Theory and evidence play an important role in the process of intervention design. This process roughly includes four phases: diagnosis, development, implementation and evaluation.

In the diagnosis phase, health promoters start with a needs assessment in which they identify and analyse target populations, their social and health problems, and their needs and capabilities. Needs assessments are theory- and evidence-based, usually rely on epidemiology, sociology and psychology, and use a variety of research methodologies. A tenet of needs assessments is a close collaboration between planners, target populations and intermediaries.

In the development phase, planners define objectives for their interventions on the basis of their needs assessment. Subsequently, they identify theory-based strategies to accomplish these objectives, and combine these strategies into an intervention programme. Planners guide the production process, and conduct small-scale pilots of programme components. Again, they collaborate with target groups, decision-makers and stakeholders to identify the optimal intervention for a particular problem, target population and intervention context.

In the implementation phase, health promoters plan and design a strategy to facilitate the dissemination and implementation of their intervention. Again, close collaboration with programme users and stakeholders is crucial.

In the evaluation phase, health promoters evaluate the implementation of their programmes, and the success of the programme in accomplishing the objectives defined.

The importance of theory- and evidence-based stigma interventions

Theory and scientific evidence play an important role in health promotion for a number of reasons. First, AIDS stigma is a complex phenomenon involving different cognitive, emotional and behavioural aspects. Without a theory- and evidence-based understanding of these aspects, we lack the insight in what should change to reduce AIDS stigma. Second, theory-based interventions are more likely to be effective as they provide an insight in the working mechanisms and effectiveness of stigma intervention components. Third, pilots of intervention materials among the target group and implementers – especially on sensitive and difficult topics like AIDS stigma – are essential for designing interventions before disseminating them.

Understanding AIDS-related stigmatisation

Several factors influence stigmatisation of PLWHA. First, perceived contagiousness of HIV is related to fear and stigmatisation. Although HIV/AIDS is not contagious in everyday contact, many people respond with fear and social rejection. A second factor is perceived seriousness: people also respond negatively to PLWHA because of the life-threatening nature of the disease and its association with death. Thirdly, people tend to respond with less pity, stronger anger and more stigmatisation towards PLWHA who are held personally responsible for the onset of the disease, e.g., due to unsafe sexual behaviour. Fourth, when people attribute HIV infection to norm-violating behaviour (for example, homosexual intercourse), they tend to react with negative emotions and stigmatisation.

Currently, research on determinants of AIDS stigma is lacking in developing countries, but urgently needed to find essential elements of stigma-reducing interventions. A notable exception is the research conducted by the International Center for Research on Women (ICRW) together with in-country research partners in Ethiopia, Tanzania and Zambia. This research project called "disentangling HIV and AIDS stigma" provides important information about causes of AIDS stigma in developing countries, as described by Laura Nyblade in this issue.

What can we learn from theory about stigma reduction?

Social psychological insights on changing attitudes are extremely useful in trying to reduce AIDS stigma. Research on changing stereotypes has shown that conscious suppression of stereotypes is extremely difficult and that suppressed stereotypes may become even more accessible. Exposure to stereotype-inconsistent information is a more promising way. Stereotype-inconsistent information challenges stereotypes by presenting examples or individuals that have different characteristics than assumed by the public on the basis of the existing stereotype.

However, one should be careful that the stereotype-inconsistent individual is not regarded as an exception to the group. Therefore, stereotype-inconsistent characteristics should be present among a large number of PLWHAs. Furthermore, new information disconfirming stereotypes should not differ too much from people's pre-existing stereotypes.

Another important research area is the impact of personal contact with members of stigmatised groups on attitudes. The so-called contact hypothesis proposes that under certain circumstances interpersonal contact between members of different groups can be a useful tool to reduce prejudice and combat stigmatisation. Similarly, creating empathy for a stigmatised individual seems another promising way to improve inter-group attitudes.

In 2001, a review was published on the impact of AIDS stigma-reducing interventions.¹ Only a limited number of AIDS stigma interventions has been evaluated, and most only investigated short-term effects. The limited number of published articles on AIDS stigma interventions suggest that unpublished stigma interventions were not effective. Nevertheless, the review provides some interesting suggestions for future programmes. Most reviewed studies show that information together with skills building is more effective than information alone. Furthermore, personal contact with PLWHA, combined with information about the disease, is one of the most promising approaches.

The ICRW-led research mentioned before reveals five important guidelines for AIDS stigma interventions in developing countries. First, interventions should create greater recognition about stigma and discrimination. People should become aware that stigma exists, that it can take certain forms, that it is harmful, and that each person can contribute to reducing stigma. Second, programmes should provide in-depth knowledge about all aspects of HIV and AIDS. Third, AIDS stigma interventions tackle difficult issues that are often taboo. Therefore, programmes should provide safe spaces to discuss stigma-related values and beliefs. Fourth, interventions should use the language of the target population. This can be accomplished through participation of the target population in intervention development and pretests. Fifth, PLWHA should be involved as they have personal experience and knowledge needed to design appropriate AIDS stigma interventions.

AIDS stigma in developing countries is a complex phenomenon, closely related to ingrained values and beliefs. The best approach to tackle AIDS stigma in developing countries are theory- and evidence-based interventions that are developed in close collaboration between programme developers, stigma researchers, PLWHA and implementers. Evaluation is vital for identifying effective elements for future stigma interventions.