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Health Promotion International Advance Access published June 9, 2013

Health Promotion International # The Author (2013). Published by Oxford University Press. All rights reserved.
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A health promotion logic model to review progress


in HIV prevention in China
DON NUTBEAM1*, SABU S. PADMADAS2, OLGA MASLOVSKAYA3
and ZHIWEI WU4
1
Office of the Vice-Chancellor, 2Centre for Global Health, Population, Poverty & Policy, Social Statistics
and Demography Division and, 3EPSRC Care Life Cycle Research Programme and Southampton

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Statistical Sciences Research Institute, University of Southampton, UK and 4Centre for Public Health
Research, Nanjing University, PR China
*Corresponding author. E-mail: d.nutbeam@soton.ac.uk

SUMMARY
Using the theory and concepts of health promotion, this and after 2003 when China commenced its ‘official’ response
paper proposes a logic model for HIV/AIDS prevention to the HIV epidemic. The logic model was useful in compar-
and control which provides a structure for describing ing actions taken over these two periods highlighting the
planned actions and predicted impacts/outcomes from com- importance of political leadership in distinguishing between
prehensive HIV prevention interventions. The potential use- the two phases, and the continuing importance of systematic
fulness of the model is examined by reviewing the evolution and broadly based public education and communication.
of HIV prevention and management in China, drawing on We conclude that the logic model can not only be used as a
evidence from interventions reported from a mixture of planning model, but can also be applied retrospectively to
study designs and formats. It reports that HIV interventions assess successes and failures in national and local responses
in China can be considered in two distinctive phases, before to HIV in complex social settings.

Key words: China; HIV/AIDS; health and social policy; behavioural interventions

BACKGROUND: ‘NEW’ PUBLIC HEALTH The epidemic is no longer largely confined to


RESPONSES TO THE HIV EPIDEMIC identifiable high-risk groups, and by far, the most
common route for infection is sexual transmission.
Since the early 1980s, HIV has emerged as one Interventions remain challenging, needing to
of the most challenging threats to public health account for the complex socio-economic and cul-
worldwide. In the early phases of the epidemic tural influences and taboos associated with the
HIV was found most commonly in developed sexual behaviours leading to transmission (Parker
nations and among gay men, injecting drug users and Aggleton, 2003). Because of its behavioural
(IDUs) and to a lesser extent among sex and pathological determinants, geographic spread
workers. Since this early phase, knowledge of and the lack of progress in the development of af-
HIV and its transmission have improved signifi- fordable treatment and health infrastructure, be-
cantly, and treatments that make it possible to havioural interventions to prevent HIV infection
live with HIV have been developed. However, remain the most cost-effective and sustainable
the epidemic has evolved disastrously and moved way of managing the epidemic (Hecht et al., 2010;
from high-risk groups to general populations in UNAIDS, 2010). Such a complex set of bio-
some of the world’s most populated and poorest behavioural risk factors and structural determi-
countries, particularly in sub-Saharan Africa. nants has demanded innovation in public health

Page 1 of 11
Page 2 of 11 D. Nutbeam et al.
interventions and bold political leadership. In par- social determinants of health and understanding
allel with the evolution of the HIV epidemic, of the importance of community mobilization in
the science and the art of public health interven- achieving sustainable change in populations.
tions have also had to go through a radical Combining these different public health strat-
transformation. egies has been found to be more effective in sup-
During the 1980s, the World Health porting sustainable behaviour change, and more
Organization was at the forefront of a radical re- suitable for use in general populations in poorer
assessment of the way in which public health pro- countries where the HIV epidemic is now
blems were conceptualized and addressed. centred.
Through a series of meetings and papers, WHO This paper reflects on this transformation in
developed a ‘new’ approach to public health the theory and concepts of public health action
intervention described as health promotion and and proposes a ‘logic’ model for HIV/AIDS pre-
defined through the WHO Ottawa Charter for vention and control. It considers the potential
Health Promotion (WHO, 1986). In one sense, usefulness of the model by examining the evolu-
this returned public health to its more traditional tion of HIV prevention and management in the
roots, reflecting a contemporary interpretation of world’s most populous country, China.

