Behavior Change Communication Strategies on Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome Risk Reduction for Long-Distance Truckers in Kenya

Abstract

Background

Long-distance truckers (LDTs) not only experience heightened risk of human immunodeficiency virus (HIV) infections due to risky sexual networks, but are also hard to reach with consistent risk reduction messages due to their often disruptive work schedules. Besides, evidence of the existing behavior change communication (BCC) strategies to enhance HIV/ acquired immunodeficiency syndrome (AIDS) risk reduction is limited. Thus, the study sought to explore the most effective and preferred BCC strategies for adoption among LDTs in Kenya.

Methods and Methodology

Nine key informants and 18 in-depth interviews were used to gather qualitative data from purposively sampled participants at Kenya's Busia and Namanga border points. A thematic analysis was conducted using a hybrid of inductive and deductive approaches, through the Qualitative Data Analysis Miner (QDA-Miner) software for QDA.

Results

Almost half of the key informants (44%) were aged 25-34, whereas half of the in-depth interviewees were 35-44 years old. Media-based communication channels were the most common and accessible. Other BCC strategies included interpersonal communication and healthcare worker service-driven strategies, peer-led open discussions and shared experiences on HIV/AIDS risk reduction, outreach activities to reach more of the underserved LDTs, and non-governmental organization (NGO)-driven approaches to fill gaps left by the public healthcare systems.

Conclusion

Media-based communication channels were the most common BCC strategies. However, a combination of interpersonal communication, peer-led services, outreach activities, and NGO-driven approaches played a key role in enhancing the HIV/AIDS risk reduction message reach to the LDTs.

Keywords

behavior communication HIV & AIDS risk reduction truck drivers

Introduction

Even with the advent of the current cutting-edge drugs like pre-exposure prophylaxis (PrEP), new human immunodeficiency virus (HIV) infections continue to occur at an alarming rate globally. According to the Joint United Nations Programme on HIV/acquired immunodeficiency syndrome (AIDS) (UNAIDS) report of 2024, more HIV infections occurred outside sub-Saharan Africa (SSA) in the year 2023.¹ Nonetheless, Kenya, among other SSA countries, still bears the highest burden of HIV globally.¹ Evidence is available that the burden of HIV is concentrated among key population groups, such as long-distance truckers (LDTs).² Specifically, HIV prevalence rates of as high as 26.49%,³ 18.13%,⁴ and 17.8%,⁵ have been previously reported between 1991 and 1999 among LDTs along the Northern Corridor highway in Kenya. However, more current statistics are missing. Nevertheless, a recent systematic review and meta-analysis identified HIV prevalence rates of 14.34% among LDTs in SSA, meaning that LDTs in the region, including Kenya, are still at high risk of new infections.² Understandably, the high prevalence rates are due to a myriad of barriers, such as systemic health system inequalities along transit routes and chronic trucking career-related obstacles among LDTs.⁶ Indeed, most recent evidence has shown that the burden of HIV among LDTs is 14.34% in SSA, almost five times that of the general population.²

The high burden of HIV among LDTs has been attributed to several factors. First, LDTs are known to exhibit high-risk sexual networks characterized by poor condom use, substance use, and frequent interactions with female sex professionals whose risk of HIV is also high.^7–9 Moreover, LDTs’ nature of trucking career, among other health system barriers while on transit, could delineate or prevent them from accessing key HIV prevention services from mainstream healthcare services.⁶ The LDTs have irregular work schedules and may usually experience unforeseen delays while in transit.^10,11 Thus, LDTs are also understood to be hard to reach with HIV prevention services. As such, their routine access to HIV prevention services is often disrupted. In such a scenario, LDTs may miss the updates on the currently available HIV prevention services such as PrEP. Consequently, LDTs’ knowledge and awareness of the current HIV prevention services are limited. Therefore, to promote safe sexual practices and enhance knowledge and awareness of HIV prevention, behavior change communication (BCC) strategies are strongly recommended for hard-to-reach populations like LDTs.¹²

Briefly, BCC strategies entail applying communication approaches and tools to support, promote, and sustain positive health behaviors among individuals.¹³ The BCC strategies can be peer-led, health worker-led, or even delivered through mass media, print media, and social media, among many other platforms.¹⁴ In the context of HIV/AIDS prevention among LDTs, behavior change entails sexual partner reduction, enhanced use of condoms during sexual intercourse, avoidance of illicit drugs and substances during or before sexual intercourse, delay of sexual intercourse, HIV testing, sexually transmitted infection prevention (STI) treatment, and PrEP use.^15,16 Indeed, BCC strategies form an integral component of the UNAIDS recommendation for combination prevention since they create demand for the uptake of biomedical services among hard-to-reach groups like LDTs.¹²

