CHAPTER SIX RISK PERCEPTION OF HIV/AIDS. This chapter looks at the concept of risk perception among the truck

Transcription

1 CHAPTER SIX RISK PERCEPTION OF HIV/AIDS This chapter looks at the concept of risk perception among the truck drivers and mathadi workers. It also attempts to bring out other factors that create vulnerability for the respondents at the place of destination. This chapter also includes the testing of the hypotheses. 6.1 Risk perception Early HIV prevention efforts have brought out that information alone is not enough to effect behavior changes. This finding has been supported by KABP studies. Beyond a certain level, knowledge by itself is not enough to bring about behavior changes specifically safer behavior practices. One important variable that needs to be examined in this context is risk perception. To mitigate the spread of HIV/AIDS, it is crucial to understand the way in which individuals look at their behavior and assess whether it is risk or not in the context of HIV infection. Several theories of human behavior suggest that it is an individual s perception of risk rather than actual risk involved that determines the behavior. Akwara et al. (2003) [6] opines that the association between perception of risk of HIV infection and sexual behavior remains poorly understood, although perception of risk is considered to be the first stage towards behavioral change from risktaking to safer behavior. 204

2 Perception of risk goes beyond the individual, and it is a social and cultural construct reflecting values, symbols, history, and ideology (Weinstein, 1989). It follows from the specificity and variability of human social existence that it should not simply be presumed that scores and ratings on identical instruments have the same meanings in different contexts (Boholm, 1998). The concept of risk perception has to be understood in both micro and macro levels - an individual s predisposition to be risk seeking or risk averse and his/her knowledge regarding the situation at hand and secondly the social structures and institutions that harbors the power to shape risk perception. Tsasis and Nirupama (2008) hold that this process of negotiating risk demonstrates the way people choose to organize their universe through cultural and social biases and choose what to fear based on their way of life and patterns of culture and social norms. Risk perception is culturally shaped and therefore risk behavior is a social rather than an individual issue. However, though risk perception is largely shaped by the social structures, risk factors and behaviors are usually individualized i.e. associated with choice, responsibility and blame. Thus perception, if present leads, to worryand tension among persons regarding specific threats. In the event of negative outcomes, the individual is held accountable rather than the society. It is this individualization of risk within the health discourse that it is an individual s choice to engage in risk behavior that has led to labeling of certain groups of individuals and population as at risk groups. Media plays an important role in perpetuating risk as an individual issue and unique to certain population. Such a projection shapes or reinforces risk behavior as individual choice, thereby negating the macro level issue such as social, economic and political factors that also plays a major role in risk perception. 205

3 One of the objectives (objective number 4) is to determine the risk perception of the truck drivers and mathadi workers and study the association between knowledge of HIV/AIDS and risk perception. To determine the level of risk perception, the respondents were asked to state their perception of risk in terms of no risk, low risk, moderate risk and high risk. An ordinal scale is used to assess the risk perception of the respondent. The respondents were asked open-ended questions to gauge their opinion on HIV testing and elaborate on instances of HIV risk in their life. The respondents were asked about their partner s risk perception to determine correlation between partner s risk perception and self risk perception. The section also includes social network and whether it affects the risk perception Risk perception of respondents The overall data show that a high proportion of respondents (85.1 percent) report no risk perception to HIV/AIDS while 12.4 percent report low risk perception. A small proportion of respondents (2.3 percent) report moderate risk perception and high risk perception (0.2 percent). Among the respondent group of truck drivers, a majority of drivers report that they do not perceive risk to HIV infection (76.8 percent), while a small proportion of the respondents report perception of risk (23.2 percent). Within this category, the respondents are further divided into three sub-categories low risk perception (19.3 percent) followed by moderate risk perception (3.9 percent) and none of the truck drivers report high risk perception. Among the mathadi workers, a very high proportion of respondents report that they do not perceive risk to HV infection (93.7 percent). Among those respondents who report risk perception, a majority report low risk perception (5.3 percept), followed 206

