Results

Healthcare provision for truck drivers in sub-Saharan Africa: a systematic review of interventions, methods and evaluations of impactAuthors: Lalla-Edward, ST ; Fobosi, SC ; Stadler, J ; Venter WDF ; Gomez GB

1. Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa2. Amsterdam Institute for Global Health and Development, University of Amsterdam3. Department of Global Health, London School of Hygiene and Tropical Medicine

Searches yielded 12077 records. After removing duplicates 5598 records were screened. Of the 244 articles eligible 22 programs were included in the review (Figure 1).

Figure 1: Prisma four phase flow diagram

1 1 1 1 2.3

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BackgroundDue to the nature of their occupation, truck drivers are susceptible to poor health outcomes yet experience difficulties in accessing healthcare services. Healthcare interventions tailored to the needs of truck drivers have been proposed and implemented in varied contexts. Currently, the implementation of effective health interventions for truck drivers is hindered by a lack of knowledge of what is currently available for truck drivers and the impact of these services on health outcomes. The aims of this review are: (a) to describe health interventions implemented in sub-Saharan Africa amongst truck drivers and the methods used to evaluate them; (b) to assess the impact these interventions have had on truck drivers’ health outcomes.

MethodsThe review was conducted using a desktop review of published and unpublished material.

The published literature was searched using both MeSH headings and free text (twenty nine permutations of the search terms ‘truck driver’, ‘lorry driver’, ‘long haul driver’, ‘long distance driver’, ‘driver’, ‘health or intervention’, ‘odds ratio’, ‘risk ratio’, ‘evaluation’, ‘cost-effectiveness’, ‘effect or impact or effectiveness’), with no date or language limitations, was used to search PubMed/Medline, ISI Web of Knowledge, and eleven online search engines. Unpublished reports (other sources) were sourced from researchers and organisations who provide health services for truck drivers.  All publications (peer-reviewed articles or reports) describing a health intervention in sub-Saharan Africa and its evaluation where the main clients were truck drivers were included. Citations and bibliographies of records were reviewed to identify additional relevant material. Two reviewers selected records to be included and data related to both truck driver health intervention descriptions and evaluation results were extracted.  This systematic review has been registered on the international prospective register of systematic reviews, Prospero (registration number CRD42014013327) .

Full-text articles excluded, with reasons (n = 208)

No intervention described: 4Books: 4Not an intervention: 65Not truck drivers: 105Not in sub-Saharan Africa : 30

Records excluded (n = 5,354)

Records after duplicates removed (n = 5,598)

Records screened (n = 5,598)

Full-text articles assessed for eligibility (n =244)

Studies (programs) included in qualitative synthesis (n = 22)

Iden

tifica

tion

Scre

enin

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igib

ility

Incl

uded

Records identified through database searching (n = 5,686)

Additional records identified through other sources(n = 6,391)

Table 1: Regional distribution of interventions(Note: some programs operate in multiple regions)

REGION

# OF COUNTRIES

# OF PROGRAMS

# OF INTERVENTIONS

Southern

11

12

33

East

8

9

22

West

9

7

15

Central

2

4 4

Geographical distribution of programsEight of the 22 programs were delivered in a single country setting whilst the remaining 14 programs adopted a multi country approach. There was a distribution of 74 interventions (sub-sets/country level implementation of programs) in 30 countries (Figure 2 and Table 1).

Figure 2: Number of interventions per country against the 2011 general population HIV prevalence

Ahmed S, Maria K, Nandita S, Phelps R, Sabelli R, Diallo M, et AIDS. 2013; 27(Suppl 2):S235-45.

2012; 26:2361–73.

Acknowledgements

PROGRAM NAME IMPLEMENTATION YEAR AMREF Truck Driver Project(3,5) 1989-1993 World Vision(4) 1990-current Prevention of sexual transmission of HIV through information, education and communication(6)

1991-1994

NECTOI's AIDS education program(7,8) 1992-1997 Behavioural risk-reduction program(9) 1993 The Nigeria STD control intervention(10) 1996-1997 Prévention du SIDA sur les Axes Migratoire de l’Afrique de l’Ouest (AIDS Prevention on the Migratory Axes of West Africa) (PSAMAO)(11)

