Migrants’ Sexual Health Intervention Project – Kerala

Introduction

India has among the highest number of persons living with HIV/AIDS in the world today, although the overall prevalence remains low. Some states experience a generalized epidemic with the virus transmitted from high-risk groups into the general population. Though Kerala is rated as a low prevalence state, the in –migrants from other high prevalent and neighboring state pose threat to Kerala. Kerala being rated as the best in implementing the TI projects by controlling the incidence of the infection among SWs and MSMs, the area of In-Migrants needs special attention to sustain the credit attained Apart from the other risk factors Migration and Mobility is likely to be a major threat factor for Kerala as the rate of In- Migrants is increasing fast and is beyond control. Migration for work for extended periods of time takes migrants away from the social environment provided by their families and community. This can place them outside the usual normative constraints and thus more likely to engage in risky behavior. Concerted efforts are needed to address the vulnerabilities of the large migrant population in Kerala. Addressing the migrant population is not an easy task due to the high volatile residential characteristics and due to the varied cultural and language factors.

Goal

The intervention program aims to halt, reduce and prevent the transmission of STD / STI / HIV / AIDS among the 5000 identified migrant workers by bringing change in sexual behaviour through BCC, health promotion and education, provision of appropriate facilities and services.

Objectives

Identification of the targeted migrant population
To identify and treat incidence of STI infections among the identified stakeholders
To develop health seeking behavior
To increase the correct and consistent usage of condom among identified stakeholders
To create and maintain an integrated supporting system by collaborating with different development institutions for the empowerment of primary stakeholders
To create a safe space for migrants to enhance collectivity and cohesion

Major Activities

Identification of stakeholders
Spot Analysis
Development of Voluntary Peer Leaders (VPL)
Contact Mapping
Capacity building program
Develop peer communication group
Implementation of BCC program
STI/STD treatment and Management
Condom program
Developing Linkages
Monitoring and evaluation

Technical Strategies for Interventions

Stakeholder analysis:

A stakeholder analysis comprising the primary, secondary and tertiary stakeholders
Behavior Change Communication
Condom programming
STI Management
Advocacy and networking
Community mobilization initiatives

Behavior Change Communication (BCC)

Behavior Change Communication (BC) is a multi-level tool for promoting and sustaining risk-reducing behavior change in individuals and communities by imparting tailored health messages through different communication channels.

Before reducing the risk and vulnerability to HIV, individuals and communities will be oriented on the urgency of the epidemic. They will be given basic facts about HIV/AIDS, taught a set of protective skills and offered access to appropriate services and products.
The strategic role of behavior change communication

BCC has many different, but related roles to play in HIV/AIDS programming. To make the BCC Effective thrust will be put on to:

Increase Knowledge

BCC will ensure that people have the basic facts in a language, visual medium or other media that they can understand and relate to. Effectiveness will motivate the target group to change their behaviors in positive ways.

Stimulate Community Dialogue

Encourage group and focused group discussions on the underlying factors, such as risk behaviors, risk settings and the environments that create these conditions. Create a demand for information and services.

Promote Advocacy

Through advocacy, BCC can ensure that policy makers and opinion leaders approach the intervention. Advocacy takes place at all levels, from the primary to the tertiary level.

Reduce Stigma and Discrimination

Communication on HIV/AIDS should address stigma and discrimination and attempt to influence social responses from the local self government and policy makers.

Promote Services for Prevention

Health seeking behaviour will be a priority in all BCC activity so that the stake holders go I for routine check ups, treatment and regular follow-ups

There are four important things that we need to take into account when we are trying to decide the goal of BCC:

If a person knows what he or she should do, it does NOT mean that he or she will do it. Other factors influence our decisions. Having knowledge about a behavior is only one factor. People often learn about a behavior long before they are willing to adopt it.

If a person wants to do a behavior, it does NOT mean that he or she will do it. Sometimes we are blocked and cannot do what we want to do and know we need to do (e.g., for lack of time, money). In addition, people often do not seek help from others (e.g., friends, health providers, God) to overcome a problem or change a habit.

Many times, we try to increase the level of FEAR that a person has in order to get him/her to do a preventive action. However, sometimes the problem is too much rather than too little fear of the disease or problem. However, sometimes too much fear can keep a person from doing something.