4 by moderate risk perception (0.7 percent) and none of the respondents report high risk perception. TABLE 6.1 PERCENTAGE DISTRIBUTION OF RISK PERCEPTION AMONG RESPONDENT GROUPS Variable Truck Driver Mathadi Worker Total No Risk 76.8 (239) 93.7 (282) 85.1 (521) Low Risk 19.3 (60) 5.3 (16) 12.4 (76) Moderate Risk 3.9 (12) 0.7 (2) 2.3 (14) High Risk 0.0 (0) 0.3 (1) 0.2 (1) Total (311) (301) (612) Figures in parentheses represent actual number A comparison across the two respondent groups shows that a larger proportion of mathadi workers report no risk perception as compared to truck drivers. This trend of decreased risk perception among the mathadi workers is evident from a low proportion of workers reporting low and moderate risk perception as compared to a higher proportion of truck drivers reporting the same. None of the respondents in both the groups report high risk perception to HIV/AIDS. The mean of risk perception score among the truck drivers is 1.29 and among mathadi workers, the mean is The data indicates that a higher proportion of truck drivers perceive themselves to be at risk of HIV infection as compared to mathadi workers. The Pearson chi- square value is and p =.000. Thus the correlation between 207

5 respondent groups and risk perception is highly significant at 99 percent level of confidence. People have confidence as per their behavior. I have confidence. You can take any test. When I have not done anything why should I be afraid? But people do go to barber. Even then you can get infections. There is a new machine for testing sugar where they use one needle for pricking thumb to draw blood sample. Infection can spread through that also. There was one case of a HIV positive man. He did not believe the test report. We spent lot of money and gave sample for testing outside also. Doctor also confirmed the report. He just did not believe the report. We told him that we can recognize the symptoms like the skin had turned black. The doctor explained that you people are not in danger but he needs care. Later he expired. Mathadi Mukadham Sometimes I feel I am in danger of HIV infection. I do not go to the doctor as I am afraid. Truck driver from Tamil Nadu Looking at risk perception across number of partners, the data for both the respondent groups show that risk perception increases with number of partners. Among the truck drivers, 50.0 percent of respondents reporting one partner also report moderate risk perception and among the mathadi workers, percent of workers with one partner report moderate risk perception. A high proportion of truck drivers (45.2 percent) and mathadi workers (61.5 percent) reporting no sexu al partners are also reporting no risk perception to HIV infection. Thus the data shows that the risk perception increases with 208

6 increase in the number of partners. The Pearson chi- square value is and p =.000 for truck drivers and chi-square value is and p =.001for mathadi workers. Thus the correlation between risk perception and number of partners is significant at 99 percent level of confidence. TABLE 6.2 PERCENTAGE DISTRIBUTION OF RISK PERCEPTION AND NUMBER OF PARTNERS Respondent types Variable No Risk Risk of getting HIV/AIDS Low Risk Moderate Risk High Risk Total None 45.2 (100) 6.7 (4) 8.3 (1) 0.0 (0) 35.8 (105) One 43.0 (95) 51.7 (31) 50.0 (6) 0.0 (0) 45.1 (132) Truck Drivers Two 7.2 (16) 35.0 (21) 25.0 (3) 0.0 (0) 13.7 (40) Three or more 4.5 (10) 6.7 (4) 16.7 (2) 0.0 (0) 5.5 (16) Total (221) (60) (12) 0.0(0) (293) None 61.5 (169) 31.3 (5) 0.0 (0) (1) 59.5 (175) Mathadi Workers One 35.3 (97) 43.8 (7) (2) 0.0 (0) 36.1 (106) Two 3.3 (9) 25.0 (4) 0.0 (0) 0.0 (0) 4.4 (13) Total (275) (16) (2) (1) (294) Figures in parentheses represent actual number 209