1997-2000

Chevron Workplace AIDS Prevention Program(12) 1998-current Corridor Empower Project/Trucking Wellness(13) 1999-current Corridors of Hope (CoH)(14-18) 1999-current Reproductive Health services for populations at high risk of HIV in Mozambique(19) 2001 Ugandan Transport Sector Workplace HIV Interventions (i.e. UCTOA, ATGWU-URWU) (4,20)

2001-2003

High Risk Corridors Initiative (HRCI)(4,21) 2001-2008

ADRA's HIV/AIDS Program (22) 2002-2005 The T-MARC Project (23,24) 2004-2010 WFP's HIV/AIDS training(4) 2004-current The HIV/AIDS project for the Abidjan-Lagos Corridor (currently: Organisation du Corridor Aidjan-Lagos (OCAL) project)(25)

2004-current

GDC Haulage workplace HIV/AIDS Program(4) 2006 ROADS II Project(26-33) 2006-2012 North Star Alliance(34) 2007-current RTI International’s (RTI) HIV Prevention Interventions for Most-at-Risk Populations (HIV-MARPS) project(35)

2008-2013

Improving HIV/AIDS knowledge and risk behaviours of drivers in Nigeria(36) 2011

Table 2: Implementation period of health programs for truck drivers

Service delivery modelMajority (15/22) of the programs rely strongly on peer educators and healthcare workers (6 peer educator only implemented and 7 being peer educator and healthcare worker driven). The interventions offered a combination of services (Figure 3) but focus predominantly on behaviour change. A minority of the programs offer services such as capacity building of peer educators and community health workers, prevention of mother to child transmission (PMTCT), family planning and linkage to clinical and social support. Interventions have been refined during the implementation process with earlier interventions primarily focussing on behaviour change communication, condom distribution and referral for HIV counselling and testing. The 43 interventions implemented between 2001-2011 incorporate elements of health service delivery from roadside wellness clinics such as STI, TB, HIV and malaria identification and management.

32%

22%

15% 14%

12% 12%

24%

0%

5%

10%

15%

20%

25%

30%

35%

Behaviour ChangeCommunication

Condom distribution Sexually Transmitted Infections

Stigma Reduction Information Education Communication

HIV Counselling and Testing

Other

Perc

enta

ge o

f int

erve

ntio

ns

Intervention service delivery areas

Figure 3: Distribution of services available to truck drivers (Note: some interventions include more than one service delivery area)

(14-18) (26-33)

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(15)

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ReferencesRefer to poster handout. Also available from slalla-edward@wrhi.ac.za

ConclusionIn recent years, the number of initiatives providing services tailored to truck driver’s needs across sub-Saharan Africa has increased.

Currently there are only four programs with evaluations reporting impact indicators for truck drivers. Three of these had positive impacts (decrease in STI incidence, AIDS mortality and female genital cutting) and one had a presumed negative impact reporting increases in STI incidence in truck drivers. Yet, due to the lack of control groups, it is challenging to attribute the effect observed to the programs implemented. It is important for managers and funders to understand the impact on health outcomes of these initiatives. This review highlights the need for improved evaluation of programs.

High coverage programsFour (Corridors of Hope III Project , the ROADS II Project , the World Food Program’s HIV /AIDS training and North Star Alliance) of the truck driver health programs have a high geographical coverage. The Corridors of Hope III Project is implemented in 11 countries, while the ROADS II Project is operational in eight countries, the World Food Program’s HIV /AIDS training program is implemented in ten countries and North Star Alliance is present in 12 countries.

The Corridors of Hope III Project was developed to provide prevention services to at risk populations using transport corridors and borders. The main focus of the project includes behaviour change communication, STI management (dependent on site this could be screening, identification, referral and treatment) and condom promotion and distribution. The ROADS II project is primarily aimed at addressing HIV and other health issues in the communities in the transport corridor by engaging with leadership and the communities themselves to ensure uptake of services provided at the program’s SafeTstops. The World Food Program’s HIV /AIDS training program is a train the trainer initiative for truck drivers and contract workers with a focus on behaviour change communication and decreasing stigma and discrimination. The North Star Alliance Program is delivered through Wellness centres and mobile clinics operated by healthcare workers and peer educators It serves truck drivers, their assistants, sex workers, local community at border posts with HIV identification services and management, behavioural change advice, condom promotion and distribution, STI testing and syndromic treatment, TB and malaria pre-screening, vital signs check-ups and referrals/linkage to appropriate care. EvaluationsOf the 22 programs that were delivered in 30 countries, 11 programs were evaluated in 13 countries. Evaluations were conducted between 1990 and 2011. Evaluation methods varied from pre- and post-intervention surveys to the analysis of routinely collected data. There was no dominant method of evaluation with four using the KAP (knowledge, attitudes and practices) survey method and three each being cross sectional and mixed method in design.

