Comprehensive Intervention among Long-distance Truck Drivers and Waitress of Roadside Inns in Datong City

——Datong Health Bureau Office of Health Project Supported by World Bank, Datong City, Shanxi Province

Starting from December 2003, Datong City, Shanxi Province launched the “Behavioral Intervention among Long-distance Coal Truck Drivers for the prevention of AIDS and STIs and 100% Use of Condom in Roadside inn Program in Datong City”. Intervention plan was determined based on the baseline survey (in qualitative or quantitative) according to the features of target population (long-distance truck drivers and roadside inn waitress), for the purpose of disseminating knowledge on the prevention of AIDS and STIs among the target population and carrying out interventions in high-risk behaviors. Ever since the program was implemented one year ago, interventions in various forms have obtained sound effect, and have played an important role in preventing and controlling the prevalence of AIDS and STIs in Datong City.

——Editor

1. Background

Datong is located in a triangular area bordering Shanxi, Hebei and Inner Mongolia. Datong is the energy chemical base in Shanxi Province, which has 431 coal mines. The number of Long-distance truck drivers in Datong is more than 30, 000.

In view of the fact that long-distance truck drivers are on the road for the most of time in the year, inns along the highways began to recruit waitress for the purpose of providing sex services to some drivers. As long-distance truck drivers and waitress of inns around the roads are far away from urban areas, it is very difficult to incorporate them into the community life. Furthermore, the educational level of these waitresses is normally very low, and there is a lack of health service in the living and working environment, especially the lack of opportunities to receive information on the prevention of AIDS and STIs. 

According to interview with 1000 long-distance truck drivers along Beijing-Datong, Datong-Tanggu, Datong-Zhangjiakou and Datong-Fengxian highways at the preliminary stage of the implementation of the program, most of Long-distance truck drivers hear about the AIDS, but know little about the routes of infection of AIDS as well as STIs. The knowledge rate of routes AIDS transmission as well as the knowledge on the prevention of AIDS among the drivers is respectively 55.65% and 51.78%. The rate of condom use by drivers having sex intercourse with female sex workers for the last time is 53.00%, and the rate of condom use by drivers having sex intercourse with female sex workers in recent 12 months is 18.00%. As indicated by the questionnaires oriented towards 47 waitresses working in roadside inns, most of them are lack of the consciousness of self-protection. Around 70% of these waitresses regard the major function of the condom is for contraception. Most of them take other contraceptive measures rather than condom use, such as contraceptive devices and ligation. At the same, the condom use is normally up to the clients. Therefore, the knowledge rate on the prevention of AIDS among long-distance truck drivers and waitresses working in roadside inns as reflected in the baseline survey is very low. AIDS infection is normally incurred by non-protective sex behaviors and incorrect medical treatment that are in existence in large proportion. Furthermore, there exists the potential risk of further prevalence of AIDS in Datong and in surrounding provinces and cities. Meanwhile, this kind of situation has also been confirmed by the discovery of HIV infected cases in previous years. Since the first HIV infection was discovered in 1996, 22 HIV infection case had been confirmed up to the end of December 2003. With the discovery of new HIV infections every year, the situation of AIDS epidemic is in a year-on-year upward trend, and the transmission of AIDS is gradually shifting from high-risk population to common people.

In view of the potential risk of prevalence of AIDS and STIs among long-distance truck drivers and waitresses working in roadside inns, Datong Municipal Health Bureau and Office of Health Project Supported World Bank have carried out proactive interventions under the leadership of Shanxi Provincial Health Bureau and Office of Health Project Supported by World Bank. Furthermore, Health Project Supported by World Bank which has been implemented in Datong since 2000 has also laid a solid foundation for the interventions. On one hand, it is necessary to further optimize the monitoring system of AIDS and STIs so as to provide scientific basis for the preparation of strategies on interventions; on the other hand, it is also a must to build a intervention team with high professional quality and high enthusiasm for work with the further implementation of the project. All this has provided adequate guarantee for the high quality fulfillment of behavioral interventions among long-distance truck drivers and in roadsinde inns in Datong.