7 On being asked about instances in one s life when the respondents perceived themselves to be at risk, various instances were shared. Some of them are when respondents engaged in sexual relations without condom, frequent relations with sex workers, and reoccurrences of symptoms of sexually transmitted infections. Many respondents also reported instances when they have been hospitalized and have been operated and they report that may have put them at risk of HIV infection. Risk perception is highest among the young adults i.e years and years. As age increases, the risk perception decreases among both the respondent groups. Among the truck drivers, 48.6 percent in age group years report risk perception followed by 33.3 percent in the age group years. Only 4.2 percent report risk perception in years. Among the mathadi workers, 52.3 percent report risk perception in the age group of years while 26.3 percent do so in age group years. This percentage starts decreasing with age percent in age group years and 5.3 percent in age group years report the same. On asking the respondents about their behavior changes in the last six months and risk perception, the data shows a correlation between the two variables. Among the truck drivers, 17.0 percent of respondents who report behavior changes in the last six months also report risk perception. In the respondent group of mathadi workers, 5.6 percent report the same. (Pearson chi -square is and p =.000). This data supports the literature review that postulates that risk perception is the first step towards safer behavior practices. It is this perception that triggers the need for behavior modification in an individual that leads to actual behavior changes decreasing the risk to HIV/AIDS. 210

8 6.1.2 Partner s risk perception to HIV/AIDS The respondents were asked whether their partners perceive risk to HIV infection. This question is set within the limitation of trying to understand partner s risk perception through the respondent since it is not possible to ask the partner directly. Since the respondents report that HIV/AIDS is not discussed much within their personal relations, this question is based on the respondent s assumptions about partner s risk perception to HIV/AIDS. Overall data shows a large proportion of respondents report that their partners do not perceive risk to HIV infection (89.7 percent). Only 3.4 percent report that the partner perceives risk to HIV infection. There is not much difference between the two respondent groups in terms of partner s risk perception as 3.8 percent of truck drivers report that their partners perceive risk while 3.0 percent of mathadi workers report the same. TABLE 6.3 PERCENTAGE DISTRIBUTION OF PARTNER S RISK PERCEPTION Variable Truck Drivers Mathadi Total Workers Yes 3.8 (12) 3.0 (9) 3.4 (21) No 89.4 (279) 90.0 (271) 89.7 (550) Not applicable 6.7 (21) 7.0 (21) 6.9 (42) Total (312) (301) (613) Figures in parentheses represent actual number 211

9 Whether partner s risk perception affects respondent s risk perception Correlation between self and partner s risk perception shows that a majority of the respondents who report that their partners do not perceive risk also report no risk perception percent of truck drivers and 94.1 percent of mathadi workers who report no risk perception also report nil risk perception on behalf of the partner percent of truck drivers who report low risk perception also report that their partners also perceive risk while 11.1 percent of mathadi workers also show similar trends. For Truck drivers Pearson Chi-square value is and p =.000 and for Mathadi workers Pearson Chisquare value is and p =.002. Thus the correlation between respondent s perception and partner s perception is significant at 99 percent level of confidence. TABLE 6.4 CROSS TABULATION OF RESPONDENT S AND PARTNER S RISK PERCEPTION Respondent types Self risk perception Partner s risk perception Yes No Total No Risk 16.7 (2) 77.8 (217) 75.3 (219) Low Risk 58.3 (7) 19.0 (53) 20.6 (60) Truck Drivers Moderate Risk 25.0 (3) 3.2 (9) 4.1 (12) High Risk 0.0 (0) 0.0 (0) 0.0(0) Total (12) (279) (291) 212

