Challenging Dogma - Spring 2011

Saturday, May 21, 2011

The Socio-cognitive Approach of the “Healthy Relationships” Intervention: A Critique of the Current System – Lali Reddy


HIV is a rapidly spreading sexually transmitted disease that has implications on both the individual and societal levels. An example of an intervention that specifically addresses AIDS is Healthy Relationships, which is funded by the CDC’s Replicating Effective Programs (REP) Project (1). The aim of this intervention is to reduce the transmission of HIV in HIV positive individuals by targeting their behavioral patterns using the social cognitive theory. With the application of this theory in their intervention, Healthy Relationships concentrates on enhancing the individual’s perceived self efficacy and outcome expectations of his or her actions, modeling after a social worker to build behavioral skills, and using the individual’s own personal objectives to manage HIV. Although these objectives are well intentioned, there are better ways to approach HIV positive individuals who want to have control over their disease as well as reducing its further transmission. For example, the Healthy Relationships intervention needs to focus more on instilling positive behavioral patterns, avoiding deviant sexual behavior, and clearly defining both safe and unsafe sexual behavior. This can be done by certain revised intervention methods that include creating small groups of about four people (ideally two couples) who can all share their experiences with HIV to form a social structure of support for each other. Another method involves creating a blog or forum online where the participants can discuss his or her own personal progress and can see how their peers are developing their safe sexual behavioral patterns. This will play a huge impact in redefining the norms of safe sex and promote such positive behavior among HIV positive individuals. [1]

Overview of “Healthy Relationships”

Healthy Relationships is an individual-level public health intervention, which was evaluated through a randomized clinical trial and whose goal is to reduce HIV-transmission risk behaviors in men and women living with HIV by incorporating the use of small social support groups to discuss the problem as well as how best to deal with it (1). This is accomplished through group discussion, role-play, and skill-building exercises to help these individuals cope with HIV-related stressors and learn the skills to maintain safe sex practices. There were 328 HIV-positive participants in this study who were randomly assigned to either the intervention group (n=185) or the comparison group (n=143). The intervention group consisted of small group discussions, informational videos, and personalized evaluations to help them create strategies to reduce risky sexual behavior. On the other hand, the comparison group consisted of social support groups that provided basic information about HIV and how to properly manage this disease through the use of personalized health maintenance plans. (5)

Outcome expectancies and self-efficacy

Although this intervention is well developed in terms of providing the HIV-positive individual with the opportunities for change, it does not consider the fact that an individual alone may not have the adequate decision making process skills to assess his or her problem and then use the given resources to create a solution. The flaw here is that this intervention has the pre-conceived notion that planning out the proper behavior of these individuals will lead to them accurately abiding by the plan and leaves no room for failed attempts or other modes of improvement. As a result, a flawed assumption of Healthy Relationships is that the participant will be able to watch HIV videos and listen to lectures on safe sex practices and automatically be able to follow such pre-planned behaviors, like increased condom use. This is where two principles of the social cognitive theory arise, which are outcome expectancies and self-efficacy. These concepts work together to fully define the planned behavioral process that this intervention wants these individuals to follow. Self-efficacy is based on the idea that the individual believes he or she has the capability to assess a situation and then evaluate its consequences in terms of how he or she should behave accordingly (2). This refers to beliefs in one’s capabilities to coordinate and undertake actions required to attain certain goals which involve regulating one’s own motivation, thought processes, and behavior patterns depending on which aspects of life one wants to control (2). The main idea is that the individual has the capacity to prioritize his or her goals and take the necessary steps to reach these goals alone. This is also exemplified in the objectives of the Healthy Relationships intervention as they use visual aids such as video demonstrations to communicate the message of safe sex and let the individual assess the content of the video while supposedly building certain skill sets simultaneously.

Outcome expectancies are simply the perceived consequences of these situations or actions that are solely based on what the individual perceives (3). As a result, the person is given full authority to not only realize that there is a problem in the first place, but also to comprehend the implications of this problem and find out ways to appropriately handle the situation. Through these ideas, the individuals are given false beliefs that if they simply follow the planned behavior that is taught to them, they will be able to create their own personalized self-care plans and adhere to these practices.

