June 2003

Reaching Highly Mobile Workers with HIV/AIDS Prevention Programs
Vietnam-based study examines impact of peer education, motivating management

In developing countries, highly mobile workers—truckers, traders, construction workers, domestic help—are among the populations in the work force that are most vulnerable to HIV infection, due to the social context of these jobs.

“Such workers are at increased risk of HIV because their mobility makes it hard to reach them with health information and services,” said Dr. Julie Pulerwitz of Horizons/PATH, a principal investigator for the study. “Since they work away from home, many also have multiple sexual partners.”

In Vietnam, HIV incidence—the rate of new infections—is rising as the virus moves into the general population. In 1994, officials from the Ho Chi Minh City Labor Union decided to target the city’s highly mobile workers, who make up about one-quarter of the city’s work force, with AIDS prevention activities. With financial support from the city’s AIDS Committee, the union initiated a project to increase HIV/AIDS knowledge and promote preventive behaviors in workplaces with many mobile workers.

Reaching workers in the construction industry was a major goal. The program used teams of volunteer visiting health communicators (VHCs) to make the rounds of construction sites and distribute condoms and leaflets on HIV/AIDS prevention. While they were not allowed to enter the work sites for safety reasons, they were able to speak to small groups of workers or in one-on-one sessions during work breaks and after the work day ended. The VHCs—mostly female social work students in their early 20s—were easy to recruit and train, requiring little initial investment. But the program soon found itself with a high dropout rate, since most VHCs left the program when they graduated.

“The number of dropouts was a weakness of the VHC program,” said Dr. Vu Ngoc Bao, a principal investigator for the study. “Since their first motivation was to improve skills to complement their social work studies, their commitment to the program was not that strong, and this affected the quality of communication activities.”

A Second Approach

To explore other options, the union agreed to work in partnership with the Horizons Program, Population Council/Vietnam, the Ho Chi Minh City AIDS Committee, and Ho Chi Minh City National University on a study comparing the effectiveness and affordability of the existing VHC program with an alternative peer education program, using workers at the sites as health educators. Peer educators (PEs) have long proven effective in more stable workplaces, but the feasibility and effectiveness of peer education programs among a highly mobile construction work force had not been tested in Vietnam.

“In fact, there are few examples of well designed operations research on HIV/AIDS in Vietnam, so, in addition to the importance of the findings of this particular study for Vietnam’s response to the epidemic, this research has also helped in the development of operations research within the country,” said Dr. Bao.

To select construction sites for the study, the research team conducted a mapping exercise of all sites with more than 50 workers in 19 of Ho Chi Minh City’s 22 districts. The research team then identified 23 sites, using criteria such as length of expected time to completion of the work and selection of only one site per construction company, and randomly assigned them to the PE or VHC groups.

Of the 12 identified for the PE intervention, six companies agreed to participate after hearing a formal presentation to management, as did the first six of the 11 contacted to receive the VHC intervention. After six months, all six of the VHC sites had closed, and six more sites were selected. Similarly, after six months, when PEs moved on to new sites—often with fellow workers—the companies managing those sites were asked to join the study.

The research included a formative phase to help develop the intervention activities, and an evaluation phase to assess the impact of the two programs. Workers, their families, and managers at nine construction sites participated in the formative research. Later, the research team gathered baseline data by interviewing 1,244 workers before the intervention began, then interviewed 1,256 workers six months later, and finally 574 workers twelve months after the start of the intervention. Eighty-five percent were males and 15 percent were females (in general, male and female workers were based at different sites). To assess the affordability of both types of programs, project staff, PEs, and VHCs maintained detailed records on all costs.

Intervention Activities

The companies chose peer educators from among their workers, approximately one for every 20 workers on the site. The selection process focused on workers who were team leaders or key workers who were respected by their co-workers and who had at least a secondary school education, an interest in helping fellow workers, and good communication skills. According to interview data, workers who became PEs were usually better educated, had lived in the city longer, and were already functioning as sources of advice and information for co-workers.

PEs received an initial four-day training course, followed by refresher raining in the fourth and eighth months of the intervention. The training enabled the PEs to discuss HIV/AIDS with co-workers and promote such preventive behaviors as abstinence, reducing the number of sexual partners, using condoms, and getting treated for sexually transmitted infections (STIs).

In their encounters with workers, PEs often conducted workshops using participatory approaches that they learned during training, including role playing, educational games, and drama and songs. PEs also held small interactive group sessions and informal one-on-one counseling, which was often requested by workers. These kinds of learning and counseling methods were new to many workers.

“Such interactive activities are not common in Vietnam, where educators tend to lecture to people,” said Dr. Pulerwitz. “The construction workers reported that they really liked this new format, but it takes training and practice to develop these new types of skills.”

In addition to distributing leaflets and condoms outside of work sites, VHCs—who also received initial and refresher training—spoke to small groups of workers, or with individual workers. Unlike the PE intervention, construction management was not actively involved in the VHC program, which was directed by the labor union. This may help explain why PEs reported receiving greater support from site managers than VHCs did.

