Note
Chapter 2 HIV and behaviour change theories
4.3 The social nature of action
As individuals we do not exist in isolation, but rather in a social context. We are ‘situated’, in a context of social institutions, “those rules and related patterns of action by which a culture is socially organized” (Doyal & Harris, 1986, p. 78). The rules and social practices are not of our own (individual) making, and yet they play a fundamental role in what might seem to be private and individual actions (ibid). It is in this sense that our “schemata of possible actions is prefigured” (Kelly et al., 2001, p. 259). Doyal and Harris summarise the significance of this:
The repertoire of actions you perform is therefore like the vocabulary of the language you speak. It is the collective possession of the social group within which those actions are performed and that language is spoken. So, just as the conscious formulation of what you want to say depends upon the prior social existence of language rules in terms of which
words have their meanings, so the conscious formulating of an intention to perform an action depends upon the prior social existence of rules in terms of which actions have their justifications. You can only form an intention to do something that already makes sense to you as something that might be done. (1986, p. 80)
Kelly et al. (2001) argue that we thus ‘choose’ our ‘individual’ actions from a repertoire of actions that pre-exists and which is defined socially in the conventions, tradition and rules present in the numerous social roles and institutions which form part of our daily life. This context of conventions exists prior to us and it exists ‘outside’ of us and our immediate action.
It determines what we do, not in a deterministic sense, but in the sense that it ‘affords’ us our actions. We can only act in ways that are perceived as possible, and rhetorically defensible.
For example, the individual’s ability to use a condom depends on the social rules available in the context which afford the action. If condom use is a derisory action, if it is not afforded in the context, then it is unlikely that an individual will be able to enact it.
In addition to this, ‘choosing’ an action means that we “choose a course of action which has bound within it conventions about doing and appropriate doing” (Kelly et al., 2001, p. 259).
For example, when I choose to speak to my partner about safe sex, I do this in the way that is available, within the norms of our relationship (for example, that the relationship does not involve other partners and that talking openly about sex is a ‘normal’ part of the way that we communicate). I can only talk in the way that is afforded me to talk. We thus enact social roles which we have not generated, we perform actions for reasons beyond ourselves as individuals, and behaviour cannot be said to be ‘individual’, original or novel (Kelly et al., 2001). We therefore cannot assume that sexual activity is the outcome of individual decision- making processes (ibid). Sex may be private, but it is not individual.
This perspective is, to a limited degree, evident in some of the theorising in the HIV and AIDS literature. Parker (2001, p. 169) argues that social orders “structure the possibilities (and obligations) of sexual contact” through defining the available range of potential sexual partners and practices; and the sexual possibilities and options that will be open to
differentially situated actors. This, in turn is intricately related to the “socially and culturally determined differentials in power - particularly between men and women” (ibid, p. 169).
Sexual experience and thus the conditions under which HIV is transmitted are shaped by these
‘social orders’.
The fact that our behaviour is neither ‘individual’, nor ‘original’, brings into question the possibility of the individual being perceived as agentive. Kelly et al. (2001. p. 258) argue that health behaviour theory gives “unjustified power of agency … to the actions that we
knowingly perform, and to the technologies of self-management that may direct such behaviours”. The assumption is that we are agents of our own behaviour (that we have self- agency), and that our behaviours have their origins in us. Harré (1995, cited in Kelly, 2001) rejects the understanding of human agency as arising from an independently active human mind to which capacities of agency are assigned. He argues that action is not the production of individual intentional life but is rather a product of many contingencies which are not products of self-agency. Kelly et al. (2001, p. 258) argue that agency “resides elsewhere, in predisposing conditions or in the combined action of a complex of contingencies”. Behaviour thus cannot be said to originate in the ‘mind’ of the actor, and actions are not derived from
‘us’ as individuals (Kelly et al., 2001). This is a major critique of the rationalist and
cognitivist assumptions inherent in the individually-centred behaviour change theories. The reason a person engages in a particular behaviour therefore “is not carried in the mind of the actor, but is carried in the social model of action that the person adopts with all of its
attendant meanings and determinants” (Kelly et al., 2001, p. 254). The individuals’ ability to be agentive is therefore proscribed by context not in the sense that structure limits agency as discussed above, nor in the sense that the individual is ‘affected’ by context, but in the sense that individual activity is not ‘individual’.