In order to go through this whole process alone, this intervention requires that one must completely understand the consequences of his or her actions. For example, a participant of the Healthy Relationships intervention group would need a well-rounded understanding of HIV and how it is spread as well as a comprehension of the possible results of their practice of unsafe sex, including the transmission of infection to not only themselves but also their respective partners. This is one of the main outcome expectancies that Healthy Relationships should instill in its participants—HIV is a sexually transmitted disease that also has the potential to be spread throughout society due to unsafe sexual behaviors. It is a disease that is highly dependent upon the behavior patterns of the individual and whether or not they themselves fully understand the social implications that are involved with this life-threatening disease (6). This is exemplified in a prospective cohort study that analyzed an HIV-positive individual’s network dynamic and found that this particular individual is on the periphery of a rather normal population (about 3600 people), but is in the center of a population consisting of injecting drug users near Brooklyn, NY (6). This shows that social network structure and dynamics of network change have great impact on an understanding of HIV transmission (6). Rather, this intervention falsely assumes that by educating and talking to these HIV-positive individuals about unsafe practices, they will foresee the previously mentioned outcome expectancy and refuse to participate in unsafe sex altogether. An example of this would be the HIV-positive individual self-evaluating his or her lack of condom use as a satisfying and pleasurable experience rather than a preventative measure, as was indicative of a study using HIV-positive gay and bisexual men (3).

An alternative approach to this intervention that would build on their existing skills would involve creating small interactive discussion groups where individuals can feel comfortable sharing their experiences with HIV. The group as a whole would be able to give suggestions as to how they would change not only their own behavior but what the other members of the group could do to practice positive behavior. This concept is called reciprocal peer learning where individuals in a particular group or cohort act as both teachers and learners (7). As a result, not only will the group members be able to teach their peers about their personal experiences with HIV, but they will also have the opportunity to learn from others’ stories. This group would be more effective if it consisted of two couples so that each partner can directly talk to their counterpart and discuss the underlying issues that result in their practicing unsafe sex. By using this intimate group-based intervention, one of the key components of a successful public health intervention will be fulfilled, which involves enhancement of skills by providing the opportunities for guided practice and corrective feedback (1). As a result, as the couples individually discuss their disease management strategies, they will also have the chance to give each other feedback, in turn, strengthening their own relationship with each other. This will also apply in the case that couples are not used because individuals will be able to both bond with and support each other as they share their experiences living with HIV.

There are two key areas that this revised intervention will address and that is a clear understanding of HIV as well the proper social supports to promote behavioral change. In a study done by Bandura using HIV-positive individuals, it was shown that people achieve self-directed change when they clearly understand how their personal habits affect their well being, and this change occurs within a network of social and interpersonal influences (1). It is these unbreakable interpersonal influences within the individual’s social network that plays a crucial role in claiming a strong regulatory function in terms of behavior assessment (1). Referring back to the social cognitive theory, instead of assuming that through an individual’s self-efficacy he or she will be able to easily comprehend and adhere to the planned behavior is erroneous. As a result, in order to receive a positive response from the intervention participants, it is important to show them through interactive groups that they are not alone in this struggle. It is crucial to use instructive methods such as reciprocal peer learning to illustrate the idea that this behavior is not planned but rather a collaborative effort in order to attain the ultimate goal of reduced HIV transmission. Also, the necessary feature of this intervention should be providing the opportunities for these individuals to use their social support systems to go through the right decision making process, instead of relying solely on their own perceived self-efficacy. This continues to hold true because what we see through our own eyes may not be what others see through their own eyes. Consequently, to achieve the best outcome expectations, the aspect of HIV management should be viewed not on an individual and planned level, but rather on a social standard of improvement.

Modeling as a method of disease management

Modeling is used in the Healthy Relationships intervention as an observational method for the participants in order to exemplify the right behavior to portray (1). A social worker or counselor is the one modeling the behavior in a small group setting, and the participant is the observer who is supposed to watch the behavior being done and act accordingly. Although this method seems practical, not all people learn via modeling, and this may even lead to reluctance to learning the correct behavior (8). In other words, when these HIV-positive individuals are shown the right way to practice safe sex they may feel overwhelmed that they may never reach that point. According to the flow theory, the perceived challenges that an individual faces in a particular situation are closely in tune with the person’s perceived skills (8). This would indicate that while the individuals are taught to model after the social worker, they might feel like they do not have the skill set to do so. Consequently, they will act in accordance with what they feel and when they feel capable of doing it (8). This exemplifies self-determination theory which concludes that intrinsic motivation is the satisfaction of human needs, such as competence, and motivation still varies with the individual and his or her interests (8). Consequently, if the participant in this intervention has no interest or motivation to learn the desired behavior like the social worker has modeled, then it is important to nurture a connection with the individual that will increase their motivation. The idea that someone who does not have HIV, such as a social worker, is showing them how to practice safe sex is not relatable to their situation.