Initially, PEs were less knowledgeable than VHCs about HIV/AIDS and appeared less comfortable discussing risky sexual behavior and other sensitive topics. After six months of training and experience, though, PEs had become as knowledgeable as VHCs and in fact more comfortable than VHCs about discussing sensitive issues.

Motivating the Management

An important goal of the research was to explore how best to promote the value of workplace HIV/AIDS programs to managers, particularly in a country with low HIV prevalence, where the threat of the epidemic may not be as evident as in regions where infection rates are high. To get feedback from managers on what motivated them to support such interventions, the research team interviewed 12 managers from the companies involved in the PE program.

A peer educator training session. Photo credit: Dr. Vu Ngoc Bao

They found that managers must be aware that their workers are at risk for HIV/AIDS. Some of the managers in the study appeared to be aware of such risks, and that in fact their employees’ vulnerability is greater because, as migrant workers, they are often away from spouse, family, and community, and are more likely to abuse alcohol and visit sex workers. Other managers became fully aware of the risk to workers only after they had spoken with labor union officials or members of the research team.

“Some managers thought of HIV/AIDS as a ‘social evil,’ like drug abuse, that had no effect on workers who appeared to be healthy and productive,” said Duong Xuan Dinh, director of the Ho Chi Minh City Labor Union. “They thought it wasn’t necessary for them to participate in workplace HIV/AIDS programs because their companies didn’t appear to have any workers infected with HIV.”

Managers must also understand that the wellbeing of workers helps determine the success or failure of the company and that they—as “caretakers” of their businesses—have a responsibility to promote worker health. Managers who believe they have a responsibility to Vietnamese society as a whole are also more likely to participate in prevention activities.

Some managers expressed concern about the potential effect of stigmatization within the atmosphere of the workplace. They felt that uninformed workers could have negative attitudes about working with someone who is HIV-positive, and that the resulting fear and conflict could lead to declining productivity and teamwork.

“Participating in this program is first to prevent workers from getting AIDS, and second, to change attitudes of our employees toward people living with AIDS,” said the director of a state-run construction company that participated in the study. “People may not want to work with [HIV-infected co-workers]…and this really affects productivity.”

Finally, how managers are approached by prevention programs appears to be important to ultimately gaining agreement to participate. Busy construction managers appreciated the systematic approach that union leaders—well-known and trusted colleagues—took in introducing the workplace prevention program, which included a letter to the director, a follow-up call, and a formal presentation to company management. The presentation was tailored to answer the questions and concerns of management and addressed estimated costs to the company.

Evaluating the Programs

Researchers found that workers in both PE and VHC interventions became more knowledgeable about HIV and other STIs, and about where to buy condoms and how to use them. Confidence to insist on condom use also improved significantly in both groups.

But data analysis shows that the PE programs reached more workers. At six months follow-up, 73 percent of surveyed workers at PE sites compared to 57 percent at VHC sites reported participation in group or one-on-one sessions. In addition, PEs had an overall broader reach among workers because the information they disseminated more likely diffused to non-participating workers as well.

The greater success PEs had at communicating with fellow workers—even those with whom they had not directly spoken—is due to several factors, including receiving greater support from their managers in implementing peer education activities and having more time than VHCs to interact with workers.

“Another important reason is that PEs, who are themselves workers, understand better what workers need and how best to communicate with them,” said Dr. Bao. “They use the same terms that workers use, and the workers feel more comfortable sharing intimate and private issues with PEs, who are often friends.”

PEs also distributed more condoms. At 12 months, 78 percent of workers surveyed at PE sites had received condoms, compared to 65 percent of workers at VHC sites. Levels of confidence in obtaining and using condoms, as well as lack of embarrassment in asking for condoms, were greater at PE sites.

Several specific measures of knowledge—including knowledge about HIV/AIDS, where to get and how to use condoms, and STIs and life skills—increased more for workers at PE sites. So did adoption of values that support HIV risk reduction (for example, whether it’s acceptable for a woman to ask a man to use a condom).

These results, in addition to the finding that the PE approach was more affordable per worker reached, have built support among public health authorities for the peer education model for migrant construction workers in Ho Chi Minh City and elsewhere in the country. At a workshop in Ho Chi Minh City in December 2002, officials and researchers discussed how best to motivate management to consider peer education strategies for their workplace HIV/AIDS programs.

This article was written by Margaret J. Dadian in conjunction with the study team, which includes Vu Ngoc Bao of FHI (formerly with the Population Council/Vietnam); Le Truong Giang and Le Thuy Lan Thao of the Ho Chi Minh City AIDS Committee; Duong Xuan Dinh and Nguyen Thi Hue of the Ho Chi Minh City Labor Union; Julie Pulerwitz of Horizons/PATH; Ann Levin of Horizons/FHI; and Philip Guest of Population Council/Thailand.

© 2003 The Population Council, Inc.

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This page updated
19 October 2007