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Articles  文章

A Critical Assessment of Theories/Models Used in Health Communication for HIV/AIDS


The Pennsylvania State University
University Park, Pennsylvania, USA


Universidad del Norte 北方大学Colombia 哥伦比亚

Abstract 摘要

Most theories and models used to develop human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) communication are based on social psychology that emphasizes individualism. Researchers including communication and health scholars are now questioning the presumed global relevance of these models and thus the need to develop innovative theories and models that take into account regional contexts. In this paper, we discuss the commonly used theories and models in HIV/AIDS communication. Furthermore, we argue that the flaws in the application of the commonly used "classical" models in health communication are because of contextual differences in locations where these models are applied. That is to say that these theories and models are being applied in contexts for which they were not designed. For example, the differences in health behaviors are often the function of culture. Therefore, culture should be viewed for its strength and not always as a barrier. The metaphorical coupling of "culture" and "barrier" needs to be exposed, deconstructed, and reconstructed so that new, positive, cultural linkages can be forged. The HIV/AIDS pandemic has served as a flashpoint to either highlight the importance or deny the relevance of theories and models while at the same time addressing the importance of culture in the development and implementation of communication programs.
大多数用于发展人类免疫缺陷病毒(HIV)/获得性免疫缺陷综合症(艾滋病)传播的理论和模式都是基于强调个人主义的社会心理学。现在,包括传播学者和健康学者在内的研究人员都在质疑这些模式的假定全球相关性,因此有必要发展考虑到地区背景的创新理论和模式。在本文中,我们将讨论艾滋病传播中常用的理论和模式。此外,我们还认为,在健康传播中应用常用的 "经典 "模式之所以存在缺陷,是因为在应用这些模式的地方存在背景差异。也就是说,这些理论和模式被应用的环境并不是它们设计的初衷。例如,健康行为的差异往往是文化造成的。因此,我们应该看到文化的力量,而不是总是将其视为障碍。文化 "与 "障碍 "之间的隐喻关系需要加以揭示、解构和重构,以便建立新的、积极的文化联系。艾滋病毒/艾滋病的流行是一个爆发点,它凸显了理论和模式的重要性或否定了理论和模式的相关性,与此同时,它也解决了文化在制定和实施传播计划中的重要性问题。

Introduction 导言

An effective communication strategy is a critical component of the global efforts in HIV/AIDS prevention and education. Such a strategy should be grounded in a sound theory such that the resulting framework is flexible enough for application in different regional and cultural contexts. Given the emphasis placed on HIV/AIDS prevention and care, mostly because of the absence of cure for or vaccination against the disease, employing effective communication strategies becomes pivotal in controlling the pandemic. Consequently, evaluating and redefining approaches to communicating relevant messages to different populations and the public at large has become a critical aspect of HIV/AIDS prevention and care. Since HIV/AIDS was first reported, broad-ranging strategies based on social psychological theories and models of behavior that are believed to be effective in guiding communication approaches to HIV/AIDS prevention and care have been introduced. These strategies range from a single universal approach to a multiple integrated approach in understanding health behaviors. After more than a decade of battle with this pandemic, there are now serious questions raised regarding the relevance of some of the most commonly used theories/models that guide communication strategies to prevent HIV/AIDS (Freimuth, 1992; Yoder, 1997) particularly in Africa, Asia, Latin America, and the Caribbean as well as their diaspora (Airhihenbuwa, 1995). These questions focus not so much on the value of the theories as such but on their adequacy, or lack thereof, in contexts different from those where they were initially developed and tested.
有效的传播战略是全球艾滋病毒/艾滋病预防和教育工作的重要组成部分。这种战略应当以合理的理论为基础,从而使由此产生的框架具有足够的灵活性,以适用 于不同的地区和文化背景。鉴于对艾滋病毒/艾滋病预防和护理的重视,主要是因为这种疾病没有治愈的方法或 疫苗采用有效的传播战略就成为控制这种流行病的关键。因此,评估和重新确定向不同人群和广大公众传播相关信息的方法已成为艾滋病 毒/艾滋病预防和护理工作的一个重要方面。自艾滋病毒/艾滋病首次被报道以来,基于社会心理学理论和行为模式的广泛战略被引入,这些理论和模式被认为可以有效地指导艾滋病毒/艾滋病预防和护理的传播方法。这些策略既有单一的通用方法,也有理解健康行为的多重综合方法。经过十多年与这一流行病的斗争,现在人们对一些最常用的指导预防艾滋病传播战略的理论/模式的相关性提出了严重的质疑(Freimuth,1992;Yoder,1997),特别是在非洲、亚洲、拉丁美洲和加勒比地区及其散居地(Airhihenbuwa,1995)。这些问题的重点并不在于理论本身的价值,而在于这些理论在不同于最初发展和检验这些理论的环境中是否适当或缺乏适当性。
A critical point in this debate about relevant health communication theories/ models is the recognition of culture as central to planning, implementation, and evaluation of health communication and health promotion programs in general (Airhihenbuwa, 1995; Edgar, Fitzpatrick, & Freimuth, 1992; Lupton, 1994) and HIV/AIDS prevention and care in particular (Airhihenbuwa, DiClemente, Wingood, & Lowe, 1992; Crawford, 1994; Michal-Johnson & Bowen, 1992; Schoepf, 1991; Seidel, 1993). In fact, designing a culturally relevant program and communicating messages in small groups are two critical factors reported to influence positively the outcome of 37 community-based HIV/AIDS prevention programs evaluated in the United States (Janz et al., 1996).
在这场有关健康传播理论/模式的争论中,一个关键点是人们认识到文化对于健康传播和健康促进计划的规划、实施和评估至关重要(Airhihenbuwa, 1995; Edgar, Fitzpatrick, & Freimuth, 1992; Lupton, 1994),特别是对于艾滋病的预防和护理至关重要(Airhihenbuwa, DiClemente, Wingood, & Lowe, 1992; Crawford, 1994; Michal-Johnson & Bowen, 1992; Schoepf, 1991; Seidel, 1993)。事实上,设计一个与文化相关的计划和在小组中传达信息是两个关键因素,据报道,这两个因素对美国评估的 37 个以社区为基础的艾滋病毒/艾滋病预防计划的结果产生了积极影响(Janz 等人,1996 年)。
It has long been known that every project implemented is guided by certain sets of assumptions, whether or not these assumptions are obvious to the interventionist, which are often discernible as theories and models designed to facilitate the implementation of a given project in a population. Very often, however, these theories and models are not evaluated for their relevance in project implementation. Thus much of communications research in HIV/AIDS tends to focus on theories "for" intervention rather than theories "of" interventions (Guttman, 1997a). Stated differently, commonly used communication strategies often attempt to fit implementation processes into the rules of a dominant theory or model in social psychology rather than allowing the field experience to shape its own framework. Moreover, the role of cultural contexts in successful implementation of programs often is omitted, even though evidence abounds that culture is a central feature in health behaviors and decisions particularly in the context of behaviors that may predispose people to HIV/AIDS (Airhihenbuwa et al., 1992; Crawford, 1994; Michal-Johnson & Bowen, 1992; Schoepf, 1991; Seidel, 1993). Consequently, it was inevitable that the integration of knowledge about the importance of communication strategies and the importance of culture in health behavior became a critical component of HIV/AIDS prevention and care in the new millennium.
众所周知,每一个项目的实施都以某些假设为指导,无论这些假设对干预者来说是否显而易见。然而,这些理论和模式在项目实施中的相关性往往没有得到评估。因此,艾滋病病毒/艾滋病传播研究的重点往往是 "促进 "干预的理论,而不是 "干 预 "的理论(Guttman, 1997a)。换句话说,常用的传播策略往往试图将实施过程纳入社会心理学的主流理论或模式的规则中,而不是让实地经验形成自己的框架。此外,文化背景在项目成功实施中的作用往往被忽略,尽管大量证据表明,文化是健康行为和决策的核心特征,尤其是在可能使人感染艾滋病毒/艾滋病的行为背景下(Airhihenbuwa 等人,1992;Crawford,1994;Michal-Johnson & Bowen,1992;Schoepf,1991;Seidel,1993)。因此,在新的千年里,将有关传播策略的重要性和健康行为中文化的重要性的知识结合起来,成为艾滋病预防和护理工作的一个重要组成部分是不可避免的。
In this paper, we discuss definitions and conceptions of commonly used theories/models in communicating HIV/AIDS messages and how these definitions/ conceptions often are offered through certain disciplinary and professional lenses that render adaptation in other contexts questionable at best. We examine strengths and weaknesses of commonly used social psychological theories as they pertain to individual actions and behaviors in relation to HIV/AIDS prevention and education. We discuss also the role of culture in HIV/AIDS by addressing contextual