2. Scope of Work

2.1 Mobilization of Government and Pre- Training of Manpower

Under the leadership of Shanxi Provincial Health Bureau and Office of Health Project Supported by World Bank, the “Project of Intervention in Behavior of Long-distance Truck Drivers Engaged in Coal Transportation in Shanxi Province” was formally initiated from December 2003. From then on, 12 relevant sectors as represented by Datong Municipal Highway Bureau, Datong Petroleum Company, Datong Municipal Engineering and Public Utility Bureau, Datong Traffic Police Brigade and Datong Coal Transportation Company began to carry out their respective work in cooperation with Datong Municipal Health Bureau.

Datong Municipal Government attaches high importance to the prevention of prevalence of AIDS and STIs among long-distance truck drivers and waitresses working in roadside inns in Datong. It is specified definitely in the No. 2204-11 file (Suggestions on Enhancement of Preventions of AIDS from Datong Municipal Government) as issued by Datong Municipal Government, condom dispenser or condomsdisplay in public places, such as roadside inns and highways for coal transportation in Shanxi Province to other places, so as to carry out the work of “100% Condom Program” in full swing. Furthermore, Datong Municipal Government also put emphasis on the necessity for public security bureau, judicial department and traffic police brigade to proactively coordinate with Health Bureau in carrying out physical examinations for long-distance truck drivers, and requests urban construction, public security, highway, municipal engineering and urban planning sectors to provide free of charge, Health Bureau with advantageous positions at the passageway of highways for coal transportation in Shanxi Province to other places for the purpose of issuing public service announcement on the prevention and control of AIDS. Under the guidance of Datong Municipal Government, the “Long-distance Truck Drivers Project” is proceeding smoothly.
 

In an attempt to ensure the smooth implementation of the project in regular sequence, Datong Municipal Health Bureau has respectively established project oversight group, project coordination group, project implementing group and project technical guidance group consisting of personnel from 17 units by calling on the participation of other social organizations. Furthermore, Datong Municipal Health Bureau has also countersigned liability paper with relevant cooperative institutions. As result of it, a pattern characterized by multi-sector cooperation and command efforts has been formed eventually.

In order to ensure the rationality and standardization of the interventions aiming at the target population, the project office has specially invited two professors from Shanxi Medical University to respectively act as the leader and vice leader of the technical guidance group. The two professors has provided guidance on the preparation of project executive plan as well as the quality control of the project implementation, and has also put forward relevant countermeasures for solving such problems propped up t different stage. As a result of it, each intervention activity was optimized and substantiated in a timely manner. Prior to the commencement of project interventions, project office organized trainings for total staff engaged in the intervention activities for the purpose explaining the features, significance, innovation and rationality of the “Long-distance Truck Driver Intervention Project” as well as the such contents as how to make use of conversational skill to deal with objects of interventions of different types for the purpose of providing technical guidance on the discovery of more HIV positive indexes during the project survey and intervention.

2.2. Baseline Survey and Support from Owners of Roadside inns

Prior to the formal commencement of interventions, the project office organized specialized technical personnel to carry out baseline survey along Beijing-Datong, Datong-Tanggu, Datong-Fengxian and Datong-Zhangjiakou highways, the four arteries for coal transportation. In order to facilitate the future assessment of intervention effect of the project, 500 long-distance truck drivers engaged in the coal transportation along Beijing-Datong and Datong-Tanggu highways were randomly selected into the intervention group, and another 500 long-distance truck drivers engaged in coal transportation along the Datong-Zhangjiakou and Datong-fengixan highways were randomly selected into the reference group. The core of the baseline survey is to find out detail requirements as specified by local governments for the prevention of prevalence of AIDS. Through inquiry from relevant competent sectors, special interviews, individual interviews, observation at fixed points, tour inspection and collective discussions, the project office has fully commanded the number of roadside inns and their distribution, and has plotted relevant distribution maps, found out the number of waitresses working in roadside inns and long-distance truck drivers as well as the law of their activities, made clear the source of condoms and major barriers for the promotion of 100% condom use and relevant issues concerning the medical care for target populations, for the purpose of having the objects in view.