This concept is illustrated in the social cognitive theory whose component involves the need for guidance on how to translate doubts and concerns about a particular behavior into efficacious actions (1). This would be representative of the social worker being the source of guidance and the efficacious actions would be the participants’ practice of safe sex. Another assumption of this theory that is also revealed in the Healthy Relationships intervention is the perceived value of utilizing social modeling. It is believed that the individual’s ability to learn via social modeling provides a highly effective way for not only increasing knowledge and skills, but also simultaneously transmitting these attributes to people through media such as videotape modeling (1). As a result, when these methods are applied to AIDS prevention, they would primarily focus on managing one’s own personal behavior as well as interpersonal situations (1). The aspect of this concept that is flawed is the idea that by showing the individual what the right thing to do is, the individual will make his or her own decision to follow this advice and immediately develop the accepted behavioral pattern.

Another scenario that is being used in AIDS interventions and is actually considered the “future” of these interventions is the application of computer technology to the prevention of HIV transmission. Schinke and Orlandi are developing interactive computer programs that will serve as the vehicle for instructing individuals on how to manage unsafe sexual activity by role-playing with computer characters on what they would say and do in particular risky situations (1). What is interesting to note here that is these scientists are simply assuming that when people watch these “cartoon characters” doing right thing by avoiding risk, that somehow this will translate into individuals doing the exact same thing. Consequently, the conclusion that is being drawn here is that people model after computer programmed characters. This is definitely an invalid conclusion since people are sometimes reluctant to model after real social workers, let alone computer generated ones.

The improved intervention that should be implemented into Healthy Relationships should be one that asks the HIV-positive individuals to model after their own peers. Implementing the notion of self-regulation with peer modeling will lead to more successful results (9). Self- regulation is the willingness of the individual to direct or manage his or her own learning process, and this can be further enhanced through peer modeling (9). The results of a study done at the University of Texas at San Antonio showed that self-regulation can be taught and that peer models can be an effective means of doing so (9). With respect to the Healthy Relationships intervention, this would mean having a peer member who currently has HIV and also practices safe sex illustrate the correct behavior that should be followed. What this does is it directly relates the participant to the peer leader so that a first-hand relationship is automatically made because they can both share in their experiences of living with HIV. Another way to best address this situation would be to help the individuals understand why they are even at the intervention in the first place and what can be done to change their lives for the better. In other words, it is crucial for this intervention to clearly define its goals for the individuals and the motivating factors that will be implemented to help them achieve these goals. In fact, goals are viewed as direct and sometimes sufficient predictors of behavior (3).

A perspective that can be taken to clearly establish the goal of the intervention is the use of the cognitive evaluation theory, which states that all external events have both a controlling aspect and an informational or feedback aspect (4). A controlling environmental aspect is one that puts pressure on the individual to reach some behavioral outcome or attempting to coerce the individual into acting in a particular manner, which decreases their intrinsic motivation for goal attainment (4). On the other hand, an informational environmental aspect provides the individual with beneficial information in the absence of that particular pressure to reach the behavioral outcome, and this is when there is heightened intrinsic motivation to attain that goal (4). Applying this theory to the Healthy Relationships intervention, it is clear that this intervention has certain practices that would enable the controlling aspect of this cognitive evaluation theory. For example, the use of social workers to model the correct safe sexual behavior would decrease the individuals’ motivation because now they are under pressure to reach this high level of success.

Conversely, approaching the concept of disease management using the informational aspect of the cognitive evaluation theory will produce better results because the individual is not pressured to reach a particular behavioral outcome. For example, instead of the individual modeling after a social worker, it would be more applicable to have the individual model after a peer who has succeeded in their own AIDS management and is willing to share his or her story. In this way there is no internal strain for the participants to accomplish such high standards of behavior because now they can self-evaluate themselves in terms of what their own personal goals are and how people just like them are able to achieve these aspirations. This improved intervention would provide ample support and guidance for participants to feel like they themselves have the capability to overcome any obstacles that this disease may present and have the capacity to take the necessary steps to alter their risky behavior. The main objective of this intervention is the participant and bringing them to the realization via peer leader modeling of what they see wrong with their life and what this intervention will do to positively change it.