aspects of culture rather than emphasizing only individual negative beliefs as is commonly the case. We argue that culture at the contextual level, rather than solely individual beliefs, must be located at the center of all health HIV/AIDS prevention efforts.

Theories and Models of Behavior Change

Models of behavior change typically used to guide health communication programs are the same ones used to inform health promotion programs. Some of the most important theories and models include the health belief model (HBM), the theory of reasoned action, social learning/cognitive theory, diffusion of innovation, and social marketing (Glanz & Rimer, 1995).
通常用于指导健康传播计划的行为改变模式与用于指导健康促进计划的模式相同。一些最重要的理论和模型包括健康信念模型(HBM)、合理行动理论、社会学习/认知理论、创新扩散和社会营销(Glanz & Rimer, 1995)。
The HBM (Becker, 1974) was developed in the 1950s to predict individual response to, and utilization of, screening and other preventive health services. Accordingly, the response and utilization of disease prevention programs will be predicated on an individual's perceived seriousness of the disease, severity of the disease, perceived benefit of services, and barriers to accessing such service:
健康管理(HBM)(Becker,1974 年)是 20 世纪 50 年代开发的,用于预测个人对筛查和其他预防保健服务的反应和利用情况。因此,疾病预防计划的响应和利用将取决于个人对疾病严重性的感知、疾病的严重程度、对服务益处的感知以及获得此类服务的障碍:
In general, the HBM is a rational-cognitive model and assumes a "rational" decision-maker. Most adolescents, and many adults, do not seem to approach the AIDS issue from such a logical perspective, but seem quite capable of discounting risks and optimistically perceiving themselves as invulnerable to harm. (Freimuth, 1992, p. 101)
一般来说,HBM 是一种理性认知模型,假定决策者是 "理性 "的。大多数青少年和许多成年人似乎并不是从这种逻辑角度来看待艾滋病问题的,他们似乎能够很好地降低风险,乐观地认为自己不会受到伤害。(Freimuth, 1992, 第 101 页)
The theory of reasoned action (Fishbein & Ajzen, 1975) predicts individual behavior by examining attitudes, beliefs, behavioral intentions, and the observed expressed acts. In this linear progression from attitude to action, a given behavior will be determined by an individual's intention. This theory also assumes that individuals are rational in their decision-making process, "a presumption that may not be entirely relevant for AIDS-related behaviors that are heavily influenced by emotions" (Michal-Johnson & Bowen, 1992, p. 153). Moreover, individuals evaluate information that may result in action within external constraints, which are mediated also by power relations in a society (Yoder, 1997).
理性行动理论(Fishbein & Ajzen,1975 年)通过研究态度、信念、行为意图和观察到的表达行为来预测个人行为。在这种从态度到行动的线性发展过程中,特定的行为将由个人的意图决定。这一理论还假定个人在决策过程中是理性的,"这一假定可能与受情绪影响较大的艾滋病相关行为并不完全相关"(Michal-Johnson & Bowen, 1992, p.153)。此外,个人会在外部约束条件下评估可能导致行动的信息,而外部约束条件也会受到社会权力关系的影响(Yoder,1997 年)。
The social learning/cognitive theory (Bandura, 1986) postulates that an individual behavior is the result of the interaction among cognition, behavior, environment, and physiology. The two primary domains widely used in HIV/AIDS programs are modeling (imitation of the behavior of a role model) and self-efficacy (one's perceived ability to adopt a recommended behavior). Although this model is believed to be very useful in HIV/AIDS communication campaigns in the United States (Freimuth, 1992; Maibach & Flora, 1993), there remains the question about its relevance in cultures where individual decisions are the result of group norms whereby being individualistic is going against the grain. After all, the social learning/ cognitive theory is an individual psychological model of behavior change (Yoder, Hornik, & Chirwa, 1996). Bandura (1998) advocates the need to focus on collective efficacy.
社会学习/认知理论(Bandura,1986 年)认为,个人行为是认知、行为、环境和生理相互作用的结果。在艾滋病毒/艾滋病项目中被广泛使用的两个主要领域是榜样(模仿榜样的行为)和自我效能感(一个人认为自己有能力采取建议的行为)。尽管这一模式被认为在美国的艾滋病传播活动中非常有用(Freimuth, 1992; Maibach & Flora, 1993),但在个人决定是群体规范结果的文化中,其相关性仍然是个问题,因为在这种文化中,个人主义是违背群体规范的。毕竟,社会学习/认知理论是一种改变行为的个体心理模式(Yoder, Hornik, & Chirwa, 1996)。班杜拉(1998 年)主张需要关注集体效能。
Diffusion of innovation (Rogers, 1983) focuses on the communication process by which a new idea or product becomes known and used by people in a given population. Two relevant principles of diffusion of innovation widely used in AIDS campaigns are creating awareness of HIV and using opinion leaders to influence
创新扩散(罗杰斯,1983 年)的重点是新思想或新产品为特定人群所了解和使用的传播过程。艾滋病宣传活动中广泛使用的创新扩散的两个相关原则是:提高人们对艾滋病病毒的认识和利用舆论领袖来影响他人。