At the very beginning, some owners of roadside inns refused to coordinate with working staff in carrying out the interventions in roadside inns. For instances, when the working group put up some posters and slogans in the inns, some owners of inns would say: “why do you put up this staff in my inns as if there are AIDS patients here”, “if you do like this, who dare to have dinners here?” In such case, working staff executing intervention activities would explain to them with patiently: “our job is to carry out advocacy work in every inn, and the reason why we choose your inn is that you have good business and a large number of customers”; “we expect you to coordinate with our work”; “every time when 8 members of our intervention group came here for work, we would have dinners at your inns, and therefore, we hope we can help each other”. It was most likely that the persuasion like this might not work at once or two times. Under such circumstance, working staff had to continue to persuade them patiently. Every time when the working staff carry out intervention work, they would go to the designated inns for dinner, so as to take opportunities to persuade the owner. Eventually, the trust was established between working staff and the owners of roadside inns after they had got familiar with each other. In this way, the first pilot advertising stands were established in roadside inns gradually. These advertising stands have attracted more inns to participate in the advertising work. Some inns even made rooms for the establishment of “health homestead” and “long-distance truck drivers’ club”. As a result of it, working staff eventually had their own “positions” for the execution of interventions. Furthermore, many inns also had their wall painted for the purpose of hanging up press kits and putting up posters and slogans.

As owners of roadside inns are key figures who have direct influence on the intervention work, it would be easier to persuade waitresses working in inns around the rods on condition that owners are persuaded. At present, every time when working staff carry out intervention work at roadside inns, they can obtain supports from both owners of the inns and waitresses. At the same time, working staff engaged in intervention work also respect the dignity and intimate life of waitresses. This has fully demonstrated the humanistic means of interventions. So far, some owners and waitresses have become the volunteer of peer education of the project. Normally, they would make use simple household goods as the model to demonstrate the correct condom use, and explain the importance of condom use to prevent the prevalence of AIDS.  

2.3. Multi-level Advocacy and Intervention Participated by Numerous Sectors

According to the survey of health conditions of target population, although many activities as related to the prevention of prevalence of AIDS have been carried out in the whole society, the advertising work among the long-distance truck drivers and waitresses working in roadside inns as well as the coverage are still to be enhanced and extended. While some people even have never heard of the AIDS, most people have insufficient perception of their ownrisk. In order to carry out effective health education for high risk population, arouse their consciousness of their own health, and thereby make them take healthy sex behavior proactively, project office has adopted various advertising forms. At the same time, the project office also encourage numerous department to take part in the intervention work, so as to make relevant cooperative institutions and some people with certain social influence regard the dissemination of knowledge on the prevention of AIDS as their task.
 
 