Many of the actions that people engage in that improve their health are NOT necessarily done for health reasons. It is possible to encourage a person to do something that improves his/her health for reasons that are not directed at improving health. We need to find reasons that motivate (or would motivate) people to do something that will improve their health, even if the reason is not health related

The goals of behavior change communication

BCC strategies in HIV/AIDS aim to create a demand for information and services relevant to preventing HIV transmission, and to facilitate and promote access to care and support services.

Some specific BCC objectives include:

Increasing the adoption and continued use of safer sex practices
Promoting visits to clinics treating STIs and opportunistic infections, including tuberculosis
Increasing the demand for VCT, for MTCT prevention services
Increasing the adoption and continued use of safer drug-injecting practices
Stimulating dialogue and discussion on risk, risk behavior, risk settings and local solutions
One to one and group counseling by trained professionals
Reducing stigma and discrimination for those living with HIV/AIDS
To ensure safer sex practices among the 25% of contacted stakeholders
To ensure behavior change with respect to health seeking behavior

Major intervention components

BCC
STI/STD intervention
Condom program
Enabling environment for the sustainability of the program

Sources of risk and vulnerability for male migrants

Relative freedom in the new setting as well as peer pressure to experiment with new norms
Distress migration driven by seasonal drought/disasters
Loneliness, drudgery and long periods of separation from spouse/sexual partner
Having disposable income, clubbed with limited choices of affordable entertainment and recreation

Sources of risk and vulnerability for female migrants

Poverty (usually reason for migrating in the first place) makes women more vulnerable to being pushed in to sex work at their destination to supplement their earnings

Lack o HIV and AIDS awareness, information and social support networks at both source and destination points

Loneliness, drudgery and long periods of separation from family/spouse/sexual partner

Limited or no skills to cope with the overall pressures and environment at destination places. This may lead to behaviors associated with risk for HIV infection i.e., drinking and sometimes drugs, as well as sex with male colleagues, casual sex relationships or sex work

Risk of being trafficked along the way and the risk of sexual exploitation, violence or harassment by sexual network operators/local power structures or by colleagues/supervisors/contractors in the workplace.

Lack of knowledge and negotiation skills make it difficult for women to negotiate condom use with their husbands and other sexual partners.

Lack of decision making power and reticence about seeking STI treatment often lead to a suppressed demand for health services even when the need is obvious. This results in prolonged untreated STIs and increases the risk of HIV infection.

Dearth of awareness of policies and laws which promote women’s rights to reproductive and sexual heath and equal access to education and information on heath care

Target Population

Since, the populace engaged in construction work and hotel work is more vulnerable to HIV/STI/AIDS, MCC sexual health intervention project has planned to work among them. The results of the Stakeholder Analysis (SHA) would be considered as the baseline for the prospective interventions. It would bring to light the data on their attitude, behavior and knowledge and the main thrust areas vis-à-vis vulnerability to HIV. A priority analysis also would be conducted for the right intervention among the primary and secondary stakeholders.

Typology

In general, migrants are categorized in to in-migrants and out-migrants and the various typologies of migrants are:

Constructions workers
Hotel workers
Truckers
Street vendors
Cable workers

Conclusion

The project will be implemented with a detailed stake holder analysis (SHA). The SHA will give clarity with regard to the spots and the population for the intervention. Based on the SHA findings appropriate strategy would be developed to address the issue. Being a peer based intervention, voluntary peer leaders (VPL) would be identified to support and lead the program. The VPLs would be subjected with intensive capacity building training in spot analysis and contact mapping. With the help of the VPL a detailed contact map would be drawn which would be further validated on the basis of name, sex, and language dominion. Small peer communication groups (PCG) would be formed in each site to facilitate the program. Strategic systems for BCC, Service delivery and condom promotion would be placed through these PCG. Linkages would be established between the primary, secondary and tertiary stake holders for the sustainability of the project.

The primary, secondary and the tertiary stake holders would be identified and a rapport will be established on the course. The SHA will also include a detailed spot analysis looking into the details of the number of PSH in the spot, their age range, work hours, leisure time activities, sexual activities and the time of activity, client population and the place of residence. Language specific BCC and IEC plans will be drawn for effective communication. Social marketing systems would be positioned for the easy accessibility of condoms. A very strong link would be established between the primary, secondary and tertiary stake holders for the sustainability of the project.