attitudes and behaviors (Freimuth, 1992; Rogers 1983, 1995). "Diffusion of Innovation has been criticized for being too linear, for having a pro-innovation bias, and for widening the gaps between the 'information haves' and 'have-nots' in a social system. This gap has certainly been observed in AIDS awareness and knowledge" (Freimuth, 1992, p. 103), given the positive correlation between knowledge of HIV and level of education. In spite of its limitations, however, the use of opinion leaders in helping to shape culturally appropriate strategies is a component of diffusion of innovation that offers possibilities in HIV/AIDS communications. This is particularly salient since the content (focusing on a community interpretation of disease meaning rather than an imposed germ theory), context (relationships and negotiation in families and communities), and language (codes of elasticity of usage were relevant) of communication will be a factor in the outcome of HIV/AIDS prevention and care. According to Soola (1991) an "African communicator need not bother with the strictly technical aspects of information on AIDS (at least not for some of his audience) because of the non-beneficial effect of such information to a large majority of his audience" (p. 36). Indeed, Green (1999), based on his field work in Africa, has offered an African traditional healing theory of disease that is grounded in culturally defined codes and meaning.
态度和行为(Freimuth,1992 年;罗杰斯,1983 年,1995 年)。创新扩散 "被批评为过于线性,有支持创新的倾向,扩大了社会系统中 "信息拥有者 "和 "信息缺乏者 "之间的差距。鉴于艾滋病知识与受教育程度之间的正相关关系,这种差距在艾滋病意识和知识方面也得到了证实"(Freimuth,1992 年,第 103 页)。尽管有其局限性,但利用舆论领袖帮助制定文化上适当的策略,是创新传播的一个组成部分,为艾滋病传播提供了可能性。这一点尤为突出,因为传播的内容(侧重于社区对疾病含义的解释,而不是强加的病菌理论)、背景(家庭和社区中的关系和协商)和语言(与使用弹性相关的代码)将是影响艾滋病毒/艾滋病预防和护理结果的一个因素。Soola (1991)认为,"非洲的传播者不需要费心于艾滋病信息的严格技术层面(至少对 的某些受众不需要),因为这些信息对他的绝大多数受众是无益的"(第 36 页)。事实上,格林(1999 年)根据他在非洲的实地工作,提出了一种非洲传统的疾病治疗 理论,这种理论是以文化定义的代码和意义为基础的。
Social marketing is an organized approach to promoting acceptability of a social idea. Social marketing's four Ps-product, price, place, and promotion-have been applied extensively to HIV/AIDS prevention in condom promotion. A fifth has recently been added to indicate positioning with regards to recognition of competing campaigns on the same subject in the same location. Among the criticisms of social marketing in HIV/AIDS are ethical concerns (Guttman, 1997b), given that it sometimes utilizes manipulation, such as fear, in promoting condom use. "Fear appeals emphasize the noxious consequences that will befall message recipients if they fail to adopt the recommendations of the source" (Dillard, Plotnick, Godbold, Freimuth, & Edgar, 1996, p. 44). Furthermore, it is believed also that social marketing employs a simple solution (such as condom distribution) to a complex problem without addressing the social conditions that cause the spread of HIV (Freimuth, 1992). Social marketing targets individual behavior only, "consequently reducing public health issues to individual-level problems and defining solutions within 'information deficit' models" (Guttman, 1997a). "How AIDS is discussed, how resources are allocated, who are defined as in the 'risk groups,' and who makes the decisions about AIDS highlight the inseparable connection between AIDS and power in society" (McAllister, 1992, p. 196). With respect to the limitations of social marketing Smith's (1998) evaluation of social marketing indicates that product social marketing has been used widely and praised, whereas relatively little effort has gone into behavior social marketing (using social marketing to change and maintain behavior change) and almost nothing has been done in the area of policy social marketing (using social marketing to influence policy to support HIV research and protection of persons living with HIV/AIDS).
社会营销是一种有组织地促进人们接受社会理念的方法。社会营销的四个 P--产品、价格、地点和促销--已被广泛应用于安全套推广中的艾滋病毒/艾滋病预防。最近又增加了第五个 ,以表明在同一地点对同一主题的竞争性宣传活动的定位。对艾滋病社会营销的批评包括伦理方面的担忧(Guttman, 1997b),因为它有时会利用操纵手段,如恐惧,来推广安全套的使用。"恐惧诉求强调的是,如果信息接受者不采纳信息来源的建议,他们将面临恶果"(Dillard, Plotnick, Godbold, Freimuth, & Edgar, 1996, p.44)。此外,还有人认为,社会营销采用简单的解决方案(如发放安全套)来解决复杂的问题,却没有解决导致艾滋病传播的社会条件(Freimuth,1992 年)。社会营销只针对个人行为,"因此将公共卫生问题简化为个人层面的问题,并在'信息赤字'模式下确定解决方案"(Guttman, 1997a)。如何讨论艾滋病、如何分配资源、谁被定义为 "高危人群"、谁来决定艾滋病问题,这些都凸显了艾滋病与社会权力之间密不可分的联系"(McAllister, 1992, p.196)。关于社会营销的局限性,Smith(1998 年)对社会营销的评估表明,产品社会营销得到了广泛应用和赞誉,而在行为社会营销(利用社会营销来改变和维持行为改变)方面所做的努力相对较少,在政策社会营销(利用社会营销来影响政策,以支持艾滋病研究和保护艾滋病感染者)方面几乎毫无建树。
The health belief model and other models and theories with similar principles were designed to address health prevention from an individual, linear, and rational perspective. Although these theories and models have proven effective in certain societies for addressing certain diseases, they seem to be inadequate for communicating HIV/AIDS prevention and care messages in Africa, Asia, Latin America, and the Caribbean. In fact the assumptions (such as individualism as opposed to collectivism) on which these theories and models are based are foreign to many non-Western cultures where these models/theories have been used to guide commu-