The fact that activity is contingent, and that it is not easy for the individual to manage all the conditions of this contingency, means that actions cannot be directly achieved by the
individual (Kelly et al., 2001). This has significant implications for the individual’s ability to change their health behaviour. Initiating and sustaining behaviour change cannot be solely dependent on individuals and this severely limits the potential of individual ‘choice-based’
behaviour change approaches (Parker, 2004). The intentionality of action cannot ‘escape’ the socially determined meaning of the action. The intention to use a condom will be contingent on the social modes of action available to the actor. Understanding the action (or lack of action) requires an interpretation of the social practice, in its context of rules and conventions (Kelly et al., 2001).
There are elements of this stance in the HIV and AIDS literature in the emerging emphasis on the ‘meaning’ of sexual activities in different context. Parker (2001) comments that the
significance of cultural factors in the social dimensions of HIV and AIDS risk lead to a shift in focus from ‘behaviour’, to the ‘meaning’ of sexuality in the setting in which it occurred. He comments that it is a movement beyond the identification of statistical correlates aimed at explaining the sexual risk behaviour of an isolated individual to recognising the shared collective character of sexual activity. This shift to the investigation of cultural meanings has drawn attention to the “socially constructed (and historically changing) identities and
communities that structure sexual practice within the flow of collective life” (Parker, 2001, p.
167). The cultural meanings and norms that construct and organise sexual experience affect risk behaviour and the transmission of HIV. Parker (2001) argues that sexual realities are
‘constructed’ in relation to context, rather than being biological processes which are invariant across context. Kippax (2003) argues that people do not just engage in the mechanical acts of sexual behaviour. One might have sex in a brothel or in a marriage and although the
behaviour might be the same, the social and cultural meanings of the practice differ. People thus “enact sexual practices” (or activities), and they enact these in reference to meaning, they
“‘make love’ or ‘have a one-night-stand’” (Kippax, 2003, p. 19). It is this meaning that makes sexual behaviour a social practice, mediated by the meanings formed in relations between people. All sexual practice “is produced and enacted in particular interpersonal, social, historical and cultural contexts” (Kippax, 2003, p. 20). Kippax’s (2003) distinction between behaviour and practice is similar to the distinction within the social sciences between responses being purely cognitive and biological (and somehow innate), versus those which are mediated.
This conceptual shift to a focus on norms, values and meanings has had an important effect on intervention designs. Parker (2001, pp. 167-168) argues that recognising action as “socially constructed and fundamentally collective in nature” has meant that interventions focus more on transforming social norms and cultural values, that is, at “reconstituting collective meanings in ways that will ultimately promote safer sexual practices (see Altman 1994;
Bolton & Singer 1992; Paiva, 1995, 2000)”.
5 Working with ‘context’
This review of the dominant behaviour change theories, and the critique of these theories, has revealed a conceptualisation of the nature of human behaviour which emphasises behaviour as
cognitivist, rationalist and individually driven. There is an acknowledgement (to a certain degree) within the HIV and AIDS field that various cultural, social and contextual factors frame, limit and constrain behaviour. However, some of the major assumptions about agency and the relationship between the individual and context have not been adequately addressed.
This conceptualisation of the relationship between the individual and society constrains an understanding of the process of behaviour change and potentially limits intervention design. If achieving ‘behaviour change’ is premised on inappropriate conceptualisations of the
relationship between society and the individual, then it is unlikely to succeed.
From the critique outlined above it seems that the social-individual interface needs to be conceptualised as dynamic, dialectically interactive, and analytically inseparable. Framing the relationship between the individual and society and thus ‘behaviour’ in this way might lead to an understanding of how contextual factors determine responses to the HIV and AIDS
epidemic, and how they limit ‘individual’ ability. It is also necessary to engage critically, and practically, with the notion of context. Moving away from the image of context as that which
‘surrounds’ or ‘causes’ behaviour necessitates an epistemological shift. Cultural-historical activity theory (CHAT, or activity theory) introduces critical concepts which dialectically link the individual to the social structure, and enable this shift. In the next chapters I discuss activity theory and demonstrate how the methodology inherent in CHAT-based research provides a unique way of engaging with ‘context’. Using an activity theory approach to work with context provides an alternative and useful conceptualisation of behaviour and the possibilities of behaviour change in the field of HIV and AIDS.