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the impact of the environment on health and em-
phasizing the importance of government and
communal action for health alongside the estab- USING A HEALTH PROMOTION
lished paradigm focussing on individuals and OUTCOME MODEL FOR HIV
their lifestyles. The Charter highlighted, for PREVENTION AND MANAGEMENT
example, the importance of healthy public
policy—the role and responsibility that govern- Figure 1 provides a logic model for HIV preven-
ments have to develop policies across all sectors tion and management. It is based on the health
of government in ways that ‘make healthy promotion strategies advocated through the
choices, easy choices’; and the need for genuine WHO Ottawa Charter. Such a model provides a
community engagement as a way of achieving conceptual illustration of the logic linking
locally relevant and sustainable solutions to planned actions to planned outcomes (Nutbeam,
public health problems. While drawing attention 1998). Starting at the end, the model identifies
to the range of actions necessary in the wider two goals of halting and then reversing the epi-
community, the Charter also maintained the fun- demic of HIV infections, and providing appropri-
damental role of the health system in improving ate, affordable treatment for those who are
public health, and the challenge to maintain infected. In turn, it identifies two key interven-
focus on prevention and primary health care in tion outcomes that will deliver these goals,
health systems. namely, sustained prevention behaviours and
These strategies represent a set of tools that improved (reoriented) health systems that
can be used in different combinations to plan provide effective HIV testing and screening pro-
and deliver effective and sustainable public grammes and access to affordable treatment.
health interventions that are built on a much To achieve these outcomes, the model identi-
broader theoretical base than previously had fies three public health strategies—health promo-
been the case—balancing individual responsibil- tion ‘actions’ based on the Ottawa Charter—that
ity with social and governmental responsibility will deliver change in the determinants, and the
for public health improvement. intervention outcomes, and health goals identi-
Correspondingly, as the knowledge of HIV in fied in the model, as follows:
terms of methods of transmission and risk beha-
† Public education and communication that, for
viours became better understood, more effective
example, makes use of the mass media for
and sophisticated prevention programmes and
raising public awareness, providing informa-
policies have been developed (Moatti and
tion and influencing public opinion; that
Souterand, 2000). These programmes have,
makes creative use of edutainment, photo
either deliberately or unintentionally, drawn
novellas and other media to creatively reach
upon the strategies identified in the Ottawa
specific populations with targeted messages
Charter—based on new and emerging theories of
and that delivers targeted and tailored educa-
behaviour change, better understanding of the
tional interventions to develop the life-skills
A health promotion logic model Page 3 of 11

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Fig. 1: A health promotion logic model for HIV prevention and management.

and self-efficacy needed for sustainable behav- These interventions are directed towards
iour change. achieving three key health promotion outcomes,
† Community mobilization that, for example, as follows:
targets community leaders to transmit infor-
mation, reduce stigma and discrimination; pro- † Accurate public knowledge and practical per-
vides direct support for marginalized groups sonal skills that, for example, will ensure
(such as commercial sex workers) to organize correct community knowledge about prevent-
in ways that protect their health rights, provide ive behaviours and improved understanding of
them with a voice and enable them to provide HIV/AIDS prevention and control measures,
mutual support and recognizes and supports including reduced misconceptions, discrimin-
NGOs in working effectively with margina- ation and stigma, and supports the skills and
lized groups. confidence necessary to put into practice
† Political leadership that, for example, recog- recommended behaviours in what may be chal-
nizes the social and economic origins of HIV lenging circumstances for some individuals.
risk behaviours and mobilizes resources to † Supportive social and economic environment
address these; delivers personal leadership in exemplified by interventions intended to min-
reducing stigma and discrimination; manages imize social stigma and discrimination;
the tensions between community norms and provide reliable access to relevant health and
cultural/religious sensitivities and ensures that support services including voluntary and confi-
health services are equipped to respond to the dential HIV testing and counselling services;
epidemic. provide practical access to condoms and other
protective methods and and provide economic
These interventions are not mutually exclusive alternatives to commercial sex work.
and generally need to be understood as inter- † Healthy public policy that, for example, pro-
dependent. For example, a well-informed public vides rights and protections for people living
is more likely to engage with community-wide ac- with HIV/AIDS; provides screening and control
tivities and support political leaders in making of blood products; monitors transmission risks
difficult decisions in resource allocation. Similarly, in antenatal clinics and reduces risks and harms
strong political leaders can inspire community by providing the supportive regulation of com-
mobilization, and by acting as role models, re- mercial sex industry, harm reduction policies for
inforce public education and communication IDUs and delivers supportive health services
about HIV prevention. organization and investments.
Page 4 of 11 D. Nutbeam et al.
It is tempting to imagine that the model is simple CHINA CASE STUDY: RATIONALE AND
and linear—one type of intervention leads to one APPROACH
type of outcome in a predictable way. The reality
is more complex and dynamic. In the same way China is the world’s most populous country and
that the different forms of intervention can be has experienced the development of the HIV
seen as co-dependent, so too are the different epidemic in clearly identifiable phases. It offers a
outcomes. For example, putting into practice complex case study to examine the relevance and
recommended behaviours will be fundamentally usefulness of the logic model in examining the
dependent on an individual’s knowledge and comprehensiveness of actions and effectiveness
self-confidence to act on their knowledge—but of interventions in both the initial and later
this, in turn, will be influenced by the existence response phases.
of supportive public opinion and community Broadly, four distinct phases of the HIV epi-
acceptability towards, for example, access to demic can be identified: 1985 –1988 restricted to
condoms and the regulation of the sex industry. a small number of AIDS cases in coastal cities
In turn public attitudes influence the formation among foreigners and Chinese travelling over-
of legal rights and protections offered through seas; local prevalence and isolated outbreak of