10 No Risk 77.8 (7) 94.1 (255) 93.6 (262) Low Risk 11.1 (1) 5.2 (14) 5.4 (15) Mathadi Workers Moderate Risk 11.1 (1) 0.4 (1) 0.7 (2) High Risk 0.0 (0) 0.4 (1) 0.4 (1) Total (9) (271) (280) Figures in parentheses represent actual number Risk perception and sexually transmitted infection Looking at risk perception across respondents reporting STI, the data shows that a majority of the respondents who report they do not have STI also report no risk to HIV/AIDS. Comparatively across the two respondent groups, a higher proportion of mathadi workers (94.0 percent) report this as compared to truck drivers (75.2 percent). Information dissemination plays a role in shaping risk perception whereby an individual is equipped with knowledge that he/she may be at risk of contacting infection. Biomedical researchers have shown that the presence of STI greatly increases the risk of HIV infection as open wound or infection provides for an easy exchange of infected fluid such as semen and blood. 6.2 Risk perception and social network Different approaches mostly borrowing from the field of psychology and sociology have been applied to study risk perception and the factors influencing variations in magnitude of perceived risk among populations. Perception of risk may be influenced by factors 213

11 external to the individual i.e. macro level or by factors operating at the individual level i.e. micro level factors. Proponents of external factors such as Kohler, Hans- Peter, Behrman, Watkins argue that social relationships and environmental factors act to shape how an individual perceive a risk. The structures that exist within a community may impede or allow communication channels to filter to the individual, thus, influencing the level of perceived severity to a threat. Information within a community may flow through social networks where people with similar believes or attitudes share information and hence perceiving the same level of risk (Scherer, C. W. and Cho, H. 2003). This approach, emerging largely from organizational and community social network studies, suggests that it is the relational aspects of individuals and the resulting networks and selforganizing systems that influence individual perceptions and build groups or communities of like-minded individuals. These social units, it is argued, behave as attitude, knowledge, or behavioral structures. Literature on social networks and interactions suggest that communication and interactions in social networks are likely to be important mechanisms through which individuals learn about the disease, its implications and consequences for individuals and families, and most important acceptable strategies to reduce risk. Watkins and Warriner (2003) [7] conclude from their empirical studies that networks with which whom respondents discuss issues of family planning and AIDS are characterized by a tendency to discuss these topics with others who are perceived to be similar ( like me ). Some networks are deliberately chosen because they are believed to have relevant information or competence. Social interactions are likely to have substantial impact on the course of the epidemic and magnitude of its consequences. 214

12 Though in the research study, risk perception is largely studied as an individual cognitive mechanism, it is essential to look at this concept within the nexus of social relations and network at the place of destination. In order to understand the relevance of contextual factors for individual behavior or for behavioral change in the context of HIV/AIDS, researchers need to consider both the direct as well as the indirect pathways of influence. In this section, the researcher is looking at three indicators of social network. The respondents were asked if they know of a person living with HIV/AIDS (PLWHA), whether they talk about HIV/AIDS in peer group and if they have seen HIV/AIDS awareness programme in the last six months. 6.2 (a) Knowing a person living with HIV/AIDS (PLWHA) On being asked if the respondents know a person living with HIV/AIDS (PLWHA), less than half of the respondents reported in affirmative (41.8 percent). A comparison across the two respondent groups shows little difference in the percentage distribution. Less than half of the truck drivers (41.3 percent) and mathadi workers (42.2 percent) report knowing a HIV positive person. Cross tabulation of the two variables i.e. risk perception and knowing a HIV positive person, the data shows that among the truck drivers, 45.0 percent respondents who report having met a positive person report low risk perception and 33.3 percent report moderate risk perception. Among the mathadi workers 50.0 percent respondents who have met a positive person report low risk perception and 42.2 percent report no risk perception. It can be observed that among the truck drivers there are a slightly higher proportion of respondents who report risk perception and knowing a positive person 215

13 while among the mathadi workers the data shows that the responses are divided in terms of reporting no risk and low risk. None of the truck drivers who have known a PLWHA report high risk perception while none among the mathadi workers report either moderate or high risk perception. TABLE 6.5 CROSS TABULATION OF RISK PERCEPTION AND KNOWING A PLWHA Respondent types Knowing a PLWHA No Risk Risk of getting HIV/AIDS Low Risk Moderate Risk High Risk Total Yes 40.8 (97) 45.0 (27) 33.3 (4) 0.0 (0) 41.3 (128) Truck Drivers No 59.2 (141) 55.0 (33) 66.7 (8) 0.0 (0) 58.7 (182) Total (238) (60) (12) 0.0 (0) (310) Yes 42.2 (119) 50.0 (8) 0.0 (0) 0.0 (0) 42.2 (127) Mathadi Workers No 57.8 (163) 50.0 (8) (2) (1) 57.8 (174) Total (282) (16) (2) (1) (301) Figures in parentheses represent actual number 216