Across the world, BCC strategies have been conducted to enhance HIV/AIDS risk reduction among LDTs. For instance, in Brazil, a BCC intervention integrated media campaigns (using billboards and educational materials) with outreach activities leading to positive outcomes on condom use, HIV testing, and safe sexual behaviors among LDTs.¹⁷ Peer education has been used among LDTs in India and Tanzania with enhanced condom use outcomes.^18,19 In Kenya, while there have been previous efforts to improve HIV/AIDS risk reduction through offering free oral HIV testing kits through text messages to LDTs,²⁰ evidence of the most effective, accessible, and frequently used BCC strategies is limited. As such, a systematic review and meta-analysis of global evidence has been conducted, with preliminary findings showing strong support for modern technology media-based BCC approaches, especially those delivered through mobile phone platforms to LDTs, given their constant mobility.²¹ However, to gain a deeper understanding of the BCC approaches mostly preferred by LDTs in the Kenyan setting, a qualitative study is deemed suitable to explore their lived experiences. Therefore, this study aims to understand how healthcare professionals and LDTs create meaning in HIV/AIDS risk reduction from existing BCC strategies, to develop a targeted mobile phone-based BCC intervention for them.²²

While there have been substantial recommendations for the adoption of BCC strategies to remotely reach the hard-to-reach populations, such as LDTs with consistent HIV prevention messages, evidence of their use is limited or missing in most developing nations, including Kenya.¹ By understanding the existing BCC strategies targeted for LDTs, key stakeholders will have an insight into how best they can improve them to yield better HIV prevention outcomes in Kenya. This study will partly contribute to the Joint United Nations Programme on HIV/AIDS (UNAIDS) goal to stop new HIV infections and end AIDS by 2030.¹ Therefore, it is upon this gap that the current study was conducted.

Methods and Methodology

Study Setting

The study was conducted at the Busia and Namanga towns at the western border points of Kenya/Uganda, and Kenya/Tanzania. The towns are among the busiest transit gateways to/from Kenya to other East African countries. They are also key stopover points for LDTs seeking accommodation and the services of abundant female sex workers.²³ For these reasons, the two towns were sampled as study sites.

Study Design

The current study was a qualitative arm of a larger concurrent triangulation mixed methods design. Specifically, the qualitative arm sought to answer two research questions: one on existing BCC strategies on HIV/AIDS risk reduction and the second on barriers to HIV/AIDS risk reduction among LDTs now published.⁶ The study was anchored on a constructionist paradigm to understand socially constructed realities from the perspective of study participants. The healthcare professionals and LDT peer educators constituted the key informants, whereas the LDTs formed the in-depth interviews (IDI). The consolidated criteria for reporting qualitative research (COREQ) checklist is given in Supplementary File 2.²⁴

Study Population and Eligibility

The study population involved healthcare providers and LDT peer educators who offered HIV/AIDs risk reduction services to the LDTs within Busia and Namanga towns. In addition, LDTs at moderate and high-risk levels based on a formative HIV/AIDS risk assessment in the quantitative arm were purposively selected to participate in the IDIs. Non-healthcare professionals, such as receptionists, were excluded.

The healthcare providers such as nurses, trucker peer educators, clinicians, and community mobilizers who offered HIV/AIDs risk reduction services to the LDTs within Busia and Namanga towns were also included in the study. Other healthcare professionals who were not directly involved in offering HIV/AIDS preventive services to LDTs, like receptionists and health record officers, were excluded. LDTs aged below 18 years were excluded from the study. While there were no gender restrictions, we didn’t encounter a female LDT.

Sample Size

Initially, it was projected that 10-15 key informant interviews (KIIs) and 20-30 IDIs were to be conducted. However, the actual sample size was 9 KIIs and 18 IDIs.

Data Collection Tools

A KII and IDI guide were used to gather qualitative data from study participants. The interview guides were designed based on existing guidelines.²⁵ Before the data collection exercise rollout, the tools were pre-tested at Mlolongo town in Machakos County, Kenya. The KII and IDI guides are given in Supplementary File 1.

Data Collection

Prior arrangements were made regarding a suitable site where the interview was to be conducted based on the preferences of the key informants. A consent form was given to the key informants detailing the protocol and assuring them of confidentiality and that the process would be voluntary. The KIIs were conducted in either English or Swahili. The researcher was accompanied by at least one research assistant during the KIIs. While the researcher took the participants through the KII guide, the research assistant took shorthand notes and audio recordings. Approximately, the KIIs lasted between 30 and 45 min.