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public policy. For these reasons, the model HIV especially among IDUs in the Yunnan
cannot offer a simple explanation of causality. Province of China (1989 –1993); HIV transmis-
It will also be evident that the model is not a sion beyond Yunnan province among drug users
‘one size fits all’ planning solution. It is rather and commercial plasma donors (1994 – 1998) and
conceived as an organizing framework for those an extended phase of the epidemic from 1998
responsible for planning, delivering and monitor- onwards affecting the general population
ing an effective and sustainable programme of (Kaufman and Jing, 2002; Wu et al., 2007b;
actions for HIV prevention and management. Sheng and Cao, 2008; Xinhua et al., 2010). In
There is no single theory or model which can ad- 2002, UNAIDS forecasted that, without effective
equately guide the development of a comprehen- countermeasures, China would have as many as
sive health promotion programme intended to 10 million HIV positive people by year 2010
influence the multiple determinants of HIV (UNAIDS, 2002).
transmission in populations. Practitioners, com- The risks of HIV transmission were deemed
munities and their leaders need to use local high in China because of its large population,
knowledge and experience and available re- high rates of internal migration reflecting both
search information to make judgements about rural –urban and urban– urban movement,
community needs and the local determinants of massive urbanization and poor knowledge of
health which are most amenable to change at a transmission routes. Cities and urban areas
particular point in time. expanded hugely across China during the early
The usefulness in the model comes from its 2000s. This period also saw a major expansion of
comprehensiveness. It provides an overview of commercial sex industry and high mobility of
the universe of actions and outcomes in a logical female sex workers (Tucker et al., 2005). By
sequence. It is an organizing framework within 2009, the estimated number of HIV cases was
which planned activities, anticipated impacts and 740 000 (UNAIDS, 2010).
predicted outcomes can be structured and exam- The response to the HIV epidemic can be seen
ined. The model can be used both for the system- in two distinct phases, pre- and post-2003. The
atic examination of past programmes and to case study below examines the response in these
structure the necessary, complementary ele- two phases. In 2003, there was, for the first time,
ments of future interventions. It does not offer a an unequivocal high-level political acknowledge-
classic causal chain, but does take into account ment of the HIV epidemic. A State Council
the complexity of a comprehensive intervention Working Group on HIV/AIDS was established
within a manageable structure. It can be used to in 2003 as a high-level interagency body to mobil-
better predict the likely outcomes of planned ize the bureaucracy and coordinate the national
interventions, as well as help explain the reasons response (Wu et al., 2007b). This coincided
for observed success or failure from past with the launch of a national treatment pro-
programmes. gramme CARES (China Comprehensive AIDS
A health promotion logic model Page 5 of 11
Response) supported and funded by the central Initially, the government did not publically
government jointly with a grant from the Global acknowledge HIV as an epidemic in China.
Fund and the ‘Four Frees and One Care’ policy Between 1989 and 1995, there were no national
implemented at the national level. public awareness campaigns, and the only public
acknowledgement of the problem nationally
came from officially sponsored study tours to
METHODS learn from the experiences of other countries
affected by HIV/AIDS epidemic (Huang, 2006;
We conducted a review of selected HIV inter- Wu et al., 2007b). Subsequent government cam-
ventions in China with a focus on prevention and paigns were largely ineffective and unsustainable
behavioural change. The search criteria included including a nationwide campaign launched in
reported interventions and reviews based on a 1995 to promote the knowledge of HIV transmis-
mix of study designs including community trials, sion, prevention and control (Huang, 2006).
ethnographic and observational studies pub- With reference to the intermediate outcomes
lished since 2000 in peer-reviewed journals and of the logic model, there is little published evi-
research reports. The electronic bibliographic dence of open horizontal or vertical public edu-