14 6.2 (b) Talk about HIV/AIDS in peer group Theories of social networks rest on the insight that actors do not make decisions in isolation, but rather with other individuals who are connected to one another (Wellman 1988, Emirbayer and Goodwin 1994, Rogers 1995). These interactions offer opportunities for individuals to exchange and evaluate information, to learn about the rigidity or flexibility of social norms, and to influence each others attitudes and behaviors. Such interactions are likely to be particularly important when an individual is uncertain about the best response to an innovation, environmental change, or to new social and economic circumstances. The literature on communication networks argues that the dissemination of information about preventative measures is not sufficient to induce behavioral change. It proposes that through social networks there is a sharing of of ideas, new practices that helps individual evaluate risks and possibly future behavior modifications. There is increasing evidence from studies in Sub-Saharan Africa that local networks are important in translating and interpreting the risk of HIV/AIDS and in facilitating the behavioral changes in response to increasing HIV/AIDS risks. Such translation and interpretation accompany the spread of HIV/AIDS, quite similar to the role of social networks in the diffusion of modern family planning (Rutenberg and Watkins 1997, Watkins 2000). On being asked if HIV/AIDS is a topic of communication within the peer group, a majority of respondents reported that they talk about HIV/AIDS at the place of destination. Among the truck drivers, 62.7 percent report that they talk about HIV/AIDS in the peer group while 73.4 percent of mathadi workers report the same. Among truck drivers correlation between risk perception and talking about HIV/AIDS show that 61.9 percent report no risk perception to HIV/AIDS while 73.4 percent report low risk and 217

15 25 percent report moderate risk. Among the mathadi workers, out of that proportion of respondents who report that they talk about HIV/AIDS in peer group, a major proportion report no risk perception (74.1 percent) and 62.5 percent report low risk. The data shows that for the group of truck drivers, there is a correlation between talking about HIV/AIDS in peer group and risk perception. Pearson chi square value is and p =.006. Thus the correlation is statistically significant at 95 percent level of confidence. For the group of mathadi workers, the data does not show any statistical correlation between the two variables. TABLE 6.6 CROSS TABULATION OF RISK PERCEPTION AND TALK ABOUT HIV/AIDS Respondent types Talking about HIV/AIDS No Risk Risk of getting HIV/AIDS Low Risk Moderate Risk High Risk Total Yes 61.9 (148) 73.3 (44) 25.0 (3) (195) Truck Drivers No 38.1 (91) 26.7 (16) 75.0 (9) (116) Total (239) (60) (12) (311) Yes 74.1 (209) 62.5 (10) 50.0 (1) (1) 73.4 (221) Mathadi Workers No 25.9 (73) 37.5 (6) 50.0 (1) (80) Total (282) (16) Figures in parentheses represent actual number (2) (1) (301) 218

16 On being asked about details of conversation regarding HIV/AIDS there were varied responses. A majority of them report that they talk about the disease after witnessing an awareness programme such as street plays or melas in the marker conducted by the local NGOs. Sometimes the conversation is initiated after reading some news item or hearing the news of death in nearby gala of a fellow mathadi due to AIDS. Conversation is generally centered on prevention in terms of abstinence and condom use. In many instances people talk about HIV/AIDS incorporating a humorous element by making a joke or laughingly refer to risk behavior among friends or colleagues. Among the drivers, 2-3 fellows have died. Generally we talk sometimes about safety and not to go to sex workers and need to get treatment. When we see some natak, then also we talk about it what to do to protect ourselves, how it spreads. We know that it is very dangerous. Truck driver from Andhra Pradesh Sometimes we joke about condom use, when everybody is together, there is lot of majamasti and we talk about how to protect ourselves and sometimes how one of our friend may be going to bar, we tease him. But at the same time, tell him to be careful. Truck driver from Latur The data shows that the topic of HIV/AIDS may be initiated at the onset of a particular event such as death of illness of colleague or after being part of an awareness programme. It may be dealt with in a superficial manner as respondents report a fear that others may regard them in a suspicious way if they keep talking about it in depth. 219