As shown in figure 4, only a minority of evaluations included impact indicators. A total of four programs reported results under one or more of the impact indicators which were related to changes in STI incidence, mortality, AIDS stigma and social norms. Yet the lack of control groups in these evaluations made it difficult to attribute the changes observed in impact indicators to the programs.

Other programs focussed the evaluation on changes in outputs and outcomes as shown in Table 3 - all reporting a significant benefit for clients

Figure 4: Impact assessment results

INDICATORS # OF PROGRAMS

# OF COUNTRIES

PROGRAMS CHANGE

Output Change in HTC and receiving an HIV test result 2 11 Corridors of Hope(15-18) Increase: 90 to 98%

Reproductive Health services for populations at high risk of HIV in Mozambique(19)

Increase: 54 to 115

Change in condom distribution 2 2 Prevention of sexual transmission of HIV through information, education and communication(6)

Increase: 33% in intervention; 2.5% in control

Reproductive Health services for populations at high risk of HIV in Mozambique(19)

Increase: 3151 to 9200

Change in ART access 1 1 High Risk Corridor Initiative(21) Increase: No reported statistics Change in clinic attendance 1 1 Reproductive Health services for populations at high risk of HIV in

Mozambique(19) Increase in STI visits: 20 to 28

Outcome Change in sexual behaviour 2 12 Corridors of Hope(15-18) Decrease in risky sexual behaviour

Behavioural risk-reduction program(9) Change in condom usage 7 17 Corridors of Hope(15-18) Increase in consistent condom use

NECTOI's AIDS education program(7,8) Increase: no reported statistics

AMREF(3,5) Increase (1990 – 1991): 56.1 % to 73.7% Decrease (1991 to 1993): 73.7% to 71.5%

The HIV/AIDS project for the Abidjan-Lagos Corridor (currently: Organisation du Corridor Aidjan-Lagos (OCAL) project)(25)

Increase: 59.% to 78.8 %

The Nigeria STD control intervention(10) Increase: no reported statistics Improving HIV/AIDS knowledge and risk behaviours of drivers in Nigeria(36)

Increase: 34.3% to 51.9%

High Risk Corridor Initiative(21) Increase: no reported statistics Change in alcohol and drug use 1 11 Corridors of Hope(15-18) Decrease: 11% to 3% Change in HIV/AIDS awareness and knowledge 5 7 ADRA's HIV/AIDS Program(22) Increase: no reported statistics

AMREF(3,5) Increase (modes of transmission) Intercourse: 97.4% to 99.0% Decrease (misconceptions) Shaking hands: 40.7% to 17.4% SW: 42.4% to 19.2% Mosquitos: 40.7% to 17.4%

High Risk Corridor Initiative(21) Increase: no reported statistics Improving HIV/AIDS knowledge and risk behaviours of drivers in Nigeria(36)

Increase: 89.3% to 100.0%

The HIV/AIDS project for the Abidjan-Lagos Corridor (currently: Organisation du Corridor Aidjan-Lagos (OCAL) project)(25)

Increase: 68% to 90%

Change in risk perception 2 2 AMREF (3,5) Increase: 54.5% to 62.1% NECTOI's AIDS education program(7,8) Decrease: 52.7% to 30.2%

Change in knowledge, perceptions and attitudes of HIV/AIDS 2 12 Corridors of Hope(15-18) Increase (modes of transmission)

Abstinence: 91% to 98% Decrease (misconceptions) Mosquitos: 17% to 8%

AMREF (3,5) Increase Willing to live in the same house: 66.7% to 90.8% Willing to eat together: 57.6% to 69.5% Willing to stare toilet: 53.1% to 56.1%

Change in HIV awareness and condom knowledge 2 2 Improving HIV/AIDS knowledge and risk behaviours of drivers in Nigeria(36)

Increase: 81.4% to 100%

NECTOI's AIDS education program(7,8) Increase: no reported statistics Change in knowledge of STIs 1 11 Corridors of Hope (15-18) Increase

Table 3: Evaluation results

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