Given the hard-to-reach nature and constant mobility of the LDTs, it was almost impossible to mobilize them for a focus group discussion. Therefore, the IDIs were deemed suitable to generate an in-depth understanding of LDTs’ experiences with existing BCC strategies on HIV/AIDS risk reduction. The language of choice for the IDIs was either English or Swahili. The participants of the IDIs were purposively sampled from among the LDTs registering high HIV risk scores from the main questionnaire in the quantitative arm of the current study. An appropriate venue for the IDIs was sought according to the interviewees’ preferences. The interviewees were taken through the study protocol and made aware that the process was voluntary and that their identities would be kept confidential. Approximately, the IDIs lasted between 30 min and one hour. While the researcher took some shorthand notes, the interview session was audiotaped for record-keeping. Alongside getting study participants’ experiences on BCC strategies, sociodemographic variables such as age, gender, cadre, and duration of experience were also collected.

Research Team and Reflexivity

In particular, the principal investigator was primarily responsible for conducting all the KIIs and IDIs. The principal investigator was of male gender and a doctoral student with a background training in nursing and public health and a master's degree in international health. Understandably, given the lack of prior connection with the study participants, the principal investigator's role may have affected the type of data collected. The participants may have withheld some information from someone not familiar to them, hence limiting the depth of conversations around their experiences on existing BCC strategies on HIV/AIDS risk reduction. This was mitigated by creating a rapport that allowed the participants to share their experiences freely and without feeling coerced.

The data collection exercise was supported by two research assistants who had background training in nursing and public health and were both Female. The research team had no prior knowledge of the research participants. The presence of two female research assistants may have made some male LDTs withhold their experiences around BCC risk reduction strategies due to the cultural perceptions around men sharing sexual health with women.

By understanding the above potential sources of bias, the research team took various actions to minimize their effect throughout data collection and analysis. First, while in the field, we took reflective notes to document how our thoughts and assumptions were likely to affect the interpretation of the research findings. Moreover, the principal investigator engaged in frequent debriefing sessions with the research team to cross-check and compare responses and interpretations on barriers to HIV/AIDS risk reduction from different participants. Lastly, we used triangulation during the analysis to compare the qualitative findings across various interviews.

Data Management and Analysis

A hybrid of inductive and deductive thematic analysis was used. Here, while some themes were identified in advance, others were derived during the data analysis. This approach sought to organize and describe the qualitative data into themes and sub-themes.²⁶ As such, the analysis followed six steps: data familiarization, generating child and parent codes, clustering the child and parent codes to generate themes and sub-themes, reviewing the themes and sub-themes, defining and naming the themes and sub-themes, and reporting.²⁶

A total of 9 KIIs and 18 IDIs informed by saturation had been conducted and prepared for qualitative data analysis (QDA). The researcher, assisted by one research assistant, transcribed and translated the audio-recorded data verbatim. A transcript was generated for each KII and IDI. All transcripts were exported into the Qualitative Data Analysis Miner (QDA-Miner) statistical software version 2024.0.5 for analysis.²⁷ Subsequently, child codes were developed by reviewing the transcripts and identifying items related to each research question. After the child codes were generated, the researcher categorized them into their respective research questions. The categorization involved screening the child codes for similarities and differences. Thereafter, the child codes were retrieved and saved in an MS Excel sheet in preparation for clustering to generate parent codes. Child Codes that appeared closely related were clustered and merged to form parent codes in the QDA-Miner software. From the parent codes, themes and sub-themes were generated.

Afterward, the researcher retrieved an MS Excel sheet from the QDA-Miner software comprising the initial child codes, parent codes (themes and sub-themes), number of mentions for each theme, and number of cases (participants concerning the themes). The transcripts were shared with a second coder to verify the codes, themes, and sub-themes the researcher had initially generated. Triangulation of the qualitative findings from the KIIs and IDIs was done.²⁶ Here, a comparison of findings from KIIs and IDIs was made to compare and contrast emerging BCC strategies on HIV/AIDS risk reduction among the LDTs. Lastly, a narrative detailing the themes and sub-themes is given.

Results

Participant Characteristics

The study comprised nine key informants and 18 in-depth interviewees. Most of the key informants 4 (44%) were aged between 25 and 34 years. A majority of the key informants were female (5 (56%)) and were from Busia site 8 (89%), Table 1.

Table 1.

Sociodemographic and Socioeconomic Characteristics of Key Informants.

Variable	Category	N = 9 (%)
Age in years	18-24	1 (11)
	25-34	4 (44)
	35-44	2 (22)
	Above 44	2 (22)
Gender	Male	4 (44)
Gender	Female	5 (55)
Study site	Busia	8 (88)
Study site	Namanga	1 (11)
Profession	Nurse	3 (33)
	Pharmacist	1 (11)
	Peer-educator	1 (11)
	Community mobilizer	2 (22)
	Trucker's Association Leader	2 (22)
Years of experience	1-4	2 (22)
	5-9	3 (33)
	Above 9	3 (33)

About 50% of the IDIs were aged 35-44 years. Slightly above half of the in-depth interviewees were from Busia 10 (56%), whereas the majority, 15 (83%) of them, were truck drivers, as shown in Table 2.

