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HIV/AIDS – Research and Palliative Care 2013:5 51–60
HIV/AIDS – Research and Palliative Care
Evaluating the McDonald’s business model
for HIV prevention among truckers to improve
program coverage and service utilization in India,
2004–2010
Vasudha Tirumalasetti Rao
1
Bidhubhusan Mahapatra
2
Sachin Juneja
1
Indra R Singh
1
1
Transport Corporation of India
Foundation, Gurgaon, Haryana, India
2
Population Council, New Delhi, India
Correspondence: Vasudha Tirumalasetti
Rao
TCI Foundation, TCI House, Plot 69,
Institutional Area, Sec-32, Gurgaon,
Haryana 122 001, India
Tel +91 124 2381603
Fax +91 124 2381611
Email vsrao20@gmail.com
Background: This study describes the experiences and results of a large-scale human immu-
nodeficiency virus (HIV) prevention intervention for long-distance truck drivers operating on
the national highways of India.
Methods: The intervention for long-distance truckers started in 2004 across 34 trans-shipment
locations. However, due to poor coverage and utilization of services by truckers in the initial
18-month period, the intervention was redesigned to focus on only 17 trans-shipment locations.
The redesigned intervention model was based on the McDonald’s business franchise model
where the focus is on optimal placement of services, supported with branding and standard-
ization of services offered, and a surround sound communication approach. Program output
indicators were assessed using program monitoring data over 7 years (2004–2010) and two
rounds of cross-sectional behavioral surveys conducted in January 2008 (n = 1402) and July
2009 (n = 1407).
Results: The number of truckers contacted per month per site increased from 374 in 2004 to
4327 in 2010. Analysis of survey data showed a seven-fold increase in clinic visits in the past
12 months from 2008 to 2009 (21% versus 63%, P , 0.001). A significant increase was also
observed in the percentage of truckers who watched street plays (10% to 56%, P , 0.001), and
participated in health exhibitions (6% to 35%, P , 0.001). Furthermore, an increase from round
1 to round 2 was observed in the percentage who received condoms (13% to 22%, P , 0.001),
and attended one-one counseling (15% to 21%, P , 0.01). Treatment-seeking from program
clinics for symptoms related to sexually transmitted infections increased six-fold during this
period (16% versus 50%, P , 0.001).
Conclusion: Adoption of a business model for HIV prevention helped to increase program
coverage and service utilization among long-distance truckers. Implementing HIV prevention
programs in a highly mobile population such as truckers, in a limited number of high-impact
locations, supported by branding of services, could help in saturating coverage and optimum
utilization of available resources.
Keywords: truckers, human immunodeficiency virus, HIV prevention, program redesign,
coverage, sexually transmitted infection
Introduction
The role of truckers, particularly long-distance truckers, as an effective bridge in
spreading human immunodeficiency virus (HIV) infection from high-risk groups,
such as female sex workers, to low-risk women in the general population has been
highlighted.
1,2
Truckers spend much of their time on the road, where they are likely
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to engage in risky sexual activities. Their likelihood of
exposure to HIV prevention programs is also restricted due
to their constant mobility. The situation of truckers in India
is no different from that in other countries. There are about
5 million truckers including helpers in India, of whom about
40% operate on long-distance routes covering more than
800 km one way.
3
Previous research in India among truckers
has revealed a high rate of unprotected sex with female sex
workers and sexually transmitted infection (STI).
4–7
A large
biobehavioral survey indicates that one-fifth of long-distance
truckers were using condoms inconsistently with paid female
partners and one in five truckers were diagnosed with an STI,
including HIV and syphilis.
7
HIV prevention interventions targeted at truckers started
in India in 1993, when truckers were provided clinical services
at major highway stopping points.
8
Thereafter, an upscaled
intervention, popularly known as “healthy highways,” was
introduced in 1996 across 200 sites spread over 19 states.
The intervention sites were either trans-shipment locations
(places where trucks are unloaded and reloaded, or halt for
maintenance and replenishing supplies) or roadside cafes
along the highway.
9–11
An evaluation of the healthy highways
intervention in 2000 revealed that only 43% of truckers and
29% of helpers reported consistent condom use with nonregu-
lar female partners.
12
An independent survey among health
care providers indicated that STI care management in the
healthy highways intervention lacked attention, particularly
in physical examination, prescription of standard medicines
and regimen, counseling on condom use, and partner referral
for STI treatment.
