Introduction

The challenges of HIV prevention, particularly amongst ‘hard-to-reach’ groups in marginalised settings, has highlighted the urgent need for theoretical renewal in the field of the psychology of health promotion. This is particularly the case in relation to understanding how social factors impact on the possibility of health-promoting behaviour change. Psychologists have traditionally sought to explain health-related behaviour in terms of individual-level psychological constructs, usually within the ‘social cognition’ tradition (Conner and Norman, 1995). Within this tradition, behaviour is explained in terms of properties of the individual, such as individual cognitions, behavioural intentions and behavioural skills. Accordingly, first generation HIV-prevention programmes sought to promote sexual behaviour change at the individual level, through providing people with knowledge about sexual health risks, and training them in the behavioural skills necessary for the performance of new behaviours.

However, one study after another has highlighted that people often have unprotected sex with multiple partners despite having the necessary knowledge and skills to protect themselves. In her review of HIV-prevention programmes in a range of low income countries, Gillies (1998) concludes that individual-level approaches are unlikely to change the behaviour of more than one in four people, generally the more affluent and educated. This is because health related behaviours are determined not only by conscious rational choice by skilled and knowledgeable individuals, but also by the extent to which community and societal contexts enable and support the performance of such behaviours (see also: d'Cruz-Grote, 1996; Sumartojo, 2000).