Table 2.

Sociodemographic and Socioeconomic Characteristics of In-Depth Interviewees.

Variable	Category	N = 18 (%)
Age in years	18-24	4 (22)
	25-34	3 (17)
	35-44	9 (50)
	Above 44	2 (11)
Study site	Busia	10 (56)
Study site	Namanga	8 (44)
Profession	Truck Driver	15 (83)
Profession	Assistant trucker	3 (17)
Years of experience	1-4	1 (6)
	5-9	8 (44)
	Above 9	9 (50)

A total of five themes emerged. These include media-based communication channels were most common and accessible, interpersonal communication and healthcare worker service-driven strategies, peer-led open discussions and shared experiences on HIV/AIDS risk reduction, outreach activities to reach more of the underserved LDTs and enhance tailored messaging, and non-governmental organization (NGO)-driven approaches to fill gaps left by the public health systems. A summary of the themes, sub-themes, codes, and illustrative text is given in Table 3. Also, a word cloud visualizing the frequency of the qualitative responses on BCC strategies from the study participants is presented in Figure 1.

Figure 1.

A word cloud visualizing the frequency of qualitative responses for BCC strategies on HIV/AIDS risk reduction among LDTs. LDT, long-distance trucker; HIV, human immunodeficiency virus; BCC, behavior change communication; AIDS, acquired immunodeficiency syndrome.

Table 3.

Summary of BCC Strategies on HIV/AIDS Risk Reduction Targeting LDTs in Busia and Namanga Sites.

Theme	Sub-theme	Codes	Illustrative Quote
Media-based communication channels were the most common and accessible	Broadcast media-based communication channels	Radio	“The only communication on behavior change I have heard was on radio programs, and this is about condom use messages and having faithful partners, and you know this was not even specifically for truck drivers but the general population.” (IDI05, 43 years old, Male)
	Print media-based communication channels	Pamphlets	“The only place where I have been approached and given some small pamphlets on HIV prevention mechanisms like condom use is in the Tunduma border of Zambia and Tanzania, but within Kenya and Tanzania, not really.” (IDI14, 38 years old, Male)
	Modern technology/media-based communication channels	Flash-drives Text-messages	“Previously, an NGO called ‘Terres de Homes’ provided flash drives with messages on HIV prevention for truck drivers so that they can play the HIV risk reduction messages while in transit. But they just provided 15, which is inadequate for all the truck drivers.” (KI008, 45 years old, Male)
Interpersonal communication and healthcare worker service-driven BCC strategies		Clinicians Nurses	“Generally, we (nurses and clinicians) ensure they (LDTs) get condoms (as you can see, there is a dispenser around the corner there full of condoms). We also share with them health messages and other key services, not just on HIV prevention, but also other non-serious illnesses.” (KI004, 24 years old, Female)
Peer-led open discussions and shared experiences on HIV/AIDS risk reduction		Peer-educators	“Like, they are supporting us in conducting an outreach here this week. They have trained over 60 peer educators, and they will attend this outreach and others in the past and future. That is why these peer educators are here. They are the ones who are educating the truck drivers on the updates on PrEP and PEP.” (KI004, 24 years old, Female)
Outreach activities to reach more of the underserved LDTs and enhance tailored messaging		Outreach	“Sometimes we organize outreaches for HIV preventive services, but still you will find that LDTs don’t access them.” (KI004, 24 years old, Female)
Non-governmental organization (NGO)-driven approaches to fill gaps left by the public health systems		NGOs IRDO North-Star Alliance	“We have an NGO called IRDO, at least it supports us in various ways like for the outreaches, they give us the equipment needed for HIV prevention services; they compensate in terms of enumeration, and also provide drugs and condoms. (KI004, 24 years old, Female)

LDT, long-distance trucker; HIV, human immunodeficiency virus; BCC, behavior change communication; NGO, non-governmental organization; PrEP, pre-exposure prophylaxis; AIDS, acquired immunodeficiency syndrome.

Theme 1: Media-Based Communication Channels Were the Most Common and Accessible

Broadcast Media-Based Communication Channels

Participants cited radio as the most common broadcast media through which they had previously received BCC messages.

‘It is just the normal radio programs for everyone. And you know nowadays it is not very common because many people know about HIV.’ (IDI18, 41 years old, Male)

‘The only communication on behavior change I have heard was from radio programs, and this was about condom use messages and having faithful partners, and you know this was not even specifically for truck drivers but the general population.’ (IDI05, 43 years old, Male)

To enhance the media-based communication channels, one key informant recommended the following;

‘I call upon stakeholders to support us. Also, the media can play a role in educating truck drivers on HIV risk reduction and current updates. For example, you see the truck drivers spend a good time listening to the radio. That way, they can be reached with key HIV risk reduction messages.’ (KI009, 38 years old, Male)

Print Media-Based Communication Channels

Several participants also shared that they had received BCC messages on HIV/AIDS risk reduction printed in the form of posters, pamphlets, and information, education, and communication (IEC) materials. Two participants disclosed that they had been issued with some pamphlets on HIV prevention, though it was not certain from which organization.