nication strategies for HIV/AIDS prevention and care. "We should not expect these models to be productive in explaining behavior in social contexts where commonsense knowledge of the world takes a quite different form" (Yoder, 1997, p. 136).
艾滋病毒/艾滋病预防和护理的宣传策略。"我们不应该指望这些模式能够有效地解释社会环境中的行为,因为在这种环境中,人们对世界的常识性了解采取的是完全不同的形式"(Yoder, 1997, 第 136 页)。

Theories and Models Applied to HIV/AIDS Prevention Programs

Theories, models, or frameworks are designed to guide the implementation and evaluation of programs along certain processes that are believed to yield an expected outcome. Even though practitioners in the field implement programs without self-expressed pathways of models and theories, they are still guided by sets of assumptions that form the foundations on which the ideas, funding, and successful outcome evaluation of such projects are based. In evaluating the continuous reliance of health communication on social psychology, Lievrouw (1994) comments:
理论、模式或框架的目的是指导计划的实施和评估,使其遵循某些过程,并相信这些过程会产生预期的结果。尽管该领域的从业人员在实施计划时没有自我表达的模式和理论路径,但他们仍然受到一系列假设的指导,这些假设构成了这些项目的想法、资金和成功结果评估的基础。在评价健康传播对社会心理学的持续依赖时,Lievrouw(1994 年)评论道:

Abstract 摘要

While there is no doubt that the social-psychological theory "classics" are relevant to health communication and that they have been valuable exploratory tools, they nonetheless leave certain premises undisturbed. Chief among these is the presumption that communication in health is mostly a matter of interaction between institution message "sources" (e.g. medical research, professionals, government, foundations) and individual "receivers" (e.g. patients, their families, school children, employees). (P. 94)
毫无疑问,社会心理学理论的 "经典 "与卫生传播相关,而且是宝贵的探索工具,但它们仍保留了某些前提不受干扰。其中最主要的假设是,健康传播主要是机构信息 "来源"(如医学研究、专业人士、政府、基金会)和个人 "接收者"(如病人、家属、学生、雇员)之间的互动。(P. 94)