The role of environment

Society and social media itself play major roles on both individual and group-level behavioral patterns (1). How people interact with each other and how they deal with their own personal issues are both part of a major network of personal and societal relationships. In the social cognitive theory that is applied in the Healthy Relationships intervention, normative influences regulate behavior through two systems—social sanctions and self-sanctions (1). Social sanctions are demonstrated in the notion that social norms convey standards of conduct and people behave in ways that give them self-satisfaction and refrain from ways that violate these norms because that will bring self-censure (1). With respect to the intervention, participants will act according to the unspoken norms that are present among the other HIV positive participants of the group. As a result, no matter how many instructional videos and social worker-led seminars they attend, their individual actions will always be a reflection of the group’s actions. Another interesting point that also arose in the previous sections of this paper was the idea of interpersonal relationships. It is these interpersonal influences operating within one’s immediate social network that have a stronger regulatory function than when simple general norms are considered (1). In other words, if everyone in the small group discussion had friends or family who feel that practicing safe sex is a good idea and should be promoted, then each individual within their respective social network will act in accordance with this belief. This idea was also illustrated in a study done among drug-dependent women in which it was shown that the more their friends use and regard condoms positively, the stronger the women’s beliefs in overcoming interpersonal barriers to safer sex practices (1). As a result, the Healthy Relationships campaign should focus more on influencing the masses and the social networks that these individuals are immersed in on a daily basis in order to persuade each individual’s behavior and attitude toward safe sex.

Dzewaltowski states that there are four main environmental factors that have an impact on health behavior, and these are feelings of connection between people, feelings of autonomy, skill-building opportunities, and healthy norms that refer to group norms (3). Even though the Healthy Relationships intervention touches on these four factors in some way, it needs to redirect its methods to clearly address each factor individually and then assess the potential impact of the desired results. One way to modify the current intervention would be to redefine the group norms among HIV-positive individuals in order to promote healthy behavior. In a study among HIV-positive adolescents in Zambia, the researchers created an innovative behavioral intervention called the value utilization/norm change model (VUNC) in order to reduce HIV transmission among this highly sexually active group (10). The basic elements of this model, which borrow concepts from the Theory of Reasoned Action, are ethnographic fieldwork, domain and consensus analysis, strategic planning, and peer leader training (10). These various steps are integrated into one cohesive behavioral structure and have been beneficial in redefining social norms about sexual behavior and instilling healthy behavior (10). A model like this could be applied to the Healthy Relationships intervention in order to bring a new perspective to the evaluation of social norms among HIV-positive individuals. By instituting safe sexual behavior as the norm among this group of people, the rates of HIV transmission have the potential to be reduced.


In conclusion, the Healthy Relationships intervention uses the social cognitive theory to focus their approach on the individual’s perceived self-efficacy leading to positive outcome expectations, modeling using social workers, and personal objectives. Although this approach has certain constructive themes, this intervention would be more effective if there were changes made in its core concepts. As a result, more benefits for the participants would result if the focus of the Healthy Relationships intervention was geared toward fostering interpersonal relationships, modeling after peer leaders who are appropriately managing living with HIV, and emphasizing more on the role of the participant’s environment. These modifications would lead to better health outcomes as well as safer sex practices among the participants of this intervention. Overall, the proper management of a life-threatening disease such as HIV requires strong social support and the implementation of strong behavioral patterns, which are both provided in revisions to the current system.


1. Bandura, A. (1998). Health promotion from the perspective of social cognitive theory.

Psychology and Health, 13, 623-649.

2. Bandura, A. (1994). Social cognitive theory and exercise of control over HIV infection. In R. J. DiClemente and J. L. Peterson (Eds.), Preventing AIDS: Theories and methods of behavioral interventions (pp. 25-59). New York: Plenum.

3. Luszczynska, A. & Schwarzer, R. (2005). Predicting Health Behaviour: Research and Practice with Social Cognition Models. Social Cognitive Theory (pp. 127-169). Open University Press: New York.

4. Ryan, Richard M. (1982). Control and Information in the Intrapersonal Sphere: An Extension of Cognitive Evaluation Theory. Journal of Personality and Social Psychology. Vol. 43. No. 3: 450-461.

5. Information on Healthy Relationships from CDC website:

6. Rothenberg, Richard B., Potterat, John J, Woodhouse, Donald E., et. al. (1998). Social Network Dynamics and HIV Transmission. AIDS 12: 1529-1536.

7. Boud, David, Cohen, Ruth, & Sampson, Jane (1999). Peer Learning and Assessment. Assessment and Evaluation in Higher Education. Vol. 24. No. 4: 413-426.

8. Turner, Julianne C. Using Context to Enrich and Challenge our Understanding of Motivational Theory (Chapter 5). Motivation in learning contexts: theoretical and methodological implications. (2001). pp. 85-104.

9. Orange, Carolyn (1999). Using Peer Modeling to Teach Self-Regulation. The Journal of Experimental Education. 68 (1): 21-39.

10. Feldman, Douglas A., O’Hara, Peggy, & Baboo, K.S., et. al (1997). HIV Prevention among Zambian Adolescents: Developing a Value Utilization/Norm Change Model. Soc. Sci. Med. Vol. 44, No. 4: 455-468.

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