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database and search engines used were ISI Web cation, political commitment and cross-sector
of Science, Medline, Google Scholar, online coordination to address HIV prevention. A high-
journal resources and UNAIDS database. level workshop organized by the Chinese
Restricted information from website resources Academy of Preventive Medicine in 1997
and abstracts from conference proceedings were acknowledged the need for interventions but
not considered. their attention was limited to stigmatized high-
risk groups such as commercial sex workers,
IDUs and men having sex with men.
REPORTED HEALTH PROMOTION The strategies to prevent HIV at this time were
STRATEGIES AND IMPACT largely ineffective. Public laws and regulations,
for example, were generally punitive and often
The analysis below follows the structure and counterproductive, clamping down on drug users
interdependent pathways of the health promo- and sex workers, alongside attempts to prevent
tion strategies illustrated in the logic model the introduction of HIV through imported blood
(Figure 1). The review identified major HIV products, and requiring blood tests among tour-
interventions in China targeted at both the ists and returning overseas Chinese. This evi-
general population and high-risk groups. It is dently overlooked the generalized nature of the
evident that the way in which HIV interventions epidemic and emerging routes of HIV transmis-
were planned and implemented varied consider- sion and had the effect of driving further under-
ably before and after the official response in ground the high-risk groups such as the IDUs
terms of scale and coverage. and sex workers. Restricted public knowledge
and community involvement particularly in HIV
affected provinces remained barriers to com-
Prior to official national HIV response munity mobilization, and the development of
(1989 –2003) supportive public policies. At this stage of the
The first indigenous cases of HIV were reported epidemic, health systems lacked essential infra-
in 1989 among IDUs localized within the structure, technical knowledge and skills to deal
Yunnan province of southwest China (Wu et al., with HIV cases. For example, only about 16% of
2007b). The infection spread gradually along the healthcare workers in highly concentrated epi-
major drug trafficking routes affecting the IDUs demic areas knew how to prevent HIV and over
and their partners and children. Towards 90% of IDUs in high user areas were unaware
mid-1990, a second major HIV outbreak was that sharing needles could spread HIV (Huang,
reported among sexual partners of commercial 2006). As a whole, the strategy (such as it was)
plasma donors in the east-central provinces. By offered few of the key interventions described in
1998, a generalized epidemic phase with all pos- Figure 1.
sible modes of transmission was reported across One of the most important determinants of
regions and municipalities of all 30 provinces in this ineffective response was political sensitivity
China (Sheng and Cao, 2008). to HIV and consequent weak political
Page 6 of 11 D. Nutbeam et al.
commitment at the central level which even led report the epidemic in a number of hot spots
provincial and local authorities to justify the but their efforts were largely disregarded
cover-up of HIV cases (Liu, 2004; Huang, 2006). (Huang, 2006).
This lack of political will combined with ineffect-
ive public education probably led to an extended
phase of HIV epidemic across Chinese Official national HIV response post-2003
provinces. If the H9 intervention helped build political con-
A significant development in HIV prevention fidence for intensifying the HIV prevention
between 1997 and 2002 was the World Bank efforts at the national level, the outbreak of
funded Health-IX (H9 or the Ninth Health Severe Acute Respiratory Syndrome (SARS) in
project) programme implemented in four pro- 2002– 2003 provided a trigger for an abrupt
vinces (Jiang et al., 2010). The salient features of policy shift towards HIV prevention policy in
the H9 intervention were the promotion of the China (Huang, 2006; Gill and Okie, 2007; Wu
consistent and 100% condom use model, routine et al., 2007b). Following international criticism
diagnosis and treatment of STDs with a focus on for a failure to openly and energetically respond
female sex workers and capacity building in local to the SARS crisis, the Chinese central adminis-