‘There have been times when we met some people along the way; I think they were from an organization, and they gave us condoms and some papers with good information about HIV prevention. But I don't remember their name’ (IDI01, 37 years old, Male)

‘The only place where I have been approached and given some small pamphlets on HIV prevention mechanisms like condom use is in Tunduma on the border of Zambia and Tanzania, but with Kenya and Tanzania, not really.’ (IDI14, 38 years old, Male)

Another participant disclosed that they had posters around the facility for LDTs to read on HIV risk reduction.

‘If you have looked at our walls, we have a few posters there, but these truckers don't have time to read them.’ (KI002, 39 years old, Female)

A key informant shared that they only received a few IEC materials, which were insufficient to share with the LDTs.

‘We only get these IEC materials when we go for training, and you know we are only given copies that are enough for us, so we are not even left with any to give to the truckers.’ (KI003, 28 years old, Male)

In addition to the IEC materials, another participant shared that they had been issued branded driver accessories with messages on HIV risk reduction.

‘We used to have BCC materials like IEC materials, but they are no longer available. Donors had only given a few previously. There is an organization that provided us with bags and reflector jackets branded with HIV prevention information, but only 15 of them, so we couldn't give these BCC materials to many truck drivers. I wish they could provide many of them so that we can distribute to more truck drivers.’ (KI008, 45 years old, Male)

When asked how the print BCC strategies could be enhanced, one participant recommended the following;

‘By printing many of those pamphlets, I think many truck drivers can be given them to read.’ (IDI14, 39 years old, Male)

Modern Technology/Media-Based Communication Channels

Participants also stated that they had received certain aspects of BCC messages through modern technology/media devices like flash disks.

‘Previously, an NGO called “Terres de Homes” provided flash drives with messages on HIV prevention for truck drivers so that they can play the HIV risk reduction messages while in transit. But they just provided 15, which is inadequate for all the truck drivers, given their huge population. So if there were more materials, we could enhance the HIV risk reduction messages to reach more drivers.’ (KI008, 45 years old, Male)

‘You know, as you can see, these clearing agents have our phone numbers, sometimes they will give them to certain agencies, and they send us text messages telling us to use condoms and other examples of HIV prevention messages. But the problem is that many truck drivers delete them without reading what is there.’ (IDI12, 23 years old, Male)

When asked to recommend what they would recommend concerning modern technology communication channels, one participant stated the following;

‘When a text message is incoming in the phone, they will hear or see a notification and read. Yes, so I think they can be informed, and they will read and understand what you were telling them. You see, no one ignores text message notifications. They will read, even if they don't complete the whole message, they will have read it to some extent anyway.’ (KI005, 26 years old, Female)

On the timing of the text messages, one participant recommended the following;

‘I think the best time to read messages is when we are resting and not very busy with our activities. You know it's good to read when you are relaxed. That is the time we find it easy to read the messages. Otherwise, we may receive many other notifications during the day, and when we open our phones to see new messages later in the day, we may not have time to read all of them.’ (IDI06, 23 years old, Male)

Another participant felt that if more flash drives were made available, then more LDTs could be reached with the audio-recorded risk reduction BCC messages.

‘I recommend the provision of similar items like more flash drives, IEC materials, placards, and brochures on HIV prevention among the truck drivers.’ (KI008, 45 years old, Male)

Theme 2: Interpersonal Communication and Healthcare Worker Service-Driven Behaviour Change Communication Strategies

The key informants expressed the role they played in disseminating BCC messages and HIV/AIDS risk reduction among LDTs. Some of their key roles included educating LDTs on condom use, providing condoms during routine HIV testing and STI screening, organizing and participating in “moonlight” HIV prevention outreaches, and providing medication refills for PrEP and ARTs.

‘Generally, we (nurses and clinicians) ensure they (LDTs) get condoms (as you can see, there is a dispenser around the corner there full of condoms). We also share with them health messages and other key services, not just on HIV prevention, but also other non-serious illnesses.’ (KI004, 24 years old, Female)

Theme 3: Peer-led Open Discussions and Shared Experiences on Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome Risk Reduction

Participants felt that peer educators were central in disseminating BCC messages among LDTs. This was so, especially at the Busia border customs health facility for LDTs. On the contrary, no peer educators were at the Namanga border point.