13
Subsequently, a few small-scale interven-
tions engaged peer educators as part of their behavior change
communication strategy.
14–17
These programs focused on the
distribution of educational materials on safe sex practices,
condom promotion, and treatment for STI-related symptoms
at STI clinics run by the program. In the late 1990s, the
Bhoruka Public Welfare Trust established “free tea parlors”
at major truck halt points where truckers were encouraged
to utilize STI clinic services.
18
However, the healthy highways and other small-scale
interventions supported by the government and donor agen-
cies worked independently without any coordinated efforts to
scale up the program. Further, most of these programs were
mainly driven by the peer education strategy to change the
behavior of truckers, which may have resulted in low out-
reach among these men, given their high degree of mobility.
In order to reach the target population at scale, the Bill and
Melinda Gates Foundation initiated a comprehensive nation-
wide intervention for long-distance truckers in 2004 known
as Kavach (meaning “shield” in Hindi/Urdu).
19
The highlight
of the Kavach intervention was to adopt a successful business
model to increase the effectiveness of the HIV prevention
program. The program was founded on the basic principles
of how an intervention can be designed to reach a highly
mobile population like truckers, and how innovative com-
munication mechanisms can be designed to sustain behavior
change in this group. This paper describes the intervention
and discusses how the challenges were addressed through
a redesign process with the adoption of a business model.
Further, it examines the program outputs in terms of coverage
and service utilization by long-distance truckers.
Materials and methods
Intervention
The Kavach intervention was initiated in 2004 by contracting
34 local nongovernmental organizations with prior experi-
ence of working with truckers to cover various trans-shipment
locations across the country. The program implemented
activities similar to those used for healthy highways and
other small-scale interventions.
An assessment of the program monitoring data in
2005 revealed that only 4% of those who accessed STI
services were indeed long-distance truckers, which was
significantly lower than the expected project target. Further,
half the individuals who accessed program services were
either short-haul truckers or workers in the trans-shipment
locations. Qualitative discussions with local nongovern-
mental organizations and other stakeholders revealed that
the main reason for suboptimal performance of the program
was inappropriate allocation of services/resources. Several
other factors were identified, including lack of standardiza-
tion of services, continued communication fatigue, limited
branding and visibility, the short attention span of truckers,
and the need for message reinforcement. The program man-
agement decided to redesign its strategy in 2006 in order
to improve the utilization of services and coverage of the
target population.
Implementation of redesigned program
The redesigned intervention strategy was adapted from the
well known McDonald’s business franchise model, which is
based on the concept of a uniform look and service across
all franchise outlets.
20,21
Therefore, the redesigning process
focused mainly on creating convenience of access through
intelligent placement of services, standardization of service
delivery, and a uniform look and feel across network clinics.
A surround sound communication approach was used, where
the number of service touch points was increased within a
trans-shipment location to ensure message reinforcement and
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Tirumalasetti Rao et al
HIV/AIDS – Research and Palliative Care 2013:5
recall. Further, peer educators from the trucking community
were engaged to create awareness about HIV, STIs, and
condom use through different innovative interpersonal com-
munication tools. Allocation of service points at optimal loca-
tions was done by reducing the number of intervention sites.
Trans-shipment locations were selected based on information
such as volume of truckers visiting the site (10,000 truckers
per month), geographic location, and the average time spent
by truckers at the site. In addition, a broker/transporter census
was conducted in 2006 which enumerated 766,028 truckers,
of whom 451,699 were long-distance truckers. Based on
this information, 17 sites (15 trans-shipment locations and
two check posts) were identified for intensive intervention
in the redesigned phase of the program. These sites were
strategically located on the golden quadrilateral highway
route connecting the metropolitan cities of Delhi, Kolkata,
Chennai, and Mumbai (Figure 1).
Provision of STI treatment
In the redesigned intervention approach, efforts were made
to achieve high clinic visibility, efficiency, and accessibility.
Two types of clinics were set up static clinics (one at each
intervention site) and satellite/mobile clinics (six clinics at
each intervention site). Static clinics were located at a fixed
location in the trans-shipment location, while satellite clinics
were organized in natural traffic areas of the trans-shipment
location. Around 80 satellite clinics were set up initially, most
of which were in the offices of brokers/transporters, with
120 hours of clinical services provided per site per month.