The 4th Traffic Police Brigade of Datong City and project office jointly established advocacy and consultation site for AIDS prevention at “Homestead Restaurant” at Xihe along the Datong-Tanggu Highway. In addition to blocking traffic in cooperation with the intervention work carried out by intervention staffs, traffic policemen also take a hand in distributing advertising information to long-distance truck drivers voluntarily. As to drivers in breach of relevant traffic regulations, traffic policemen would request them to answer some questions on the knowledge on the prevention of prevalence of AIDS and STIs and come in for advertising information on prevention of AIDS before proceeding with matters concerning the breach of traffic regulations. In an attempt to coordinate with the project office in carrying out the advertising work in a more effective way, Datong Municipal Petroleum Company has issued in its name, Notice on Effective Prevention of AIDS to all the filling station along the highways, requesting them to provide full supports for the advertising work. For instances, employees at each filling station are requested to distribute advertising information and condoms to long-distance truck drivers parking their trucks for refueling. At the same time, each highway toll station also assigned personnel to coordinate with project office in carrying out relevant interventions, persuading drivers to accept interviews and distributing advertising information to drivers and passengers. Furthermore, each coking coal toll station affiliated to Datong Coal Transportation Company also provided great supports for the project office, and has incorporated the dissemination of knowledge on the prevention of prevalence of AIDS into the scope of its own agendum. They insist on making time schedule of interview for intervention staffs on daily basis in line with the flow rate of trucks engaged in the transportation of coal produced in Shanxi Province to other places in the country, for the purpose of facilitating intervention staffs to carry out advertising work at time intervals when the mass of vehicles are concentrated and carrying out education for more long-distance truck drivers. Normally, they would hand over the advertising information to drivers engaged in coal transportation in together with pay demand notes.
 
2.4. Peer Education and Promotion of Condom

All the efforts would be end up in vain if target populations lack the consciousness of self-protection, no matter how hard staff work. The most effective way to improve the self-consciousness is to carry out the peer education---let waitresses to tell waitresses, and let long-distance trucks to tell their fellow drivers. 

So far, working staffs have established two “Health Homesteads” and two “Long-distance Truck Drivers’ Clubs” along the highways as the special sites for carrying out peer education. Furthermore, project office has also compiled and printed 3000 copies of 200 Questions on Peer Education on Prevention of AIDS and STIs for the purpose of guiding per education volunteers to disseminate relevant knowledge. Through training, 80 long-distance truck drivers and 10 waitresses working in roadside inns acted as peer education volunteers to carry out dissemination of knowledge on the prevention of AIDS and STIs among their colleagues. According to the statistics, peer education volunteers have disseminate correct information to more than 500 long-distance truck drivers and more than 40 waitresses working in roadside inns by telling them their own experiences in preventing AIDS. As a result of it, a sound atmosphere of intervention characterized by internal interactions has been formed among the target population.

It is an important task to carry out peer education and promote the condom use. During the progress of condom promotion, the project office adopted the following measures in combination with the peer education activities at all levels:
 

Firstly, establish mode for the promotion of condoms, which is applicable to long-distance drivers and waitresses working in roadside inns, provided condoms bags at 40 advertising and consultation stands, 2 health homesteads and 2 long-distance truck drivers’ clubs for the convenience of use by long-distance truck drivers and waitresses working in roadside inns, and has established the network for promotion of condom use characterized by coordinated points and lines, for the purpose of enhancing the accessibility of the condoms. Up to the present, more than 60000 condoms printed with aphorisms on the prevention of AIDS and STIs have been distributed to long-distance truck drivers and roadside inns for free.

Secondly, create sound social environment which is available for the promotion of condoms by preparing public service billboard for the promotion of condoms, distributing advertising information and advocating the importance of condom use in preventing AIDS and STIs in various forms, so as to enhance people’s consciousness of the use condoms; explain to waitresses working in roadside inns that the purpose of distributing condoms is to show concerns for them instead of supporting their behaviors.

Thirdly, demonstrate the correct condom use among the target population by means of individual interviews and training for peer education volunteers, so as to promote the condom use among their fellows.

Fourthly, Make full use of the role of cooperative institutions in promoting the condom use: for instance, Datong Petroleum Company requests each filling station along the Datong-Tanggu Highway to distribute condoms to long-distance drivers for free according to the refueling volume.

Fifthly, promote the condom use in full combination with health consulting and testing services. Major organizers represented by Datong Municipal Center of STD and AIDS Prevention and Control provided voluntary consultations and examinations for long-distance truck drivers and waitresses working in roadside inns during the promotion of condom use. In 2004, the major organizers conducted HIV testing for 325 long-distance truck drivers, disclosed the hot line for prevention and control of AIDS, and provided numerous consultations. Through the implementation of the activity, long-distance truck drivers and waitresses working in roadside inns further commanded relevant knowledge on the prevention of AIDS, dispelled their fears for AIDS and set up correct attitudes towards the AIDS.  

