Intention-Behavior Gaps in HIV Care

Last week at the bi-annual Ryan White Program Conference on HIV Care and Treatment, HIV care providers from across the country heard from the U.S. Secretary for Health and Human Services (DHHS), the head of the Health Resources and Services Administration (HRSA), and the head of the National Institute for Allergy and Infectious Diseases at NIH. These experts highlighted a central fact of the HIV epidemic, which is that it has for the past 20 years been as much a result of gaps between intention and behavior as it has been a medical crisis. The HIV treatment cascade shown here illustrates the patient behaviors needed to successfully manage this chronic disease. First, people at risk for HIV can avoid infection through appropriate prevention behaviors, like using condoms or taking pre-exposure prophylaxis (PrEP) medications. Once people are infected with HIV, they need to be tested in order to initate treatment. Then they must be linked to the care system, a barrier for younger people who may never have been involved with routine health care for a chronic condition. Once engaged in care, they must remain in care over time, and in order to gain the benefits of treatment they must stay adherent to medication. Each of these steps in the treatment cascade is one where patients' intentions may not match their behaviors, resulting in unnecessary health problems, gaps in care, or even treatment failure. Successfully supporting patients with each of these behaviors also requires health care practitioners to change behaviors, such as always testing for HIV or following up intensively when patients miss an appointment. Behavior change is a key to successful treatment in HIV and other chronic diseases.

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Prototypes and Willingness: The Theory of Planned Behavior Revisited

You may recall my blog post from last year on the Theory of Planned Behavior (TPB) , titled "in praise of a failed model." My evaluation of this model was that it accurately describes the Narrative Mind, which does control intentions. But the ultimate goal of the TPB is to predict behavior, and the relationship between intentions and behavior is weak at best -- in fact, it is entirely attributable to the fact that when someone says they don't intend to do something, they probably won't do it. When they say they do intend to do it, their actual results are no better than chance, a result of the intention-behavior gap as described in Two Minds Theory. The full TPB is shown in this diagram: Cognitive constructs like attitudes, subjective norms, and perceived behavioral control (i.e., self-efficacy) are Narrative-system phenomena, and they do indeed have relationships with each other and with intentions (which are also products of the Narrative Mind). Perceived behavi...

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Inside the Intuitive Mind: Social Support Can Facilitate or Inhibit Behavior Change

This week I'm looking at another concrete tool in the behavior-change armamentarium, social support . I have written previously about the Narrative mind's strong focus on social cues , and indeed perhaps the Narrative system evolved specifically to help us coordinate our behavior with groups of other humans. As a behavior-change strategy, social support can be used in several different ways. Instrumental Social Support . The most basic form of social support is instrumental, the type of help that a neighbor gives in loaning you a tool or that a friend provides in bringing you a meal. This type of concrete support can be helpful for diet change -- e.g., here are some fresh vegetables from my garden -- or exercise -- e.g., you can borrow my tent for your camping trip. Although instrumental support is particularly powerful because someone is actually doing something for you or giving you resources that you don't have, it is also usually short-term (I probably don't want...

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