Behaviours are actions. They are what we see and experience. They come about through a micro-process. Human behaviour is a function of the steps highlighted above. They are catalyzed by the type and magnitude of emotion generated.

NOTE: The discussion above shows that the human behaviour can be changed or modified at any level of the AVER acronym above. However, the most important aspect in changing human behaviour is the attitude. That means, to attack any kind of behaviour, we have to attack the attitude with greater measure than the other elements. You are us healthy and alive as your

Attitude allows you to be.

The difficulty with Behaviour Change

It is common knowledge that it is not easy to change one’s behaviour.  There are no easy answers as to why this is so; it is a complex problem.  However, there are conditions that can be recognized as affecting the ease or difficulty of change. Two complexities explain why human behaviour is difficult to Change:

1. The Reward/ Punishment Challenges.

2.  Distorted thinking patterns

The Reward/Punishment Challenges-Human behaviour has the following traits:

a) Habits

As behaviours are repeated, habits are formed.  The stronger the habit, the harder it is to break it.  Everyone has habits they have tried to break without much success.  Motivation is important; the person must want or admit to the need to change.  The process used to change is also important.  Often we can discover this process by examining the habits that we ourselves have managed to change.

b) Comfortable

Human beings choose behaviour that leads to comfort; it takes strong motivation to choose what is uncomfortable.  Abstaining from sexual intercourse is seen as uncomfortable by many.  Young people are very aware of their sexual feelings and energies; they often see abstinence as painful and as a deprivation.  For adults the refusal to have sex may result in loss of livelihood, spouse or partner, or sense of identity; all of which is seen as uncomfortable.    

c) Without Resistance

Familiar behaviour occurs without resistance; any attempt to change meets with resistance.

d) Rewarded

People often repeat behaviours that are rewarded and avoid those that are punished.  This appears a simple fact at first but in AIDS prevention it becomes very complex; only the person concerned really knows what is reward or punishment for him/her.  Culture, gender, economic condition, education and many other factors come into play here.  Women have often been heard saying that they would rather have a child and die young that to live an old age childless; the child is a greater reward than their own life.

e) Self Chosen

The “child” inside each person fights to maintain autonomy and resists changes that are seen to be imposed by another.  This again is especially true of young people.  They are in the process of determining their own identity and accepting boundaries for their actions; independence is important to them as they consider it a sign of being “grown up”. 

Distorted Thinking Patterns

1. Permanence

Permanence;-assumes that people and things either can’t change or are predetermined. Permanence as a distorted thinking can best be emphasized by Theories of Determinism.

§ Genetic determinism – We have inherited all that we have. Our genes are to be blamed for our behaviour.

§ Psychic determinism – we behave the way we behave because of how our parents brought us up. Our parents are to be blamed for our behaviour.

§ Environmental determinism – We behave the way we behave because of our culture, place of work the situation we are in.

§ Biological determinism – we behave the way we behave because of our biological status. (Girls behave like this, so don’t blame me, all pregnant women behave like this so don’t blame etc.)

2. Pervasiveness

This is blowing things out of proportion. It is composed of a number of distorted thinking styles;

· Exaggerating:  This girl always goes out and sleeps with all men (and yet she did     it once)

· Over-generalizing: People who smoke can’t just stop it.

· All-or-nothing thinking: You either do it all or else you have done nothing.

·  Perfectionism: It fails to recognize that change is a process.

3. Negative Predication-Going to the process of change half heartedly.

4. Down Playing: Underrating or discounting achievements. (I can’t believe I am the one who has done it, I of all the people have attained this)

5. Name Calling: Calling yourself bad names-I am stupid, silly etc.

6. Mind-reading Thinking that other people think badly of you. (They think I am weak, stupid, immoral, a failure etc.)

7. Pressure: Engaging in change due to pressure. (I must start doing physical exercises; I should start dieting, etc.). If the words are used to show the need of doing them it is harmless. But if they are used to indicate pressure as the basis of your decision then it is harmful. You need to base your decisions on logical reasoning and conviction. Decisions based on pressure are likely to be temporary, artificial, regrettable, on-and-off (on when the pressure is there; and off when the pressure ceases etc.) again if you use these words, you indicate that you have no power of choice in certain situations. I this case, pressure thinking style become a way of avoiding responsibility for your decisions. Instead of I must… say I choose to…

The true sign of being grown up is the ability to make free responsible choices.  This is true freedom.  Today, many people operate out of license which often is enslavement to public opinion, peer pressure, or social dictation

The motivation in the use of the Education for Life Process ( Behaviour Change Process) in Kenya in responding to the HIV prevention.