Moreover, these theories and models of health behavior change, such as social learning/cognitive theory and the hierarchy of effects, are based on individual psychology (Yoder, Hornik, & Chirwa, 1996) as opposed to family, group, or community locus of decisions. This application of individual and psychological models, in contexts where decision originates from group norms and processes, led Yoder et al. (1996) to question claims made by researchers regarding the program impact on behavioral outcomes from exposure to a radio drama on HIV/AIDS education in African countries.
此外,这些改变健康行为的理论和模式,如社会学习/认知理论和效应层次理论,都是基于个人心理学(Yoder、Hornik 和 Chirwa,1996 年),而不是家庭、群体或社区的决策中心。在决策源于群体规范和过程的情况下,这种个人和心理模型的应用导致 Yoder 等人(1996 年)质疑研究人员的说法,即在非洲国家,通过观看有关艾滋病毒/艾滋病教育的广播剧,节目对行为结果产生了影响。
Theories based on the individual, which may be effective and meaningful in a Western context, have lesser relevance in self-effacing cultures of Asia, Africa, Latin America, and the Caribbean. In these regions, family and community are more central to the construction of health and well-being than the individual, even though the individual is always recognized as an important part of the cultural context. In these cultures, individuals are less likely also to express themselves and less likely to articulate their level of well-being from the standpoint of "ego" (the "I"). It is the state of well-being of family and community that regulates how individuals measure their state of health. Moreover, theories and models based on measuring how the individual feels about himself or herself (e.g., "I feel good about myself") could never capture the health locus of control in many societies because such control rests somewhere outside the self. Within this self-effacing construct, individuals are not always accustomed to expressing their attitudes and beliefs by using extreme descriptors often found on social science survey instruments such as "strongly agree" or "strongly disagree." In fact, to do so within such a cultural context is considered disrespectful. Yet instruments designed to measure health behavior, for example, self-efficacy, often are presented on such a continuum of two extremes (strongly agree to strongly disagree) in cultures where such measures are not only irrelevant but could also be considered offensive. To capture the complexity of the
以个人为基础的理论在西方背景下可能是有效和有意义的,但在亚洲、非洲、拉丁美洲和加勒比地区的自我封闭文化中,其相关性较低。在这些地区,与个人相比,家庭和社区对健康和幸福的构建更为重要,尽管个人始终被认为是文化背景的重要组成部分。在这些文化中,个人不太可能表达自己,也不太可能从 "自我"("我")的角度来阐述自己的幸福程度。家庭和社区的幸福状况才是个人衡量其健康状况的标准。此外,基于衡量个人对自己的感觉(如 "我对自己感觉良好")的理论和模型永远无法捕捉到许多社会中的健康控制点,因为这种控制在自我之外的某个地方。在这种自我贬低的结构中,个人并不总是习惯于使用社会科学调查工具中常见的极端描述来表达自己的态度和信念,如 "非常同意 "或 "非常不同意"。事实上,在这种文化背景下这样做被认为是不尊重他人。然而,旨在测量健康行为的工具,例如自我效能感,在一些文化背景下,往往是在两个极端(非常同意到非常不同意)的连续体上呈现的,在这些文化背景下,这种测量方法不仅无关紧要,而且可能被认为是冒犯性的。为了捕捉

context within which an individual is a part, one needs a framework that underscores the component of context that features culture as a central and organizing theme (Airhihenbuwa, 1995; Sue, 1994).
因此,我们需要一个框架来强调以文化为核心和组织主题的背景要素(Airhihenbuwa, 1995; Sue, 1994)。
The professional and cultural partiality of the Westernized approach to the understanding of self renders problematic findings from much social and behavioral science research in Africa, Asia, Latin American, and the Caribbean. For example, one can appreciate differences between individual-centered versus family- and community-centered cultures by examining cultural differences in daily salutations. Greetings such as, "How are you doing today?" may elicit a range of self-assured responses that captures how a Westerner actually feels on a given day-from "I'm well" to "Great" and "Wonderful." The same greeting among the Yorubas or Edos of Nigeria almost never elicits a state of being "Great" or "Wonderful" even if this is how the individual feels. Instead, a common, nondefinite response is "O.K.," "Fine," or "We give thanks to the Almighty." Furthermore, such a response is consistent with cultural values and meanings that promote and reward a tempered expression about one's well-being.
在理解自我方面,西方化的方法在专业和文化上的偏颇使得非洲、亚洲、拉丁美洲和加勒比地区的许多社会和行为科学研究结果都存在问题。例如,我们可以通过研究日常问候语的文化差异来了解以个人为中心的文化与以家庭和社区为中心的文化之间的差异。诸如 "你今天好吗?"这样的问候语可能会引起一系列自我肯定的回答,从而反映出西方人在某一天的实际感受--从 "我很好 "到 "太好了 "和 "太棒了"。在尼日利亚的约鲁巴人或埃多斯人中,同样的问候语几乎不会引出 "好极了 "或 "太棒了 "的状态,即使这就是个人的感觉。取而代之的是 "好的"、"很好 "或 "我们感谢万能的主 "等常见的非限定性回答。此外,这样的回答也符合文化价值观和意义,即促进和奖励对个人福祉进行有节制的表达。
The corpus of social psychology is based on the behaviors of people in Western cultures (Triandis, 1994). According to Triandis (1994), culture is the man-made part of the environment; therefore, culture is a group's attempt to control its environment. Thus the relationship between the individual and her or his environment is unidirectional with the individual always shaping the environment and never the reverse. As a result, measures of skill acquisition and self-determination are based on the individual's perception of his or her ability to control his or her environment. Thus controlling one's environment is a central theme in Western conceptions of culture-a conception that eschews other cultural realities such as harmonizing with nature or adapting to one's environment or both. If controlling the environment is the raison d'être of cultures, then the inability to control one's environment suggests retrogression, a barrier to be overcome. Hence, "cultural barriers" (never cultural strength) become a common expression in this discourse.
社会心理学的研究对象是西方文化中人们的行为(Triandis,1994 年)。Triandis (1994)认为,文化是环境的人造部分;因此,文化是一个群体控制其环境的尝试。因此,个人与其环境之间的关系是单向的,个人总是塑造环境,而不是相反。因此,技能习得和自我决定的衡量标准是基于个人对其控制环境能力的认识。因此,控制自身环境是西方文化概念的核心主题--这种概念忽略了其他文化现实,如与自然和谐相处或适应自身环境,或两者兼而有之。如果控制环境是文化存在的理由,那么无法控制自己的环境就意味着倒退,意味着需要克服的障碍。因此,"文化障碍"(从来都不是文化力量)成了这一论述中的常见表述。
Applied to health communication, limitations easily become self-evident. For example, the cultural complexities of adhering to media messages about sexually transmitted diseases (STDs) are seldom interrogated. The call for sexual negotiation at the point of initial contact between two people who are about to begin sexual relations contradicts most culturally sanctioned behavior. Two people who are about to begin sexual relations typically avoid discussing their sexual past until they are more comfortable with each other at which point sexual intercourse commonly has occurred (Pliskin, 1997). In this case sexual behavior precedes sexual knowledge, at least in the context of relationship, which is often the basis for most interventions on preventing HIV/AIDS. This reality of "behavior first" renders the linear model of knowledge leading to attitude and behavior counterintuitive in the context of relationships and culture.
应用到健康传播中,其局限性不言而喻。例如,人们很少去探究遵守媒体关于性传播疾病(STDs)信息的文化复杂性。即将开始性关系的两个人在初次接触时就要求进行性协商,这与大多数文化认可的行为相悖。即将开始性关系的两个人通常会避免讨论他们的性过去,直到他们彼此更加熟悉,此时通常已经发生了性关系(Pliskin,1997 年)。在这种情况下,性行为先于性知识,至少在关系中是这样,而这往往是大多数预防艾滋病干预措施的基础。这种 "行为先行 "的现实使知识导致态度和行为的线性模式在人际关系和文化背景下变得反直觉。