Clinics were branded as “Khushi” clinics (Khushi meaning
“happiness” in Hindi) with a distinctive logo consisting of two
flowers, indicating happiness; these clinics were positioned
as general health clinics rather than as exclusive STI clinics
to reduce the stigma associated with such clinics. To ensure
clinical services had a uniform look and feel, all clinics were
painted yellow and blue and a standardized interface of ser-
vices was developed across the intervention sites. Truckers
visiting a Khushi clinic for the first time were issued a diary
(called a Khushi passport) in which details of the client’s
medical history, diagnosis, and medication provided at each
clinic visit were recorded. Truckers were instructed to carry
this diary with them during clinic visits. The diary also con-
tained the addresses of all Khushi clinics across the country
to encourage truckers to access services while on the move.
Enhanced communications activity
One of the important strategies in the redesigned phase was
the adoption of a surround sound communication approach,
which is an integrated and multilayered behavior change com-
munication strategy. Outreach workers were replaced with
peer educators, who were either active truckers or ex-truckers,
to conduct interpersonal communication sessions with fellow
truckers. Peer educators were given intensive training on the
use of participatory tools and audiovisual aids, including flip
books, flash cards, and discussion guides. The training ses-
sions emphasized dialog-based communication designed to
generate audience participation and interesting interaction.
Trainings were organized at the site level to enable hands-on
training. Peer educators facilitated discussions in a group of
10–12 fellow truckers on HIV, STIs, common misconcep-
tions, and the importance of condom use. Typically, group
participatory sessions lasted 60–90 minutes. In addition,
a multilayered communication strategy was used to ensure
message recall and synchronization across locations by
street plays, health games, film shows, and distribution
of audio cassettes. A series of selected themes related to
common misconceptions on STI/HIV transmission among
truckers were identified for the communication strategy.
Presentation styles of theme messages were standardized to
ensure uniform messaging across sites. Theme messages were
updated every 6 months to keep them new and contextual.
Therefore, while designing communication activities, the
views expressed by truckers during focus group discussions
were taken into account.
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McDonald’s business model for HIV prevention
Figure 1 Map of India showing trans-shipment locations and operating routes
among long-distance truck drivers.
Abbreviation: TCIF, Transport Corporation of India Foundation.
HIV/AIDS – Research and Palliative Care 2013:5
Data
The data used to examine progress in program outputs were
drawn from two sources: program monitoring data and two
rounds of behavioral tracking survey.
Program monitoring data
Program monitoring data were collected in paper formats on
a monthly basis by program implementing nongovernmental
organizations at the site level, which were then aggregated
and computerized at the national level. Truckers who accessed
services from the Kavach intervention were assigned a unique
identification number to track their service utilization in any
site across the country. Data on program coverage and service
utilization were collected in this system from 2004 to 2010
(Figure 2). Examples of key indicators for which informa-
tion was generated include number of truckers contacted,
number of truckers visiting Khushi clinics, number of truck-
ers diagnosed with STIs, and number of condoms socially
marketed.
Behavioral tracking survey
The behavioral tracking survey is a cross-sectional survey
conducted in multiple rounds to assess program exposure,
service utilization, effectiveness of communication activi-
ties, knowledge and risk perceptions about HIV, condom use,
and treatment-seeking behaviors among truckers. We used
data from two rounds of the behavioral tracking survey con-
ducted during January–February 2008 and July–August 2009
to examine program coverage and service utilization among
truckers. Six intervention sites were purposefully selected to
represent different regions of the country. The selected sites
were located at Ghaziabad and Delhi (representing northern
India), Indore (representing central India), Mumbai and Pune
(representing western India), and Bengaluru (representing
southern India). A combined sample size of 1400 across the
six sites was fixed for each round of the survey. The total
sample size was distributed across the six survey locations
according to the total population of truckers in those sites.
Samples were drawn using a two-stage sampling process;
in the first stage, clusters were formed based on the parking
areas for trucks. In the second stage, respondents were ran-
domly selected from selected clusters after screening them
for eligibility. The eligibility criteria for participation in the
study were males who were 18 years or older, had worked as
a trucker for at least 2 years, and had worked in a truck with a
national permit (ie, permission from the government to carry
goods across the country). The number of interviews to be
conducted in a cluster was decided proportionately according
to the proportion share of number of truckers in the cluster
with respect to the number estimated in the site. The regis-
tration number of trucks parked in each cluster on the day
of the survey was listed and a systematic random sampling
approach was used to select the trucks. The drivers or helpers
of the selected trucks were approached to participate in the
survey. If a respondent was not found to be eligible, he was
replaced with another respondent selected from the same
cluster following the systematic random sampling approach.