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authorities that enabled more sophisticated tration led by President Hu Jintao and Premier
public education campaigns to raise awareness of Wen Jiabao openly admitted the epidemic crisis
the health risks of commercial sex (Rou et al., and called for expeditious action for prevention
2010). Prior to the H9 intervention, condom pro- as well as treatment and care for people living
motion policies were almost non-existent and with HIV.
subject of intensive debate within the Chinese In 2004, a joint assessment conducted by the
government. The H9 intervention can be cred- State Council AIDS Working Committee and the
ited with having had positive influence in build- United Nations Theme Group on AIDS identified
ing confidence within the central government the gaps and uneven implementation of AIDS re-
that effective action was necessary, politically sponse across Ministries and between local pro-
feasible and practical to deliver. It was instru- vinces (UNAIDS, 2007). The gaps were primarily
mental in mobilizing cross-sector and govern- poor cross-sector coordination, lack of strategic
ment cooperation, particularly in relation to plans and mechanisms to monitor and evaluate
condom promotion in controlling HIV and STDs performance at the provincial and local levels.
within the commercial sex industry. Importantly, Following the joint assessment, the first legal
the H9 intervention established the feasibility of framework was developed in China (Regulation
condom promotion among female sex workers on AIDS Prevention and Treatment) in 2006 by
and led to the development of national guide- the State Council which stressed the accountabil-
lines for condom use programmes in China. In ity of governments and ministries at different
effect, public education and community mobil- levels in formulating appropriate policies and
ization strategies of H9 intervention worked in effective implementation (UNAIDS, 2007). This
tandem to slowly build the necessary political eventually led to the establishment of China’s
leadership required to scale up and systematize Action Plan for Reducing and Preventing the
the response to the emerging epidemic. Spread of HIV/AIDS (2006–2010) under a
Overall, pre-2003 activities may be character- ‘Three Ones’ principle including one national
ized as a ‘pilot phase’ in the scale and context of plan, one coordinating mechanism and one evalu-
China, identifying potential intervention routes ation and monitoring system (UNAIDS, 2007).
and policy responses to prevent HIV transmis- Political determination and leadership at the
sion among high-risk groups, but lacking broader higher level invigorated the profile of the national
public education and the political commitment campaign against the epidemic and mobilized
and leadership needed for a nationwide re- multisector coordination and resources.
sponse. During this period, local authorities Public health education was a fundamental
showed strong resistance to disclose HIV/AIDS component of post-2003 HIV intervention
epidemic in their administrative localities, failing strategy. The health education efforts focused
to allocate needed resources to diagnose, track mostly on IEC (Information, Education and
and treat infected individuals. There were very Communication) materials including posters,
few NGOs existing at that time serving the pamphlets and briefings. HIV education had an
affected communities. Individual advocates did extensive outreach through health promotion
A health promotion logic model Page 7 of 11
campaigns which comprised media, entertain- The national government-led CARES interven-
ment, schools health education as well as tion programme (2003–2008) had an overall posi-
community-based events and activities. The tive impact in improving HIV/AIDS awareness
interventions were overtly directed towards pro- and in sustaining behavioural change in the
ducing accurate public understanding of HIV general population. This has been achieved
and its transmission and to creating a more toler- through unprecedented face-to-face public educa-
ant and open public response, reducing tion campaigns for women and those who lived in
HIV-related stigma and accepting harm reduc- underdeveloped, rural and ethnic minority areas
tion strategies (Han et al., 2010; Li et al., of China (UNAIDS, 2007; Han et al., 2010). The
2010a,b). programme adopted a four-tier management
Reported HIV prevention interventions system that allowed for adaptations to local con-
focused on both the general population and high- texts based on common technical planning, guide-
risk groups (migrant workers, female sex lines and evaluation criteria. Observational
workers and IDUs), as well as institution-based studies and case–control evaluation surveys were
interventions such as workplace prevention, used to assess the CARES programme impact.
health centres including family planning service Accurate HIV/AIDS prevention knowledge