‘Like, they are supporting us in conducting an outreach here this week. They have trained over 60 peer educators, and they will attend this outreach and others in the past and future. That is why these peer educators are here. They are the ones who are educating the truck drivers on the updates on PrEP and PEP.’ (KI004, 24 years old, Female)

A peer educator expressed that they were tasked with the primary responsibility of educating truckers on various HIV/AIDS risk reduction aspects, with emphasis on the most current ones, such as PrEP, though facing a limitation in working hours.

‘Our main responsibility is that of sharing HIV/AIDS risk reduction messages with the truckers, especially when they are waiting for clearance at the customs point. We are currently encouraged to emphasize some of the latest and most effective prevention approaches, such as PrEP.’ (KI003, 28 years old, Male)

Theme 4: Outreach Activities to Reach More of the Underserved Long-distance Truckers and Enhance Tailored Messaging

Participants highlighted that they had conducted periodic outreaches to reach more LDTs with BCC messages and HIV/AIDS risk reduction services, especially at the Busia border point.

‘The clinicians and nurses at the border post sometimes conduct what we call “moonlight” testing, especially when there are many truckers. The County Aids Coordinator (CASCO), organizes the moonlight activity, and they are tested and given messages. Those who are diagnosed with HIV are initiated on treatment and care, whereas those on ART care can do their refills. They don't need to alight their vehicles; some of these services are provided to them while they are on board.’ (KI001, 47 years old, Female)

‘My role is that of a mobilizer. I am tasked with talking to the truck drivers when they are in the area, so that they can come for our services. Whenever a truck stops for clearance here at customs, I talk to the truck driver. I tell them that we have some health services like HIV testing, condoms, PrEP, and PEP. And then, if they are convinced, they can choose to come. We also do this during outreaches. This week, we will have one. During those activities, we guide the truckers to our HTC counselors, clinicians, and nurses, and then from there, they are given the services they need.’ (KI005, 26 years old, Female)

‘Sometimes we organize outreaches for HIV preventive services.’ (KI004, 24 years old, Female)

Theme 5: Non-Governmental Organization-Driven Approaches to Fill Gaps Left by the Public Health Systems

NGOs were mentioned as key facilitators of BCC strategies targeting LDTs. Participants stated that most of the HIV/AIDS risk reduction services at the Busia border point were mainly supported by NGOs.

‘We have an NGO called Impact Research and Development Organization (IRDO). It supports us in various ways, like the outreaches. They give us the equipment needed for HIV prevention services, but remember, IRDO is also supported by the Red Cross organization (Two organizations in collaboration). Yeah, during the outreach, the IRDO compensates in terms of enumeration and also provides drugs and condoms.’ (KI004, 24 years old, Female)

However, one participant mentioned that one NGO had since ceased to operate at the Namanga border point, leaving LDTs with no healthcare facility to address their needs.

‘Some years ago, we had an NGO called North Star Alliance. They used to be in a blue container on the other side, but they are no longer there. Recently, NGOs have been affected by budget cuts from major donors like USAID. So I think they were affected by that somehow, but I'm not so sure. What I know is that they are no longer in operation.’ (KI009, 38 years old, Male)

Discussion

The study established various existing BCC strategies targeting LDTs along the Northern Corridor highway in Kenya. While almost all of the BCC strategies had a common goal of enhancing HIV/AIDS risk reduction, only the “moonlight” outreach activities and NGO-driven approaches appeared to address the unique healthcare needs of the LDTs. The timing of the outreaches at night hours was somewhat considerate of the LDTs’ disruptive work schedules, similar to the NGO efforts to support risk reduction services at the Busia international border point. Conversely, the lack of media communication channels specifically designed for the LDTs highlights the lack of tailored risk reduction messages for the population. Thus, there is a need for customized communication channels that align with the unique contextual needs for LDTs. Nonetheless, there have been previous efforts to enhance oral HIV testing through tailored mobile phone text messaging for the LDTs.²⁰

