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Health Promotion International # The Author (2013). Published by Oxford University Press. All rights reserved.
doi:10.1093/heapro/dat037 For Permissions, please email: journals.permissions@oup.com
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
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.
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