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clinics, entertainment establishments, mining improved significantly in the intervention sites
and construction sites (Hong et al., 2011). An as- from less than 30% to over 80% between 2003
sessment of major HIV prevention programmes and 2008 (Han et al., 2010). The intervention also
post-2003 showed evidence of a structured linear enabled scaling up of the HIV/AIDS response in
course of action in most cases integrating mainly resource poor areas of China and contributed to
public education and community mobilization the revision and the development of national and
efforts backed up by strong political will and local laws and regulations. Nonetheless, the pro-
leadership—much more compatible with the gramme impact was only moderate in changing
logic model in Figure 1. community norms especially tackling issues
Public education and communication strategies related to social stigma and discrimination (Wu
for HIV prevention did not operate in isolation in et al., 2007b). At the prefecture level, the indica-
post-2003 China. Political support and leadership tors to monitor community mobilization were
at the provincial and local levels were at the fore- only partial (Han et al., 2010).
front in all government supported HIV preven- The review of literature identified a wide range
tion programmes, both pilot and large-scale. This of pilot projects post-2003 including community-
is particularly the case in complex situations based trials focusing on workplace interventions
where interventions targeted both the general for high-risk groups and migrant workers, class-
population and marginalized and vulnerable com- room education for adolescents, web-based inter-
munities. Health promotion strategies involving vention for students and villagers and those
IEC and community resources mobilization oper- integrating HIV education into existing family
ated in tandem, NGOs became increasingly planning services (Hammett et al., 2005; Zhao
visible in HIV/AIDS awareness raising and in pro- et al., 2005; Des Jarlais et al., 2007; Gao and
viding community outreach services to high-risk Wang, 2007; Qian et al., 2007; Tian et al., 2007;
populations. The government recognized the Lau et al., 2008; Li et al., 2008; Hong and Li,
unique roles played by NGOs in reaching the 2009; Hong et al., 2011). HIV interventions that
affected groups and in mobilizing communities in targeted marginalized and high-risk groups
ways that would be difficult for the central and varied in scale and geographical coverage
local government agencies. Condoms were also (Hesketh et al., 2005; Li et al., 2006; Liao et al.,
made easily available and publicly distributed 2006, 2011; Lau et al., 2007; Rou et al., 2007; Wu
through multiple sources including vending et al., 2007a). Though such interventions proved
machines. It is worth noting that the H9 interven- to be effective in enabling positive behavioural
tion yielded long-term impact in stimulating change, there was no direct evidence of scale-up
multisectoral coordination and community mobil- efforts or sustainability of different interven-
ization for HIV prevention. A methodical evalu- tions. Also, there was little evidence on whether
ation of H9 intervention documented evidence on the best practices from these pilot interventions
how the planned health promotion strategies were were systematically fed into the design of national
linked to expected outcomes (Xue, 2005; Jiang guidelines for behavioural interventions among
et al., 2010). high-risk groups.
Page 8 of 11 D. Nutbeam et al.
The logic model (Figure 1) proposes that suc- 2007; Xu et al., 2008; Liu et al., 2010; Chen et al.,
cessful interventions need a combination of sus- 2012). Although most of the existing interventions
tained political leadership and meaningful are scientific and evidence-based, systematic
community engagement, complemented and evaluation of intervention guidelines, programme
extended in their impact by effective public edu- management, monitoring strategies and policy
cation. In summary, these conditions for success development are still needed (Rou et al., 2010).
were rather quickly expedited in post-2003
China. This case study clearly illustrates that the
sustained political leadership was the key to sub- DISCUSSION
sequent observable success in managing the HIV
epidemic in China. More explicitly, the political The HIV epidemic is still evolving in many
leadership in China mobilized the needed low- and middle-income countries which are con-
resources and introduced public policies that suc- fronted with multiple challenges in HIV preven-
cessfully transformed the environment for public tion and management. The responses of
education and community engagement in HIV individual nations and communities within coun-
prevention and AIDS treatment. tries are shaped and constrained by political