The same process was followed in the event that a respondent
refused to participate in the survey. At the end of the survey,
1403 and 1407 truckers, respectively, in round 1 and round 2,
completed the questionnaire.
This behavioral study was conceived as routine program
monitoring to improve the program implementation and its
outcomes. Therefore, the study was not formally reviewed
and approved by any institutional review board. However,
ethical principles were followed in conducting the study,
including the use of a consent form in the questionnaire.
In order to protect the confidentiality of the respondents,
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Tirumalasetti Rao et al
National AIDS control program, phase 2 (2000–2006)
2004
• Intervention initiated in 11 sites
• Intervention expanded to 34 sites
2005
• Assessment of service delivery using program monitoring data
• Qualitative assessment of program coverage and service utilization at selected sites
• Redesign of intervention strategy based on McDonald’s franchise model
2006
• Intervention sites reduced to 17 trans-shipment locations and check posts
National AIDS control program, phase 3 (2007–2012)
2008
• Behavioral tracking survey, round 1 conducted in January 2008
2009
• Behavioral tracking survey, round 2 conducted in July 2009
2010
• Transition of program to national AIDS control organization initiated
Program monitoring data
Figure 2 Time lines of occurrence of important program activities during Kavach intervention.
HIV/AIDS – Research and Palliative Care 2013:5
we did not collect any identifiers (name or address) in the
questionnaire or any other research document, and the
participant was informed of the same. All participants were
told the possible harms and benefits associated with their
participation before the start of the interview. To maintain
privacy, interviews were either conducted inside the truck or
in a secluded public area such as road corners where others
would not be able to listen to the interview. Participants were
not given any monetary compensation for participation in
the study. Only participants who consented voluntarily were
interviewed in the study. Trained research investigators used
a structured questionnaire to collect data after taking consent
of individuals. Research investigators were graduates in
social science and native speakers of the local language of
the survey site. The questionnaires were developed in English
and then translated into the local language of the survey site.
Study investigators who were fluent in both English and the
local language reviewed the translated questionnaires. These
translated questionnaires were pretested in similar settings
before the start of the survey.
Measures
The following key indicators from program monitoring data
were used to examine program coverage and the extent of
service utilization: number of truckers contacted per month
per site, number of truckers visiting the Khushi clinic per
month, number of condoms socially marketed, and number
of condoms sold per trucker. Definitions of these indicators
are presented in Table 1.
The behavioral tracking survey collected information on
truckers’ sociodemographic characteristics, program cover-
age, and service utilization using a structured questionnaire.
Single item questions were used to gather information on
different program coverage and service utilization indicators.
The key measures used to examine program coverage in the
12 months prior to the survey were: visited a Khushi clinic,
watched street plays, participated in health exhibitions and
film shows, and attended trucker festivals. Service utilization
by truckers in the 12 months prior to the survey was assessed
using the following measures: percentage of truckers who
received health cards/condoms/one-one counseling, attended
health camps, and were referred to an integrated counselling
and testing center or detoxification center. All these measures
were coded as “1” if respondents reported in the affirmative, or
else coded as “0”. Three outcome indicators were assessed, ie,
awareness of STI-related symptoms, experience of STI-related
symptoms in the 12 months prior to the survey, and treatment-
seeking from Khushi clinics for STI-related symptoms.
Spontaneous multiple response questions were asked
to assess awareness of STI-related symptoms. Responses
included commonly occurring STI symptoms among men,
such as urethral discharge, genital ulcers, and sores, swell-
ing in the scrotal (groin) area, burning/pain on urination,
and inability to retract the foreskin. Respondents answering
to any of these symptoms were classified as being aware
of STI-related symptoms and coded as “1”, or else consid-
ered as not aware of STI symptoms (coded as 0). Respon-
dents were categorized as having experienced STI-related
symptoms (coded as 1) if they reported experience of any
of the following STI symptoms in the 12 months prior to
the survey: urethral discharge, genital ulcers, and sores,
swelling in the scrotal (groin) area, burning/pain on urina-
tion, and inability to retract the foreskin, or else they were
considered not to have experienced any STI symptoms and
coded as “0”. Respondents who experienced any STI-related
symptoms were asked if they had sought treatment for their
symptoms. Responses to this question were multiple, with
Khushi clinics as one of the response categories. Respon-
dents who reported seeking treatment from a Khushi clinic
provider were considered to have sought treatment from a
Khushi clinic and coded as “1”.