3. Result of Work

In April 2004, Datong City organized Shanxi Province AIDS Prevention and Control Project Supported World Bank On-the-spot Meeting. During the meeting, relevant department carried out on-the-spot investigation of the interventions at long-distance truck drivers’ clubs, health homesteads and advertising and consultation stations along Beijing-Datong and Datong-Tanggu highways in together with representatives presented at the meeting. In the same month, the oversight committee jointly established by World Bank and Ministry of Health carried out the on-the-spot supervision of the “long-distance truck driver project”. Members of the supervision committee were of the same opinion that the performance of interventions was satisfactory, the design and evaluation of interventions was reasonable, the intensity of interventions was high, and both contents and forms were in full consideration of local features and actual conditions. Furthermore, according to investigations carried out before and after the interventions, the rate of preventive knowledge on AIDS among the target population witnessed a significant increase. According to statistical analysis, the accuracy of answers to the questions on the routes of AIDS transmission in intervention group increased from 55.65% to 81.18%, and that in control group was increased to 59.38%. The rate of preventive knowledge on AIDS in intervention group increased from 5.78% to 81.98%, and that in control group was increased to 56.18%. The rate of condom use (used every time) by long-distance truck drivers engaged in sexual relations with waitresses working in roadside inns in the last 12 months increased from 18% prior to the interventions to 59.85%, and that in control group was increased to 26.15%. The rate of condom use (used every time) of by long-distance truck drivers engaged in sexual relations with waitresses working in roadside inns at the last time increased from 53% prior to the interventions to 91.97%, and that in control group was increased to 63.31%. 90% of female sex workers were able to refuse unsafe sex with clients. These facts have proved that interventions are capable of changing the dangerous acts of high-risk populations, and can play an important role in carrying out effective control of prevalence of AIDS among target populations.

4. Summary of Working Ideas and Modes

4.1 One Guidance

Organization by the Health Bureau and multi-sector cooperation under the guidance of the government was one of the important strategies and features of this project. The multi-sector cooperation was carried out practically in this project. Prevention and control of AIDS was no longer the task of Health Bureau. On the contrary, such sectors as highway bureau, petroleum company, municipal engineering and public utility bureau, road police and coal transportation company that are closely related to the transportation operations of long-distance truck drivers also took part in this task under the mobilization of the government. In this way, long-distance drivers could obtain advertising material and condoms whenever they refuel at filling stations, obey the command of traffic police, receive weighting at coal inspection stations and pay in at highway toll stations. As the time for health working staffs to carry out interventions at highways was so limited, working staffs from cooperative units would regard the dissemination of knowledge on the prevention of AIDS as one part of their daily work, so as to realize to the greatest extent the whole-process interventions for long-distance drivers at certain sections of the highway. In this case, the dominant role of the government has played enormous functions. 

4.2 Two Working Ideas

Establishment of Sustainable Development Mechanism through Integration of Internal and External Measures

Internal Measures: Mobilize long-distance truck drivers and waitresses working in roadside inns to carry out peer education and establish volunteer team for the purpose of disseminating knowledge on the prevention of AIDS among their colleagues and reducing high-risk behaviors. In view of their similar background, same living customs, mutual understandings and low exclusion, they can obtain sound effect in disseminating relevant knowledge and information. At the same time, it is also applicable for them to carry out advocacy of persuasion and influence by describing their own experiences and setting up good examples for other people. 

External Measures: working staffs created external atmosphere by taking various measures such as training, intervention and education to attract attentions of target populations on AIDS and STD, so as to arouse their recognition of the prevention and control of AIDS.