When HIV and AIDS situation reached worrying proportions in Kenya in the mid 80`s, several approaches based on Health Care System Management were adopted. They majorly focused on trying to reduce the risk of HIV infection but without challenging people to change risky lifestyles. The underlying principle in these approaches was that when people are informed, it translates to change in behaviour.

 The biggest lesson learnt was that; information alone was not enough to bring about the desired change in sexual behaviour to arrest the wild spread of HIV. Very quickly, the HIV prevalence in the country indicated that about 13 % of ages 15-49 years were already infected with the virus. It was even more surprising that a big number of well schooled professionals like the; teachers, the medical personnel, politicians, university students, soldiers, religious people etc succumbed to HIV infection mostly through voluntary sexual practices. These calibres of people are among the most informed in the community. It was clear that TRASFORMATION is a function more than just information on AIDS

 The motivational thrust of Education for Life-Kenya and Youth Alive Movements across Africa is reflected in the resolution of medical doctors, and health professional during a meeting in December 1991 in Dakar, Senegal. In their resolution, the medical professional at ICSAS came up with a statement of belief stated:

Statement of Belief

We believe that individuals and whole communities have the inherent capacity to change attitudes and behaviours.  The power to fulfil this capacity is often denied or is not exercised. 

This power must now be recognized, called forth and supported from both within and without.  This will enable people to initiate and sustain behaviours that promote a healthy state of mind, body, spirit and environment.  A critical component in this process is a supportive response to those living with HIV in the community.

We recognize that behaviour change at individual and community level in the present HIV pandemic is a complex and on-going process.  It is inextricably linked to such basic human values as care, love, faith, family and friendship, respect for people and cultures, solidarity and support.

The present pandemic affects everyone.  Our experience as affected and infected individuals proves that behaviour change is possible.  We believe that behaviour change is the most essential strategy in overcoming the HIV pandemic.

The Education for Life Process Steps (Behaviour Change Process)

“Education for Life” is a behavior change process that has been in use in many sub-Saharan African countries. It is an attempt to provide more than just the adequate and accurate information about HIV/AIDS to assist people take the next important step, Behavior Change. The prevention of HIV/AIDS is a call to life, the life of the whole person, who is a sexual being. It is developed with the understanding that information alone is not enough to bring about behavior change and that human behavior is determined by different factors, such as environment, socio-economic status, social and personal values, culture and tradition, religion, educational level, and others. At the same time the root causes of HIV/AIDS are linked with those factors. It is also well understood fact that behavior change is a process.

This program was developed with a solid theoretical background, borrowing from counselling methodologies used in Kitovu hospital in Uganda. It employs a problem solving and action oriented approach, utilizing Gerard Egan’s “The Skilled Helper” model. This model facilitates a person’s movement through three stages in an individual’s process towards behavior change and maintenance.         

The  Education for Life Process also referred to as the Behaviour Change Process:

Overview of the Process

Stage 1- Exploring Life (Similar to knowing and accepting the present reality). The first stage is the “Problem Exploration and Clarification” stage, in which participants explore their life, accept the present reality, and identify issues that have been overlooked

 It is facilitated by:

a) Telling the story

b) Focusing

c) Looking for what has been overlooked.

Stage 2- The New Picture (similar to choosing and committing to a possible new behaviour).  The second stage is “Developing new perspectives and setting goals”, in which alternative behaviors are explored and critiqued.  As this “new picture” emerges, participants proceed to choose and commit to healthy lifestyles.   It is facilitated by:

a) Calling forth alternative goals.

b) Critiquing them

c) Making choices and commitments

Stage 3- Action (similar to act).  The third stage is “Action”, in which participants settle on what can be done about their choices, plan How to do it, and then:

It is facilitated by:

a) Asking someone what can be done

b) Planning how to do it.

c) Doing it.

The Process is the skeleton used to design many Behaviour Change Programmes. The BCP is en-fleshed with different activities to make the Behaviour Change Training or workshop experience. Such activities include: Spiritual exercise, sharing of relevant information, testimonies, role plays, video shows, drawings, small group discussions, plenary sessions, confessions, prayers, etc. However, the use of the process is often determined by; the time available, the nature of participants, age of participants, the prevailing culture of the participants, the religion of the participants and the gender of the participants.

Conclusion

In countries where this process has been used extensively, the results have been very positive. These outcomes have been realised by external evaluators across Africa.