The participants highlighted broadcast media-based BCC strategies as the most common and accessible. Here, sub-themes included broadcast media-based communication channels, print media-based communication channels, and modern technology/media-based communication channels. Broadcast media-based communication channels are mainly channeled through radio or television. In this study, participants disclosed having received certain messages advocating for HIV preventive practices like condom use through radio when in transit. While messages shared through radio channels can reach a wide audience, it may not be easy to tailor them to certain populations, given the naturally existing diversity. The LDTs in this study disclosed that whereas they benefited from such messages, they were not the primary target audience. This suggests the need for healthcare stakeholders to look for ways in which they can develop mini radio programs that target LDTs with HIV/AIDS risk reduction. In Mexico's Southern Border, a BCC strategy provided a two-way radio to exchange information among other LDTs on HIV prevention.²⁸ Here, the radio conversations triggered deep conversations on various HIV prevention domains like the use of condoms and the reduction in the number of sexual partners. As a result, the program highlighted existing discrepancies in the knowledge of HIV among the LDTs, calling for a long-term intervention to instill the correct HIV risk reduction.²⁸ Moreover, broadcast media channels have been used to sensitize LDTs on HIV prevention practices such as condom use and sexual partner reduction in Nigeria.²⁹ Also, similar channels such as video-based counseling,³⁰ and media-based campaigns to encourage use of the “Kavach” project run HIV/AIDS prevention clinics, have been used with positive outcomes among LDTs in India.³¹ This reveals the potential that such programs possess in enhancing HIV/AIDS risk reduction among LDTs. Print media-based communication channels, such as IEC materials, pamphlets, and other documented materials, have been previously used in Mexico, Brazil, Nigeria, Morocco, and Kenya to enhance HIV/AIDS risk reduction among LDTs elsewhere.^{17,28,29,32,33}

More importantly, as mentioned in this study, modern technology strategies such as text-based messages have been adopted with successful outcomes in enhancing LDTs’ HIV/AIDS risk reduction in Kenya, Zimbabwe, Mozambique, and South Africa.^20,34 Indeed, the UNAIDS recommends the use of modern technology like mobile phone text messaging to remotely reach hard-to-reach populations like LDTs with HIV/AIDS prevention messages.¹ Conversely, modern technology-based BCC strategies were either unpopular or underutilized based on the current study's findings. Slightly different from the text-based BCC strategies highlighted here, another study in India utilized phone calls to enhance HIV/AIDS risk reduction among LDTs.³⁰ This suggests the need to embrace technology-based BCC strategies in improving HIV/AIDS risk reduction, given that almost everyone, including LDTs, owns a phone in the modern-day world.

The second most prominent theme in this category was NGO-driven approaches to fill gaps left by the public health systems. Given the unique nature of the long-distance trucking career, LDTs are mostly underserved by mainstream public healthcare facilities.^35,36 To bridge this gap, NGO-driven health facilities have been put in major stopover locations and international border points along main LDTs’ transit corridors.^37,38 The NGO-driven programs are mostly donor-funded and offer varying HIV/AIDS risk reduction services ranging from HIV testing, PrEP, and PEP, to ART care and follow-up, among many others.^38,39 North Star Alliance is in major highway corridors in South Africa, Zimbabwe, Zambia, Tanzania, and Kenya.³⁶ However, even with the presence of these NGOs, LDTs continue to face limited access to HIV/AIDS risk reduction, especially in recent years when donor funding has been significantly downsized.¹ Indeed, one of the key informants disclosed that a health unit for LDTs operated by North Star Alliance in Namanga had since been closed down owing to a lack of funding. Here, we note the central role the NGO-driven health facilities play in enhancing HIV/AIDS risk reduction in vulnerable populations like LDTs. Therefore, there is a need for NGOs like UNAIDS to advocate for more funding for these NGOs so that they can continue executing their HIV/AIDS prevention without facing financial obstacles.

Participants highlighted the existence of outreach activities to reach more of the underserved LDTs and enhance tailored messaging. It was mentioned that outreach-driven BCC strategies were very instrumental in carrying forward HIV/AIDS risk reduction for LDTs. It was stated that outreaches were often organized to align with LDTs’ schedules, especially when they could access them efficiently. For instance, two key informants mentioned that they carried out what was dubbed “moonlight” HIV testing days. Here, the word “moonlight” connotes nighttime hours when such outreaches were held. This is perhaps an indication of efforts to align HIV/AIDS risk reduction services with LDTs’ work schedules. Similarly, outreaches have been used to disseminate HIV/AIDS risk reduction services in Brazil and Morocco.^17,32 Unlike the “moonlight” outreach activities reported in this study, those conducted in Brazil and Morocco were only done during daytime, meaning that they may have missed the LDTs who needed HIV/AIDS risk reduction services at nighttime hours.^17,32

It is worth noting the role of healthcare professionals in HIV/AIDS risk reduction among LDTs. Specifically, healthcare professionals enhanced interpersonal communication on HIV/AIDS risk reduction with the LDTs. Besides, participants expressed other important roles that healthcare professionals, such as nurses, clinicians, pharmacists, and counselors, played during their interaction with the LDTs. These roles ranged from mobilization, STI screening and treatment, initiation of PrEP and PEP, HIV testing, and ART linkage and care. Other studies have similarly documented the role of healthcare professionals in HIV/AIDS prevention among LDTs.^17,40,41

The discussion on BCC strategies targeted for LDTs cannot be concluded without mentioning peer educators. Participants in this study highlighted the role peer educators play in enhancing HIV/AIDS risk reduction among LDTs. Peer educators are LDTs who are given some basic health training, mostly by NGOs, to spread risk reduction messages and other non-technical services like condom distribution to their peers. The peer educator approach has been used widely to enhance HIV/AIDS prevention among LDTs.^19,31,41 The findings suggest the need to embrace LDTs as peer educators in championing other BCC prevention strategies since they are more acceptable to their peers.

