An information-motivation-behavioral skills (IMB) model-based HIV prevention intervention for truck drivers in India

Abstract

The incidence of HIV/AIDS in India is increasing drastically, and truck drivers are seen as critical sources of HIV transmission due to their high rates of unprotected sex with multiple partners. An intervention based on the Information-Motivation-Behavioral Skills (IMB) model was compared to an information-only control condition in a randomized trial. IMB constructs were assessed among 250 male truck drivers immediately prior to and following implementation of the intervention, and sexual and condom use behaviors were assessed approximately 10 months later. The intervention consisted of a single-session group workshop with 5 interactive activities designed to address HIV prevention-related IMB constructs and to motivate condom use. Findings showed mixed support for the effectiveness of the intervention. There was an effect of the IMB intervention on attitudes, norms, behavioral skills, and intentions specific to condom use with marital partners, but no effects on constructs related to non-marital partners. There was some evidence of greater condom use with marital and non-marital partners at behavioral follow-up for participants in the IMB condition, and effects on condom use with marital partners were mediated by changes in IMB constructs. These findings provide initial evidence for the effectiveness of theoretically-based approaches to HIV prevention in India.

Introduction

The first case of HIV infection in India was diagnosed in 1986 in a commercial sex worker in Chennai, Tamil Nadu (Dakar & Dakar, 2001). HIV has since spread dramatically throughout the country, with cases having been reported in all States and Union Territories. Although the overall HIV prevalence in India is believed to be less than 1%, India has one of the largest HIV-positive populations in the world, with 5.21 million infected individuals (NACO, 2006). This represents nearly 15% of the world's HIV-infected population (UNAIDS, 2006) and 80% of Southeast Asia's infected population (World Bank, 2005).

Heterosexual transmission is the main route of HIV transmission in India, and long distance truck drivers are seen as critical sources of HIV risk and transmission (Manjunath, Thappa, & Jaisankar, 2002). They account for as much as 12% of the HIV-infected adult population, with an infection rate that is up to 10 times higher than the national average (Lane, 2005). There are an estimated 3 to 5 million long distance truck drivers and “helpers” (apprentice truck drivers) in India, who spend extended periods of time away from their families, often stopping at “dhabas,” or roadside eateries, where it is quite common for them to pick up a sex worker, have sex with her, and then drop her off at the next dhaba. Anywhere from 70% to 90% of long distance truck drivers have multiple sexual partners, and only a very small percentage of them use condoms (Bryan, Fisher, & Benziger, 2001; Manjunath et al., 2002; Rao, Pilli, Rao, & Chalam, 1999). Through their high risk sexual behavior, truck drivers not only put themselves and sex workers at risk for HIV, but also the general population when they return home and have sex with their primary and secondary partners (Bharat & Aggleton, 1999). Recent surveillance data have indicated that the epidemic is indeed spreading from high risk groups to the general population (NACO, 2005a, 2006; UNAIDS, 2004).

Although long distance truck drivers have long been implicated in the spread of HIV in India (Bansal & Nia, 1998), there has been relatively little use of behavioral science theory to develop theory-based HIV prevention interventions for this high risk population. There are several HIV prevention interventions currently being implemented with truck drivers (e.g., Healthy Highways Project—Family Health International, 2001; Operation Lighthouse—Population Services International, 2005), but most of them are atheoretical and focus primarily on disseminating information, not on increasing motivation and providing behavioral skills training. The majority of interventions have not been rigorously evaluated for their effectiveness, and when they have been evaluated, it has typically been with a process evaluation, where only the number of individuals participating in the intervention, and not the degree of behavior change, has been assessed. Those few interventions that have been evaluated for their impact on risk behavior have used pre- and post-measures with no comparison group (e.g., Family Health International, 2001), making it virtually impossible to draw any definitive conclusions about the interventions’ effects (Cook & Campbell, 1979; Shadish, Cook, & Campbell, 2002). It is thus critically important to develop theory-based interventions that have empirically demonstrated effectiveness in reducing sexual risk behavior.

The current study employed the Information-Motivation-Behavioral Skills (IMB) model of HIV preventive behavior (Fisher & Fisher (1992), Fisher & Fisher (2000), Fisher & Fisher (2002), Fisher & Fisher (1993); Fisher, Fisher, & Harman, 2003) as the basis for the development, implementation, and evaluation of an intervention to reduce sexual risk behavior among Indian truck drivers. The IMB model asserts that HIV prevention information, motivation, and behavioral skills are the fundamental determinants of HIV preventive behavior. HIV prevention information includes facts about how HIV is transmitted and prevented, HIV prevention heuristics (e.g., “Any woman who is not married must be HIV-negative.”), and implicit theories of HIV risk, which hold that one can detect and avoid HIV by assessing a partner's dress, demeanor, and social associations. HIV prevention motivation includes motivation constructs drawn from the Theory of Reasoned Action (Ajzen & Fishbein, 1980) (e.g., attitudes towards performing specific HIV preventive acts, perceptions of social support for performing HIV preventive acts, and behavioral intentions to engage in HIV preventive acts). The behavioral skills component of the model is composed of an individual's objective ability and perceived self-efficacy for the performance of HIV-preventive behaviors (Bandura (1989), Bandura (1994); Fisher & Fisher (1992), Fisher & Fisher (1993); Kelly & St. Lawrence, 1988). This model has been extensively validated in over 15 years of research with diverse populations in cross-cultural settings (see Fisher & Fisher, 2000).

Our IMB-based HIV prevention intervention for Indian truck drivers addressed the specific information, motivation, and behavioral skills deficits that were identified in elicitation research previously conducted with truck drivers in India (Bryan et al., 2001). The intervention was implemented in the city of Chennai (population ∼5 million), the leading industrial and commercial port in southern India. Chennai is the capital of Tamil Nadu, the state with the largest number of AIDS cases and one of the highest HIV prevalence rates in India (NACO, 2005b).

Due to the fact that long distance truck drivers are mobile and are rarely in one location for more than a few days, a single session workshop was developed that could be implemented where truckers congregate while they are waiting for their next assignment. In Chennai, truck drivers remain at the lorry sheds (locations where they park their trucks in between assignments) for 1–3 days before making their next delivery, so it was logical to conduct the intervention near these sheds. In order to reach the greatest number of truckers and to provide normative support for safer sexual practices, the intervention was offered in a group rather than an individual format. In order to ensure that the intervention was culturally appropriate for the target population of truck drivers and that it was feasible to implement in the chosen setting, the intervention was designed in close collaboration with the Benziger Foundation, a non-profit organization in Chennai that is dedicated to the eradication of HIV/AIDS in India. Effectiveness of the intervention was evaluated in a randomized controlled trial comparing the IMB-based intervention to an information-only control condition.