Cultural Contexts and HIV/AIDS

Culture, often appropriated as an exotic collective, is believed by many to exist only in Africa, Asia, and Latin America and in their descendants in the diaspora. According to Yoder (1997), beliefs are used often as a proxy for culture, such that beliefs and knowledge of illness become the focus of "culturally appropriate" messages and interventions. In fact, the term belief is often contrasted with knowledge such that "belief is used to connote ideas that are erroneous from the perspective of bio-
许多人认为,文化只存在于非洲、亚洲和拉丁美洲,以及他们散居各地的后代中。Yoder (1997)认为,信仰经常被用作文化的代名词,因此有关疾病的信仰和知识成为 "文化适宜 "信息和干预措施的重点。事实上,"信念 "一词经常与 "知识 "形成对比,"信念 "被用来表示从生物角度来看是错误的观念。

medicine and that constitute obstacles to appropriate behavior" (Pelto & Pelto, 1997, p. 148). Therefore, when "culture" and "belief" are coupled as in cultural belief, the resulting negative biomedical appropriation of the term becomes evident. As a consequence, culture is objectified and believed to be possessed by nonWestern people, only identifiable through research. An example of this is found "in health education campaigns that seek information about local idioms of expression to better communicate health messages" (Yoder, 1997, p. 138). As a result, it is reasoned that individual practices or behaviors found in these groups could be labeled cultural and often appropriated as a barrier. Thus "barrier" often becomes the coupling metaphor with culture.
医学和适当行为的障碍"(Pelto & Pelto, 1997, p.148)。因此,当 "文化 "和 "信仰 "像文化信仰一样结合在一起时,由此产生的对该术语的负面生物医学挪用就显而易见了。因此,文化被客观化,并被认为是由非西方人拥有的,只有通过研究才能识别。这方面的一个例子是 "在健康教育活动中,为了更好地传达健康信息,人们会寻求有关当地表达习惯的信息"(Yoder, 1997, p.138)。因此,在这些群体中发现的个人做法或行为可以被贴上文化标签,并经常被视为一种障碍。因此,"障碍 "常常成为文化的耦合隐喻。
There are three major themes that characterize perceptions about these notions of culture. First, culture is a fossilized historical artifact, which leads to such definitions as "culture is to a society what memory is to individual" (Kluckhohn, 1954). Second, culture is the observable aspect of individual behavior that is understood better by locating behaviors (particularly those that are unfamiliar) within individual beliefs. Such beliefs are distinguished from knowledge since the Knowledge Attitude Practice Behavior (KAPB) model places these domains in separate locations on a parallel continuum. In fact, belief and knowledge are thus constructed as a binarism and belief invariably becomes a code for culture (Good, 1994), a barrier that must be overcome. For example, if you learned from your grandmother that chicken soup is good for your common cold, it is a "cultural belief." However, if you were to learn the same health information from a physician, it is "knowledge." A third theme is that culture is people's ability to control/dominate their environment. Thus the onus of responsibility for adopting requisite behavior rests in the individual. The assumption is that everyone desires to, and is capable of, changing their environment to suit their needs. Each of these domains is an aspect of culture.
关于这些文化概念,有三大主题。首先,文化是历史的化石,这就产生了 "文化之于社会,就如同记忆之于个人"(Kluckhohn,1954)这样的定义。其次,文化是个人行为中可观察到的方面,通过将行为(尤其是那些不熟悉的行为)置于个人信仰中可以更好地理解文化。这种信念与知识是有区别的,因为知识态度实践行为(KAPB)模型将这两个领域置于平行连续体上的不同位置。事实上,信念和知识是二元对立的,信念总是成为文化的代码(Good,1994 年),是必须克服的障碍。例如,如果你从祖母那里得知鸡汤对普通感冒有好处,这就是一种 "文化信仰"。但是,如果你从医生那里了解到同样的健康信息,那就是 "知识"。第三个主题是,文化是人们控制/支配环境的能力。因此,采取必要行为的责任在于个人。我们的假设是,每个人都希望并有能力改变自己的环境,以适应自己的需要。上述每个领域都是文化的一个方面。
In the view of some scholars, culture is what society evolves from in the process of development-a proxy for modernization. Modernization and culture are located often at two opposite ends of the spectrum. Given this impoverished notion of culture, "it seems urgent that we concentrate on studies of the distribution of meaning in social space, and on searching social sources of diversity and heterogeneity rather than focusing exclusively on cultural sharing, uniformity, and homogeneity" (Bibeau, 1997, p. 248).
一些学者认为,文化是社会在发展过程中演变而来的,是现代化的代表。现代化与文化往往处于光谱的两端。鉴于这种贫乏的文化概念,"我们似乎亟需集中精力研究社会空间中的意义分配,寻找多样性和异质性的社会来源,而不是仅仅关注文化的共享性、统一性和同质性"(Bibeau, 1997, p.248)。
Western cultures, to varying degrees, tend to view the self as a production of the individual, whereas many other cultures view the self as a production of the family, community, and other environmental influences for which we do not have, nor desire, total control. Crawford believes "the heart of the cultural politics of AIDS is a contestation over the meaning of the self" (p. 1347). A large part of this contestation involves the definition and construction of people with AIDS and those who have tested positive for HIV as "other." In its most basic sense, health is associated with those who are not infected with HIV and illness with those who are infected with HIV. "The identity signified by HIV/AIDS comes to be seen as the other who is perceived not only as a physical danger, but as an equally threatening and dangerous identity" (p. 1348).
西方文化在不同程度上倾向于将自我视为个人的产物,而许多其他文化则将自我视为家庭、社区和其他环境影响的产物,我们无法也不希望完全控制这些影响。克劳福德认为 "艾滋病文化政治的核心是对自我意义的争论"(第 1347 页)。这种争论的很大一部分涉及到将艾滋病患者和艾滋病毒检测呈阳性的人定义为 "他者",并将他们建构为 "他者"。从最基本的意义上讲,健康与未感染 HIV 的人相关联,而疾病与感染 HIV 的人相关联。艾滋病毒/艾滋病所代表的身份被视为 "他者",不仅被视为身体上的危险,而且被视为同样具有威胁性和危险性的身份"(第 1348 页)。
The cultural politics of AIDS has caused the mobilization of many of these facets of culture with varying degrees of success. The mobilization of ethnographers to study these same risk groups has served a reductive function in terms of how culture is understood and conceptualized. "Despite their intention to break with the dominant public health models, most anthropologists are not really willing to distance themselves from the methodology and theorizing of what is perceived as 'real'