Lastly, given the severe budget cuts on HIV/AIDS donor funding from the U.S. government, a more cost-effective way to enhance HIV/AIDS risk reduction outcomes among LDTs is needed.⁴² As such, given the lessons learnt from the current study, and especially on the hard-to-reach nature of LDTs with the mainstream public healthcare services, an approach that can remotely reach them with consistent risk reduction messages can be a solution. One such approach is a mobile (m)-health intervention utilizing tailored text messaging as recommended for mobile populations by the World Health Organization (WHO).⁴³ Indeed, such interventions have been used with positive outcomes on HIV/AIDS risk reduction among LDTs in South Africa and Zimbabwe.³⁴ Therefore, the study would recommend a mobile phone text-based intervention, designed with the inputs of LDTs and relevant healthcare providers to enhance HIV/AIDS risk reduction outcomes among LDTs in Kenya.²² Ultimately, this would contribute to the UNAIDS global goal of ending new HIV infections and AIDS by 2030.¹

Strengths and Limitations

The current study followed the COREQ guidelines, thus enhancing the transparency and quality of the findings reported. The study involved participants of diverse backgrounds, such as multinational LDTs and multi-professional healthcare professionals, which largely enriched the content of the information gathered. Nevertheless, some limitations should be considered while interpreting the findings reported here. First, the fact that the study was conducted in two sites may mean that key information from other sites may have been overlooked. It is also likely that information that may have been gathered from other personnel who interact with LDTs at different levels, such as at the employer level, was also missed. Therefore, future studies should focus on incorporating a more diverse study population, which includes LDTs, healthcare providers, and key stakeholders from multiple geographical locations, to provide more robust insights into BCC strategies.

Conclusion

Broadcast media-based communication channels were the most common and accessible among the LDTs. However, a combination of interpersonal communication and healthcare worker service-driven activities, peer-led services, outreach-based approaches, and NGO-driven initiatives played a key role in enhancing the reach of HIV/AIDS risk reduction messages to the LDTs. Thus, HIV/AIDS risk reduction programs should adopt a multi-channel BCC approach that integrates broadcast media with interpersonal communication, peer-led services, outreach activities, and NGO-driven strategies to enhance prevention outcomes among the hard-to-reach LDTs.

Supplemental Material

sj-docx-1-jia-10.1177_23259582251377224 - Supplemental material for Behavior Change Communication Strategies on Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome Risk Reduction for Long-Distance Truckers in Kenya

Supplemental material, sj-docx-1-jia-10.1177_23259582251377224 for Behavior Change Communication Strategies on Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome Risk Reduction for Long-Distance Truckers in Kenya by Cyrus Mutie, John Gachohi, Kawira Kithuci and Grace Mbuthia in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-2-jia-10.1177_23259582251377224 - Supplemental material for Behavior Change Communication Strategies on Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome Risk Reduction for Long-Distance Truckers in Kenya

Supplemental material, sj-docx-2-jia-10.1177_23259582251377224 for Behavior Change Communication Strategies on Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome Risk Reduction for Long-Distance Truckers in Kenya by Cyrus Mutie, John Gachohi, Kawira Kithuci and Grace Mbuthia in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Acknowledgements

We are grateful to the nurses, clinicians, community mobilizers, and LDT peer educators at Namanga and Busia international points in Kenya for their support and collaboration during the data collection exercise.

ORCID iDs

Cyrus Mutie

Kawira Kithuci

Ethical Statement

Ethical approval was granted by the ethical review committee of Jomo Kenyatta University of Agriculture and Technology (JKUAT), JKU/ISERC/02317/1256. The study was also licensed by the National Commission for Science, Technology, and Innovation, Kenya (NACOSTI), NACOSTI/P/24/33837. More approvals were obtained from Busia (ADM 15/27 Vol.1/151) and Kajiado (KJD/CC/ADM/45 VOL.V (4) Counties in Kenya.

Informed Consent

Written informed consent was sought and granted prior to the start of interviews with the study participants.

Consent for Publication

All information used in the development of the manuscript is fully anonymized and does not contain any identifying details of study participants. Therefore, a publication consent was not applicable.

Author Contribution Statement

CM conceived the study and methodology, performed administration, data collection, software and analysis and wrote the original draft. KK, JG, and GM conceived the study and methodology, supervised the study, writing and reviewing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets and other relevant material used in the development of the current study findings are available upon request from the corresponding author.

Supplemental Material

Supplemental material for this article is available online.

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