Statistical analyses
Program monitoring data are presented either in terms of
absolute numbers or a percentage relative to a base indicator.
Bivariate and multivariate analyses were used to demonstrate
the changes in program exposure, behavioral outcome, and
service utilization from two rounds of behavioral tracking
survey data. A pooled data set of round 1 and round 2 of the
behavioral tracking survey was prepared, with an indicator
variable indicating the survey round (round 1, 0; round 2, 1).
Multiple logistic regression models were fitted, with the
survey round as the key independent variable and exposure
to communication activities and service utilization as the
dependent variables. Multivariate models were adjusted for
age, education, marital status, duration of trucking industry,
and route category where the trucker operates, and the results
are presented in terms of adjusted odds ratios (AOR) with the
corresponding 95% confidence interval (CI). All bivariate and
multivariate analyses were carried out using STATA version
12 (StataCorp, College Station, TX, USA).
Results
The intervention was started with eleven sites in 2004
and scaled up to 34 sites, with one clinic per site, in 2005
(Table 2). With the redesign of the program, the number
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McDonald’s business model for HIV prevention
HIV/AIDS – Research and Palliative Care 2013:5
of intervention sites was reduced to 17, with at least two
clinics per site after the redesign process. Post redesign, the
number of truckers contacted per month per site increased
multi-fold each year. The proportion of truckers using clini-
cal services also increased; initially, only about two-thirds
of the individuals were truckers, which improved signifi-
cantly after the redesign of intervention. Those reporting
STI-related symptoms declined over the years from 44%
in 2004 to 16% in 2010. A considerable increase in the
number of condoms socially marketed was also noted (eight
condoms sold per trucker in 2004 to 53 condoms sold per
trucker in 2010).
The independent cross-sectional surveys support the obser-
vations made from the program monitoring data (Table 3). There
was a seven-fold increase in visitors to Khushi clinics in the
12 months between January 2008 and July 2009 (21% to 63%,
AOR 6.7, 95% CI 5.6–7.9). Exposure to different communica-
tion activities increased multi-fold from round 1 to round 2,
including attendance at street plays (10% to 56%, AOR 11.3,
95% CI 9.2–14.0), participation in health exhibitions (6% to
35%, AOR 8.6, 95% CI 6.7–11.1), and participation in film
shows (4% to 24%, AOR 7.8, 95% CI 5.8–10.6). A signifi-
cant improvement was also observed in service utilization by
truckers. More than one-tenth (13%) had received a health card
at the time of the round 1 survey compared with more than one-
fifth (22%) in round 2, indicating a two-fold increase between
the survey rounds (AOR 1.8, 95% CI 1.5–2.2). Improvements in
service utilization from round 1 to round 2 were also noted with
regard to receipt of condoms from the program (13% to 22%,
AOR 1.8, 95% CI 1.5–2.2) and attendance at one-one counseling
sessions (15% to 21%, AOR 1.5, 95% CI 1.3–1.9).
Table 4 suggests that the truckers surveyed in round 2
were 20% more likely to experience STI-related symptoms
as compared with those in round 1 (27% versus 22%, AOR
1.2, 95% CI 1.0–1.5). During the two rounds of the survey,
treatment-seeking from Khushi clinics for STI-related prob-
lems increased about six times from 16% in round 1 to 50%
in round 2 (AOR 5.6, 95% CI 3.8–8.2).
Discussion
This redesigned intervention strategy has demonstrated an
increase in program coverage and service utilization among
long-distance truckers even though the number of interven-
ing sites was reduced by half. The program’s redesigned
approach offered services at selected trans-shipment loca-
tions, supported by uniform branding of clinical services and
innovative communication activities. The two independent
cross-sectional surveys supported by program monitoring
data documented a multi-fold increase in program coverage
and service utilization among truckers. The study findings
on program exposure are supported by an independent
evaluation of trucker programs in India, which indicates that
truckers’ exposure to HIV prevention intervention increased
from 14% in 2007 to 30% in 2009.
