CHAPTER TWO
2.8 Conceptual (Theoretical) framework
2.8.1 The Integrated Model for Change (I-Change Model)
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144 Applying the I-Change Model to this study, sexual abstinence is determined by learners‘
intention to abstain from sex. Such intention is mediated through motivational factors such as their attitudes towards sexual abstinence, the kind of social influences they are exposed to and their self-efficacy regarding the behaviour. Awareness factors like knowledge of HIV transmission, cues to action (severity of the disease and knowing someone with HIV) to change behaviour, outcome expectations and perceived risk of HIV infection influence motivational factors.
In addition, two constructs – predisposing and informational factors – exert influence on awareness factors. Hence, learners‘ social-behavioural and psychological characteristics such as age, gender, living arrangements, school location, religion, as well as informational factors (the quality, format and sources of HIV messages reaching them) impact greatly on their awareness factors.
Studies that have utilised the I-Change Model among adolescents are few. In a study in Europe that aimed to explain the effects of anti-smoking parenting practices on adolescents‘ smoking intentions and behaviour using I-Change Model, attitudes, perceived social influences and self- efficacy were found to predict intention to smoke (Huver, Engels and de Vries, 2006).
Significant associations were also established between practices and smoking. However, some practices were associated with less smoking (e.g., communication about health risks of smoking) while others were associated with more smoking (e.g., rewards for not smoking). One major limitation of the study was small effect sizes indicating that smoking behaviour is determined by various factors rather than only parenting practices. In another case, items on the social influence, awareness, outcome expectations and intention constructs of I-Change Model predicted HIV testing among in-school adolescents in South Africa (Taylor et al., 2007).
Though the I-Change Model is relatively new and has not been used among mild/moderate intellectually impaired adolescents before, its ability to predict sexual abstinence is tested in this study to determine which of its constructs are relevant to this group. However, a similar cognitive-behavioural model, Health Belief Model (Stretcher & Rosenstock, 1997), had been successfully simplified and adapted to develop HIV prevention educational interventions for mild/moderate intellectually impaired persons by the Young Adult Institute (YAI) in the United
145 States of America (Jacobs et al., 1989). Health Belief Model‘s principles of perceived threat (closely related to perceived risk and attitudes), prevention (perceived benefits of taking action) and self-efficacy to be able to manage necessary behavioural changes were utilised to develop a video intervention for persons with intellectual disability by YAI. A South African study by Dawood et al. (2006), on HIV knowledge, attitudes and practices among mild intellectually impaired adolescents also used a questionnaire based on similar cognitive theories (though it did not test the relevance of any of the theories). In addition, Siebelink, de Jong, Taal, and Roelvink (2006) suggest that general behavioural models may be fruitful in exploring issues of sexuality among people with intellectual disability.
Historically, cognitive-behavioural interventions are often denied to persons with intellectual disabilities and this has decreased their access to potentially beneficial services (Taylor, Lindsay,
& Willner, 2008). This, according to the authors, is due to the belief that these individuals do not have cognitive abilities required to understand or benefit from such interventions. Research show no evidence to support that deficits in particular cognitive abilities result in poorer outcomes for such clients when placed on cognitive-behavioural therapy (CBT) (Durlak, Fuhrman &
Lampman, 1991; Sukhodolsky, Kassinove & Gorman, 2004). Similarly, CBT interventions that utilise cognitive skills training like self-management, self-monitoring, self instructional-training were found to show promise (Willner, 2005). Hatton (2002) in a review of psychosocial interventions for adults with intellectual disabilities experiencing a range of mental health problems concluded that with appropriate modification, this approach may be a feasible intervention option for persons with mild intellectual disabilities. This was also supported by Lindsay (1999).
Based on the foregoing, it is therefore believed that the I-Change Model (a cognitive-behavioural model) could be useful in predicting sexual abstinence among IIL as well as ML in this thesis.
Thus, in applying the I-Change Model to this study, the study utilised procedures that are well adapted and simplified to facilitate understanding of the key concepts by persons with intellectual disability who have higher level of intellectual functioning. Additionally, about 85.0% of persons with intellectual disabilities fall within the mild category (American Psychiatric Association (APA), 2000). In a developing country like Nigeria, this is the category
146 of intellectual disabilities often found in schools, as parents often lock up the other categories of persons with intellectual disabilities at home. Moreover, there is an overlap in the categorising of mild and moderate intellectual disabilities by APA in such a way that those at the lower level (IQ
= 50-55) of mild intellectual impairment also fall within the upper level (IQ = 50-55) of moderate intellectual impairment. As a result, most of the mild/moderate IIL in this study are functioning at higher and relatively similar level and could therefore be grouped together to a good extent. Similar study by McGillivray (1999) also grouped persons with mild and moderate intellectual disabilities together and compared them with non-disabled persons. In addition, YAI (Jacobs et al., 1989) developed a HIV prevention education that targeted persons with mild/moderate intellectual disabilities together as a group.
147 Figure 2.5: The Integrated Model for Change (de Vries et al., 2003)
Predisposing Factors Behavioural factors Psychological factors Biological factors Social Cultural factors
Motivational Factors
Ability Factors
Attitude:
Pros & Cons Rational & Emotional
Social Influences:
Norms Modelling
Support
Efficacy:
Routine Social Situational
Stress
Informational Factors Message
Channel Source
Awareness Factors Knowledge Cues to Action Risk Perception
Plans
Performance Skills
Intention State
Behaviour State
Barriers Pre-contemplation
Contemplation Preparation
Trial Maintenance Outcome expectation
148 2.8.2 The ABC Model
The ABC Model is a simple human behaviour model by Skinner (1953). The model is based on three constructs: antecedents, behaviour and consequences. Antecedents can be defined as the factors (cues, signals or conditions) that precede and trigger or influence the adoption of behaviour. This is based on the fact that all behaviours are influenced by the environment. On the other hand, consequence is the perceived or actual incidents that follow as a result of behaviour.
If the consequence is perceived to be positive, the probability that the behaviour will be sustained is high. Negative consequence is more likely to discourage the behaviour from recurring.
Applying the ABC Model to sexual abstinence as behaviour of interest in this study, the antecedents will include demographics, attitudes towards sexual abstinence, beliefs about sexual abstinence, awareness of HIV/AIDS, its mode of transmission, and risk perception.
Consequences will entail the probable results of unprotected sexual exposures including, the risk of HIV infection, sexually transmitted infections (STIs) and unwanted pregnancies, knowing someone who is HIV positive. These types of negative consequences are likely to discourage sexual experiences. Whereas, the positive consequences of sexual abstinence such as being free from STIs, unwanted pregnancies and often dreaded HIV infection have the ability to reinforce sexual abstinence.
The model relies mainly on reinforcement of positive behaviours to discourage unsafe behaviours, which is more therapeutic. While this is good, the current study aims to come up with educational interventions, including skills to reduce the vulnerability and risk of HIV infection among IIL. As a result, the ABC model is not suitable for the study.
Reinforcement
Figure 2.6: The ABC Model Antecedents
Demographics Attitudes Beliefs
HIV Awareness HIV knowledge
Behaviour Sexual abstinence
Consequences Being HIV negative Free from STIs
Free from unwanted pregnancies
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