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The evidence of change can be seen from systems, social norms and structures and access to
several local and national studies. For example, resources. In analysing China’s progress in HIV
there has been a significant increase in the prevention, this political and social context is very
number of civil society organizations actively important in making observations and judge-
contributing to HIV prevention programmes ments about effectiveness and success.
across the country (Li et al., 2010a,b). The logic model described in this paper offers
Government response and greater involvement a benchmark against which a nation’s response
of NGOs and stakeholders were critical in pro- might be compared. It is based on established
moting healthy public policies, e.g. controlled health promotion strategies that can be used in
blood donation law and the ‘Four Frees and One different combinations to plan and deliver effect-
Care’ policy (Wang, 2007; Sun et al., 2010a,b). ive and sustainable public health interventions.
Successful condom promotion campaigns were These health promotion concepts and strategies
scaled-up across China which was clearly that have been successfully applied to a range of
reflected in the increase in condom uptake social and behaviourally determined health chal-
among both high-risk and general populations lenges and have clear relevance for the preven-
(UNAIDS, 2007; CPDRC, NCWCH and UoS, tion and management of HIV/AIDS in many
2011). Long-term international collaboration different populations. The model shows how pro-
and funding have also contributed to national gramme strategies are linked and might logically
AIDS response and extensive documentation of produce targeted impacts and outcomes.
HIV interventions in China (Sun et al., 2010a,b). We have examined published major HIV inter-
Efforts were also put in place to assemble, vention programmes in China in order to examine
review, test and revise key indicators identified in their fit with the logic model in relation to imple-
the national monitoring and evaluation system in- mentation strategies, impact and outcomes, as
cluding an online comprehensive web-based HIV/ well as considering their impact on identified
AIDS data system operational since 2008 (Wu high-risk populations. This case study is not a sys-
et al., 2011). Data from multiple sources indicate a tematic review but an attempt to test the feasibil-
sustained control of new HIV cases in China, ity of the logic model illustrating the pathways
although there was lack of coordination to effec- that led to the prevention and management of the
tively monitor inconsistencies and overlap in data HIV/AIDS epidemic in a large and complex
collection (UNAIDS, 2010; Wang et al., 2010; Wu population such as China. For these reasons, we
et al., 2011). Observational studies have shown recognize that the interventions considered in this
overall positive changes in HIV-related behaviour paper could be subject to risks of selection bias
(He and Detels, 2005; Wang, 2007). However, the and impact heterogeneity. However, despite these
challenges in reducing HIV risks still remain to be limitations, the results provide a sufficient spread
addressed in the case of marginalized and stigma- of information on the responses to the HIV epi-
tized bridge groups such as men having sex with demic in China to examine actual responses
men, IDUs and migrants (Zhang and Chu, 2005; alongside the ‘ideal’ described in the model.
Hu et al., 2006; Xiao et al., 2006; Gill and Okie, Some elements appear to be better and/or more
A health promotion logic model Page 9 of 11
frequently recorded than others. For example, be used to guide the assessment of impact and
there is reasonable quality and quantity of infor- outcome and to manage the expectations of com-
mation on the different forms of public education munities, policy-makers and funders as to what
in both the pre- and post-2003 phases of China’s might be achieved through different combina-
response. However, there is much less structured tions of intervention. The model provides a
and systematic recording of community mobiliza- useful reminder to practitioners, policy-makers
tion and political leadership. Although both are and those funding HIV prevention efforts that
directly or indirectly acknowledged to be import- achieving sustained behaviour change is complex
ant, they are much less commonly analysed in and takes time. Although all programmes have
papers describing interventions and their impact. public education and communication at the core
The available information can be mapped of their success, sustained success in stabilizing
against the model showing how in the pre-2003 and reversing the epidemic involves multiple
phase patchy public education and limited pilot forms of intervention. The logic model can be
projects intended to mobilize high-risk popula- used to illustrate how investing time and
tions produced outcomes that were difficult to resources in community mobilization can be ex-
sustain in the absence of supportive political tremely important in achieving both scale and

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leadership and wider societal support. During sustainability of impact. It also serves to remind
this period, these same pilot projects, notably the programme planners that political leadership is
H9 programme, produced important evidence essential, showing, for example, that community
and practical experience in tackling risk beha- mobilization efforts seem to have worked in
viours that helped to build the political confi- countries where political commitment was high
dence and consensus needed for a more at the national levels. In contrast, the position of
sustained response. The SARS crisis provided a China pre-2003 illustrates the lag and complexity
final trigger that galvanized political support at in introducing effective interventions and the
the highest level. policies that support them.
The model is also intended to signal measures
of impact and outcome that can be logically
traced to the interventions. The material used in
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