7
Another assessment of
a truckers program in India suggests that communication
activities such as mid-media and interpersonal communica-
tion used in the Kavach program contributed significantly to
increased condom use with paid and unpaid female sexual
partners.
22
The findings from this study corroborated by
other studies suggest that optimum placement of service at
few locations can yield better outcomes in HIV prevention
programs among truckers.
This redesigned intervention demonstrates that suc-
cessful business models can be adopted for health service
delivery. Influenced by the business franchise model of
McDonald’s,
20,21
the Khushi clinics were branded with a
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Tirumalasetti Rao et al
Table 1 Denition of program monitoring indicators
Indicators Denition
Number of truckers
contacted at least
once a month per site
Represents the number of unique long-distance
truckers who were contacted by the outreach
team in a month. This indicator was derived
after taking the average for all 12 months in a
year divided by the number of intervention sites.
Number of individuals
(truckers + nontruckers)
utilizing clinical services
per month per clinic
Represents the number of unique individuals
utilizing clinical services at Khushi clinics in a
month. This was calculated as the average for
all 12 months in a year divided by the number
of clinics in operation.
Percentage of truckers
among total Khusi clinic
attendees
Calculated as the number of truckers utilizing
clinical services in a month divided by the total
number of individuals (truckers + nontruckers)
utilizing clinical services at Khushi clinics in the
same month multiplied by 100.
Percentage of truckers
treated for STI-related
symptoms
Represents the number of truckers treated
for STI-related symptoms in the reporting
period divided by the number of truckers
utilizing clinical services at Khushi clinics in that
reporting period.
Percentage of truckers
who bought medicines
Represents the number of truckers buying
medicine from Khushi clinic outlets in a
reporting period divided by the number of
truckers treated with STI-related symptoms
in that reporting period.
Number of condoms
socially marketed
Represents the number of condoms socially
marketed through traditional, nontraditional
outlets and condom vending machines within
the trans-shipment locations.
Number of condoms
sold per trucker
in a year
Calculated as total number of condoms
socially marketed divided by number of
truckers who bought condoms.
Abbreviation: STI, sexually transmitted infection.
HIV/AIDS – Research and Palliative Care 2013:5
uniform look and service across trans-shipment locations.
Empirical evidence suggests that franchise models have the
potential to increase access to services and ensure standard-
ized quality of services through a recognized brand.
23–26
Franchising models of clinics have been successfully
adopted to provide reproductive health and family planning
services.
23,25,26
A social franchising clinic model in Vietnam
to provide reproductive health and family planning services
demonstrated that such a social franchise model can help
to increase the use of reproductive health and family plan-
ning services in smaller public sector clinics.
23
However,
the use of franchise models in HIV prevention programs
is rare. The branding of Khushi clinics in terms of uniform
look and color helped truckers to identify these clinics in
different intervention locations. Moreover, this strategy was
very effective in drawing the attention of truckers given the
low literacy and high frequency of mobility. Although the
findings suggest that the franchise model of service provi-
sion can be highly successful in HIV prevention programs,
it requires extensive advertising through innovative com-
munication channels. Further, a similar approach has been
used to provide STI services to female sex workers and
clients of female sex workers in different parts of India.
The findings of this intervention can serve as a stepping
stone in evaluation of such interventions in the future.
Moreover, providing STI services through a chain of uni-
form STI clinics may be highly successful among migrants
in India, who are now being recognized as a major source
of HIV infection transmission from destination areas to
source areas.
27
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McDonald’s business model for HIV prevention
Table 2 Program exposure and service utilization as observed in the program monitoring data, 2004–2010
Indicators Pre redesign stage
of intervention
Post redesign stage of intervention
2004 2005 2006 2007 2008 2009 2010
Number of sites (as of December
of the respective year)
11 34 17 17 17 15 12
Number of static clinics 11 34 34 34 34 30 24
Estimated number of truckers 43,535 270,549 322,566 295,000 295,000 285,000 311,667
Number of truckers contacted
at least once a month per site
$
374 580 910 2791 3576 4045 4327
Number of individuals (truckers +
nontruckers) utilizing clinical
services per month per clinic
$
90 253 382 515 641 682 717
Percentage of truckers among
total Khushi clinic attendees
per month per clinic
$
63.3 67.0 78.9 89.9 95.2 94.4 90.7
Percentage of truckers treated
for STI-related symptoms
44.4 33.1 26.0 23.1 22.8 21.4 16.1
Percentage of truckers who bought
medicines from Khushi clinic
0.0 0.0 7.0 74.7 91.2 95.1 97.8
Number of condoms socially
marketed
33,510 465,149 704,511 1,306,837 1,609,553 1,959,525 2,738,411
Number of condoms sold per
trucker in a year
8 24 46 28 26 32 53
Note:
$
Calculated as average of 12 months in the year of observation.