Establishment of sustainable development mechanism: Ever since the project was implemented more than one year ago, it has established an advocacy team, and has cultivated a group of advocacy talents, including educational volunteers, , and inn bosses, working staffs of cooperation institutions, bosses and employees of garages. As long as relevant guides and information can be provided and updated regularly, they would become the ‘permanent’ trainers  for continuous dissemination of knowledge on the prevention of AIDS and STD. Secondly, the promotion condom use is gradually transferring from free distribution to the sales at cost and regular dispatching. As a result of it, a network for sales promotion of condoms has been formed. Furthermore, the “long-distance truck-driver project” which was implemented in December 2003 has attracted municipal government’s attentions on the prevention and control of AIDS. The advocacy by means of the integration of both internal and external measures, fixed and stable advocacy team as well as the stable policy environment has provided sufficient guarantee for the sustainable development of “long-distance truck drivers project” in Datong, and has also laid down a solid foundation for the sustainable implementation of AIDS prevention and control in Datong City. 

4.3 Three Media
Small Media Advertising: Prepare and print in large quantity advertising materials, such as leaflets, posters, foldouts, pamphlets, telephone books and calling cards. In this way, long-distance drivers can discover these materials in the data bag and take it out for study as long as take dinners, refuel and carry out repairs along the roadside.

Large Media Communication: Set up advertising patients at the striking positions along the two highways selected for interventions for the purpose of creating an atmosphere for the dissemination of knowledge on the prevention of AIDS, such as large-size advertising billboard, advertising banners and wall advertising slogans. In this way, long-distance truck drivers can easily catch sight of the relevant contents and aphorisms related to the dissemination of knowledge on the prevention of AIDS.
Interpersonal Communication: it refers to the face-to-face knowledge dissemination, such as peer education, individual interview, team interview, consultation activities and promotion of condom use. On one hand, it is available for knowledge dissemination; on the other hand, it is also helpful in understanding the mentality and thoughts of target populations, improving the rate of knowing of relevant knowledge and providing rational guides for the hospitalization of the target populations.

4.4 “Positions” in Four Categories

2 long-distance truck drivers clubs, 2 health homesteads, 2 fixed advocating and consultation stations and 40 advocating points

  Distribution of advocacy network

4.5 Five Measures

Enhancement of Quality Control: In an attempt to ensure the implementation of the interventions as per the time schedule, technical guidance team would carry out supervision every two months to perform the analysis and study of work progress and evaluation of effects. Furthermore, technical guidance team has also enhanced the optimization of work records by providing each work with complete records, so as to carry out examination of working staffs as well as the peer education volunteers for the purpose of extend their knowledge and improving their cognition quality.

Introduction of Foreign Assistance: Relevant experts from Capital Medical University, University of Melbourne, Australia and Shanxi Medical University once provided their supports for the project at the time of designing of executive plan. Furthermore, they also carried out relevant trainings for working staffs of the project at the very beginning of the implementation of the project, and purposely provided detailed solutions as related to the effective implementation of baseline survey and settlement of relevant problems. During the implementation of the project, they also carried out supervisions of the project for many times, and provided relevant analysis of and suggestions on the problems and hidden troubles discovered during the execution of on-the-spot interventions.

Fulfillment of Responsibility System: The project office countersigned liability paper respectively with cooperative institutions, expert team and project implementation team.

Skill Training: The project office carried out stage trainings for project working staffs and peer education volunteers for many time during the implementation of the project for the purpose of ensuring the smooth and effective implementation of the project. 

Comprehensive Interventions: The project office has always been able to adopt multi-layered, multi-stage and comprehensive intervention measures to ensure the smooth implementation of the project.

Either “one guidance” or “two working ideas” or “three patients” or “positions in four categories” is able to bring into full play the dominant role of the government in combination with occupational features of long-distance truck drivers, the mobile population of high-risk behaviors, for the purpose of carrying out comprehensive interventions according to appropriate working ideas and interventions measures.