science in public health" (Bibeau, 1997, p. 247). This problem is evident in the tendency to create epidemiological categories, thus reducing culture to identifications of negative individual health practices in a subgroup of the population later generalized to be the definition of the larger group's culture.
Bibeau, 1997, p.247)。这一问题明显地表现在创建流行病学类别的倾向上,从而将文化简化为对人口中某一亚群体的消极个人健康行为的识别,然后再将其泛化为更大群体的文化定义。
In the literature dealing with cultural sensitivity, it is rare to see "strength" coupled with the concept of culture, although "cultural barrier" is commonly cited as a reason for failure in public health and health promotion and communications programs. For instance, some health communication and health promotion programs implemented in Africa have tended to undervalue the importance of oral communication as a genre. This practice is consistent with the academics' exaltation of written and visual modes of communication (slides and transparencies) as the only acceptable standard. For example, traditional communication channels, which Ugboaja (1987) terms 'Oramedia,' continue to maintain their potency in rural Africa (Soola, 1991).
在涉及文化敏感性的文献中,很少看到 "力量 "与文化概念的结合,尽管 "文化障 碍 "通常被认为是公共卫生和健康促进与传播计划失败的原因。例如,在非洲实施的一些健康传播和健康促进计划往往低估了口语传播作为一种体裁的重要性。这种做法与学术界将书面和视觉传播方式(幻灯片和透明胶片)作为唯一可接受的标准是一致的。例如,Ugboaja(1987 年)称之为 "Oramedia "的传统传播渠道在非洲农村地区继续发挥着作用(Soola,1991 年)。
We do believe and do advocate, as have others, that cultural sensitivity be central to health communication and health promotion theory and practice. This position is evident in cultural models such as PEN-3 (Airhihenbuwa, 1995), a model used in health promotion and disease prevention (Erwin & Spatz, 1996; Green & Kreuter, 1999 ; Kline, 1999 ; Paskett et al., 1999). In this model, cultural appropriateness in health promotion refers not only to the individual but also to the context that nurtures the individual and his or her family and community. This context is evaluated for attributes that are positive, existential, and negative. It is important to promote the positive, recognize and affirm the existential, and contextualize the negative, such that opportunity costs and benefits for change are understood and appreciated. With regard to communication strategies for HIV prevention within the African context, for example, message segmentation is critical to reaching a population with a diverse mode of producing and acquiring information and knowledge:
与其他人一样,我们确实相信并倡导将文化敏感性作为健康传播和健康促进理论与实践的核心。这一立场在 PEN-3 (Airhihenbuwa, 1995)等文化模型中显而易见,PEN-3 是一种用于健康促进和疾病预防的模型(Erwin & Spatz, 1996; Green & Kreuter, 1999; Kline, 1999; Paskett et al.)在这一模式中,健康促进中的文化适宜性不仅指个人,也指培养个人及其家庭和社区的环境。对这种环境的评估包括积极的、存在的和消极的属性。重要的是要宣传积极的方面,承认和肯定存在的方面,并将消极的方面与环境联系起来,从而使人们理解和认识到变革的机会成本和收益。例如,关于在非洲范围内预防艾滋病毒的传播战略,信息的细分对于接触到以不同 方式产生和获取信息和知识的人口至关重要:
In traditional societies, which most African societies are, the need for audience, message, and channel segmentation is important, considering the reach and influence of the different channels of communication and the absorptive capacity of the different segments of the population. (Soola, 1991, p. 35)
在传统社会(大多数非洲社会都是如此)中,考虑到不同传播渠道的覆盖面和影响力,以及不同人群的吸收能力,对受众、信息和渠道进行细分是非常重要的。(苏拉,1991 年,第 35 页)