Abbreviation: STI, sexually transmitted infection.
Table 3 Change in level of program exposure and service
utilization among long-distance truck drivers from January 2008
to July 2009, according to behavioral tracking surveys
Round 1
a
(n = 1402)
Round 2
b
(n = 1407)
Adjusted OR
c
(95% CI)
Program exposure in last 12 months
Visited Khushi clinic 20.5 62.8 6.7 (5.6–7.9)
Watched street plays 10.4 56.1 11.3 (9.2–14.0)
Participated in health
exhibitions
6.3 34.8 8.6 (6.7–11.1)
Participated in lm shows 4.1 23.7 7.8 (5.8–10.6)
Attended trucker festival 12.4 24.7 2.4 (2.0–3.0)
Received audio cassettes 14.1 28.5 2.5 (2.0–3.0)
Service utilization in last 12 months
Received health card 13.1 21.7 1.8 (1.5–2.2)
Attended health camp 6.2 18.9 3.7 (2.8–4.8)
Received condoms 13.4 22.0 1.8 (1.5–2.2)
Received one-one
counseling
15.4 20.8 1.5 (1.3–1.9)
Referred to ICTC,
detoxication center
2.3 8.7 4.1 (2.7–6.1)
Notes:
a
Survey round 1 was conducted in January 2008, n = 1402;
b
survey round 2
was conducted in July 2009, n = 1407;
c
odds ratio adjusted for age, education, marital
status, duration of experience in the industry, and route category.
Abbreviations: CI, condence interval; ICTC, integrated counseling and testing
centers; OR, odds ratio.
HIV/AIDS – Research and Palliative Care 2013:5
The branding of Khushi clinic resulted in a sharp increase
in the utilization of clinical services by truckers over the
years, which is evident from both the program monitoring
and survey data. In addition to the uniform look and feel of
Khushi clinics, packaging of these clinics as general health
clinics helped in reducing the stigma associated with STI
clinics and could also have translated into increased clini-
cal service utilization. The decision to establish clinics near
brokers’ premises also resulted in an increase in the number
of truckers accessing clinic services. The steady increase
in the volume of truckers visiting clinics over the years
indicates that truckers are strongly motivated to visit these
clinics due to the quality of services being offered. Moreover,
the existence of strong social networking among individu-
als would also have contributed to increased clinic outflow
over the years.
23
Consistent with the increase in program coverage over the
years, the two rounds of cross-sectional surveys also demon-
strated a significant improvement in truckers’ participation
in different communication activities, which is most likely
due to systematic peer outreach activity in conjunction with
a surround sound communication strategy. The use of peer
educators has been demonstrated to be successful in previous
interventions for truckers in India.
14–17
Discussion between
peer educators and fellow truckers helped in understanding
the attitude and expectation of truckers towards STI/HIV
services offered through the Kavach program. The concerns
expressed in those discussions were addressed and helped in
designing innovative communication materials according to
the needs of the trucking community. One of the challenges
faced by the program was the high turnover rate of peer
educators; in cases where peer educators dropped out, new
peer educators were immediately recruited and provided
with the necessary training. Further, the increase in exposure
to communication activities resulted in improved safe sex
behavior.
22
The trend emerging from the program monitoring data
suggests that there was a significant increase in program
coverage and service utilization from 2004 to 2005. This
is due to the increase in number of intervention sites which
went from 11 in 2004 to 34 in 2005. However, with the rede-
signed strategy in place since 2006, most service utilization
indicators have showed improvement or remained stable
over the years. Further, the redesigned strategy ensured
higher usage of services by trucker population rather than
by individuals from the nontrucking community as was the
situation prior to 2006. These trends suggest that approaches
used in the redesigned intervention can be effective for
increasing service utilization among truckers, who are rec-
ognized as a highly mobile population group in India and
elsewhere.
