**2. Theoretical framework**

Following prior research on stigma in relation to HIV/AIDS (Mbonu, Van Den Borne & De Vries, 2009), using an inductive approach from an extensive literature review in Sub-Saharan Africa, we adapted the Precede portion of the Precede-Proceed model (Green & Kreuter, 1999) as an explanatory model. The PRECEDE-PROCEED model provides a systematic approach for assessing quality-of-life of health and for designing, implementing, and evaluating health education and health promotion programs. PRECEDE includes five phases. In phase 1, quality of life or social problems and needs of a population are identified. Phase 2 includes an epidemiological analysis in which the relevant health problems are identified. Phase 3 involves an analysis of the behavioral and environmental determinants of a key health problem. In the fourth phase, the factors that predispose (beliefs, knowledge, self-efficacy, social norms, etc.), reinforce (e.g. social support), and enable (facilities etc.) the health behavior, are identified. In phase 5, the focus is on the development of a health education or health promotion intervention that would encourage desired behavior change, changes in the environment, and changes in the determinants of behavior and environmental factors. PROCEED includes an implementation phase, an intervention process evaluation, impact evaluation of changes in behavior or environment, and an outcome evaluation in which the impact on health and quality of life is assessed (Green & Kreuter, 1999). Since models are constantly modified to fit the situation (Chiang et al., 2003), we specified the model to the health care-seeking behaviour among PLWHA and used it to analyse people's coping strategies in dealing with stigma-related problems (Mbonu et al., 2009). The model proposes that a complex health problem, such as careseeking behaviour of PLWHA, is a function of various factors; and these factors have to be considered from a wider perspective of the social structural context.

The first component of the explanatory model is the analysis of the problem – that is, careseeking behaviour of PLWHA and how stigma influences it (see [a] in Figure 1) and how it may have an impact on the socio-structural context within which PLWHA, society and healthcare professionals are embedded. The second component of the model involves identifying the predisposing, reinforcing and enabling factors. The predisposing factors are represented as variables such as beliefs, knowledge about HIV transmission and selfefficacy. Reinforcing and enabling factors are represented as moderating variables, such as poverty, gender, age, religion and policy and how stigma may impact on the variables that determine individuals' care-seeking behaviour. The model finally specifies different coping strategies (coping with self, coping directed at others and comparison with others, coping with solving the problems of HIV/AIDS) that can lead to various care-seeking choices, such as inappropriate self-care, inconsistent use of biochemical care or use of traditional healers and faith houses, which may result in non-utilisation of healthcare institutions. In our explanatory model, non-utilisation of healthcare institutions is the outcome variable (see [n] in Figure 1).

In this study, while the interview was left open for interviewees to express a variety of issues, thoughts and feelings with respect to stigma and other concepts, we use the explanatory model as a general framework for identifying relevant categories of variables.

Fig. 1. Explanatory model of role of stigma in care-seeking behaviour. Mbonu, Van den Borne, & De Vries, 2009