Conclusion 结论

This examination of theories and models commonly used in health communication and promotion clearly shows that HIV/AIDS communication often is based on the behavior and decision-making process of so-called rational individuals who follow an established linear path from awareness to attitude to action. However, decisions about preventing HIV/AIDS are based on cultural norms that often mediate individual decisions in ways that individuals may not always realize. Moreover, decisions about HIV/AIDS often are based on emotion and thus may not follow any preestablished pattern of decision making advanced in most of the theories and models.
In an extensive review of the literature on theories and AIDS campaigns, Freimuth (1992) concluded that knowledge is not a sufficient condition for behavior
Freimuth (1992) 对有关理论和艾滋病宣传活动的文献进行了广泛的回顾,得出结论认为,知识并不是行为的充分条件。

change. "Our analysis of survey data rarely [emphasis ours] found a close correspondence between changes in knowledge and changes in behavior" (Yoder, 1997, p. 132). Most theories offer approaches to initiating behavior change but do not address maintainance of the new changed behavior. Campaign planners need a greater understanding of their "target audience," which often belongs to a culture and a social class different from theirs. Since the target population often is at a greater disadvantage relative to the priviledged location of professional researchers' income and level of education, the interventionist must be cautious about the imposition of foreign values on a group of people (Jaccard, Turrisi, & Wan, 1990).
变化。"我们对调查数据的分析很少[强调是我们的]发现知识的改变与行为的改变之间存在密切的对应关系"(Yoder,1997 年,第 132 页)。大多数理论都提供了启动行为改变的方法,但并没有解决维持新改变的行为的问题。活动策划者需要进一步了解他们的 "目标受众",这些受众往往属于不同于他们的文化和社会阶层。与专业研究人员的收入和教育水平相比,目标人群往往处于更为不利的地位,因此,干预者必须谨慎对待将外来价值观强加给一群人的做法(Jaccard, Turrisi, & Wan, 1990)。
Cognizance must be paid also to the complementary forces of endogenous (within) and exogenous (outside) influences in setting the media agenda (Dearing and Rogers, 1992). Most theories used to inform campaign strategies do not include culture as a central concept. When they do, culture is treated as a "set of beliefs, values, and individual goals that pattern behavior" (Yoder, 1997, p. 135). Culture should become a pivotal domain in the new era of HIV/AIDS prevention and care. "Culture should be a central organizing concept in developing programs of HIV education and assessing their outcomes" (Michal-Johnson and Bowen, 1992, p. 148). By culture we mean drawing from the potentiating possibilities of a hybrid of traditional and modern culture. In the context of community development, Escobar (1995) argues that no longer should we focus on futile attempts at becoming modern by substituting the traditional but rather on a "hybrid modernity characterized by continuous attempts at renovation, by a multiplicity of groups taking the multitemporal heterogeneity peculiar to each sector and country" (p. 218). In Escobar's view, "traditional cultures" do not have to succumb to notions of "development" and "modernity" but engage them in a constant relationship whereby the resulting hybrid communities can emerge with possibilities for improving conditions of life, whether it is HIV/AIDS prevention or community development.
在制定媒体议程时,还必须注意内源(内部)和外源(外部)影响的互补作用(Dearing and Rogers, 1992)。大多数用于指导竞选策略的理论都没有将文化作为核心概念。当这些理论将文化作为核心概念时,文化就被视为 "一系列信念、价值观和个人目标,它们是行为的模式"(Yoder, 1997, p.135)。在艾滋病防治的新时代,文化应该成为一个关键领域。"在制定艾滋病教育计划和评估其成果时,文化应成为一个核心的组织概念"(Michal-Johnson 和 Bowen,1992 年,第 148 页)。我们所说的文化,是指从传统文化和现代文化的混合体中汲取潜在的可能性。在社区发展方面,Escobar(1995 年)认为,我们不应再徒劳地试图用传统文化来取代现 代文化,而应着眼于 "混合现代性,其特点是不断尝试革新,由多个团体利用每个部门和 国家特有的多时异质性"(第 218 页)。埃斯科瓦尔认为,"传统文化 "不必屈服于 "发展 "和 "现代性 "的概念,而是要与它们建立一种持续的关系,从而使由此产生的混合社区有可能改善生活条件,无论是艾滋病毒/艾滋病预防还是社区发展。
With new challenges, such as a false sense of security generated by the prospect of a cure and hope for vaccine in the global efforts to control HIV/AIDS, it becomes even more critical that we pay serious attention to contextual rather than individual theories and models that inform HIV prevention messages. Moreover, it is pivotal to understand the centrality of cultural contexts, rather than simply individual beliefs, in planning communication strategies. In the final analysis, media are a part of our culture (Bird, 1996) and even more so in the definition and construction of what is considered to be media, which includes folklore, storytelling, and the many nonstructural but established oral channels for transmission and confirmation of messages within communities. As we begin this new millennium, a new global communication strategy is timely. Such strategy should locate culture within a theoretical framework that will allow the flexibility for regional and national differences in communicating HIV/AIDS prevention and care messages.
随着新挑战的出现,例如在全球控制艾滋病毒/艾滋病的努力中,治愈的前景和疫苗 的希望所产生的虚假安全感,我们更加需要认真关注为艾滋病毒预防信息提供信息的 背景,而不是个别的理论和模式。此外,在规划传播战略时,理解文化背景而不仅仅是个人信仰的中心地位也是至关重要的。归根结底,媒体是我们文化的一部分(Bird, 1996),在定义和构建媒体时更是如此,这包括民间传说、讲故事和许多非结构性的、但在社区内传播和确认信息的既定口头渠道。新千年伊始,制定新的全球传播战略正当其时。这种战略应将文化置于一个理论框架内,以便在传播艾滋病毒/艾滋病预防和护理信息时灵活地考虑地区和国家的差异。

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  1. Address correspondence to Dr. C. O. Airhihenbuwa, Associate Professor, Department of Biobehavioral Health, College of Health and Human Development, The Pennsylvania State University, One White Building, University Park, PA 16802, USA. E-mail: aou@psu.edu
    通讯地址:C. O. Airhihenbuwa 博士,宾夕法尼亚州立大学健康与人类发展学院生物行为健康系副教授,地址:One White Building, University Park, PA 16802, USA。电子邮件:aou@psu.edu
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