7
Further, the services offered in Kavach program
were aligned to guidelines prescribed by the National AIDS
Control Program (NACP). Moreover, there was a change
in guidelines for national HIV prevention programs during
the intervention period, because there was a transition from
NACP phase 2 (2000–2006) to phase 3 (2007–2012). The
NACP-2 prioritized STI diagnosis and treatment services
whereas in NACP-3 the focus was on referral to integrated
counseling and testing centers alongside STI diagnosis and
treatment.
3
As a result of these policy-level changes, the
efforts towards referral to integrated counseling and testing
centers was poor prior to 2006, and more intensive efforts
were made starting only in 2007. These efforts resulted in
a four-fold increase in referral to integrated counseling and
testing centers from 2008 to 2009.
The findings of this study should be viewed in the light
of certain limitations. The cross-sectional surveys used to
assess service utilization were conducted after the redesign
of the intervention; hence round 1 of the survey is not a
true baseline. However, post hoc comparison with selected
indicators for which information was collected prior to the
redesign suggests that service utilization was poorer before
the redesign, and improvement was significantly associated
with the redesign process. For example, only 4% of truckers
had visited a clinic in the 12 months prior to redesign com-
pared with 21% and 63%, respectively, in survey round 1
and 2. Further, the intervention had no control group, so one
can argue that the changes observed were merely temporal
rather an outcome of the intervention. Post hoc analysis
suggests that truckers who had never visited Khushi clinics
Table 4 Change in level of awareness of STI-related symptoms,
experience of STI-related symptoms, and treatment-seeking
behavior from January 2008 to July 2009
Outcome indicators Round 1
a
(n = 1402)
Round 2
b
(n = 1407)
Adjusted OR
c
(95% CI)
Aware of STI-related
symptoms
74.8 82.4 1.5 (1.3–1.9)
Experienced STI-
related symptoms
in last 12 months
22.4 27.4 1.2 (1.0–1.5)
Sought treatment from
Khushi clinic for STI
d
15.9 49.9 5.6 (3.8–8.2)
Notes:
a
Survey round 1 was conducted in January 2008, n = 1402;
b
survey round 2
was conducted in July 2009, n = 1407;
c
odds ratio adjusted for age, education, marital
status, duration in the trucking industry, and route category;
d
analyzed among
respondents who had STI-related symptoms in the 12 months prior to the survey.
Abbreviations: CI, condence interval; STI, sexually transmitted infection; OR,
odds ratio.
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Tirumalasetti Rao et al
HIV/AIDS – Research and Palliative Care 2013:5
were less likely to be exposed to communication activities
and receive program services, indicating the role of the
intervention in improving service utilization. There could
also be some degree of bias because of use of program
monitoring data. In the first year of intervention, although
a standardized data collection tool was developed and
shared with local nongovernmental organizations, some did
not collect data as per the suggested guidelines, resulting
in some bias. However, in subsequent years, training was
conducted for personnel in charge of monitoring systems
at local nongovernmental organizations, which improved
data quality.
In summary, adoption of a business franchise model
for an HIV prevention program among truckers resulted in
better program coverage and utilization of services. Imple-
menting the program among a highly mobile population
like truckers in a limited number of high-impact locations
in combination with branding and standardization
of services could help in saturating the coverage and
optimum utilization of available resources. The lessons
learnt from this intervention could be extremely useful
for HIV prevention programs throughout India and in
other geographic settings. Similar franchise models for
clinics can be established in HIV prevention programs
targeted at migrant populations. Male migrants make
both interstate and intrastate moves, and are prone to
negative health effects, including STIs, in their destination
areas. Establishing clinics with a uniform look and
services will enable migrants to locate and access these
clinics easily. Further, a consolidated national presence
through network clinics and an integrated approach to
programming rather than a stand-alone approach are
crucial for maintaining sustained engagement with
mobile populations, such as truckers and migrants.
Acknowledgment
This paper was written as part of the Knowledge Network
Project of the Population Council, which is a grantee of the
Bill and Melinda Gates Foundation through Avahan, its India
AIDS initiative. The views expressed herein are those of the
authors and do not necessarily reflect the official policy or
position of the Bill and Melinda Gates Foundation or Avahan.
We are grateful to the National AIDS Control Organization
for providing the necessary guidelines on aspects of HIV
prevention among truckers in India.
Disclosure
The authors report no conflicts of interest in this work.
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