17 We talk little bit about HIV, not in an open way with everybody, people can get suspicious, they also get afraid. Mostly people joke about this, but we do talk about it. We have heard of few patients in the market, then also the men talk. Whenever there is a natak in the market, people do listen, how to protect oneself, symptoms of the illness, we take back some message from the natak. Mathadi worker from Mahabaleshwar If someone goes wrong we tell them. Do not go there, there is danger. Baba mat karo. Bhimari hoti hai. The younger generations do not talk in front of older generation. Till date there is respect for elders in the Hindu tradition. Among friends they may be talking about it. If there is a good looking woman in that godown, people do talk. Among same level of people they do talk. Mathadi Mukadham There are a few respondents who report that they do not talk about HIV/AIDS and gave reasons for the same. HIV is very dangerous. If we talk about it, people will take in the wrong way. As it is we have a bad name in the society, if we talk about it people will get suspicious. Truck driver from Amravati We feel afraid to talk about HIV/AIDS, there is also a feeling of shame. Everybody will tease us if talk about this. Also our friends will report back at home and everybody will get suspicious. Also we do not get the time. Truck driver from Punjab 220

18 On being asked if the respondents talk about HIV/AIDS at the place of origin, they report that the topic is taboo at home. There is a feeling that the disease belongs to urban areas and people living in the rural parts will not be infected. They also report that they do not talk about HIV/AIDS in their family. In village there is no such trouble, there is no danger. They are within the four walls of the house. But when people go from village to Mumbai, we cannot give guarantee about them. They may be in danger of getting infected. We do not talk about this at home. There is feeling of sham. In Khede people do not know about these things, they do not even know about condoms. We also do not talk about this to wife. When there is no need, why talk unnecessarily. People who go out may be talking. If men talk about condom, wife may get suspicious. In city it is ok to talk but not in village. Educated people in village may know about these things but not everyone. Mathadi mukadham Generally we do not talk about this at home. People at home know, they also watch TV. They tell us go carefully, be careful. But do not talk about the subject openly. They know about women at terminus at naka. But do not talk openly. In village people are afraid of drivers. They ask for medical checkup. Otherwise nobody is ready to give their daughters for marriage. Drivers have to remain bachelors. Not possible for wife to ask husband if he has done anything wrong. So wife also does not talk. Truck driver from Andhra Pradesh 221

19 No with wife, family. Shameful to talk about this in family. When there is no need, why talk unnecessarily. People who go out may be talking. If men talk about condom, wife may get suspicious. In city it is ok to talk but not in village. Educated people in village may know but not everyone. Mathadi Mukadham 6.2 (c) Seen HIV/AIDS awareness programme in last six months Mass media interventions aim to prevent HIV by increasing knowledge, improving risk perception, changing sexual behaviors, and questioning potentially harmful social norms. Local NGOs have been conducting mass awareness praogrammes such as group awareness sessions, one to one sessions, street plays, melas as a part of work place intervention programmes. On being asked if respondents have seen an awareness programme in the last six months, less than half of the respondents report having seen awareness programmes on HIV/AIDS in the last six months (30 percent). It is interesting to note that larger proportion of truck drivers (39.8 percent) report having seen awareness programmes in the last six months as compared to the mathadi workers (19.9 percent). Among the respondent group of truck drivers, 86.2 percent who have seen HIV/AIDS awareness programme report no risk perception and 13.8 percent low risk perception Among the mathadi workers, 93.3 percent of workers who report seeing a HIV awareness programme report no risk while a small proportion of 5.0 percent report low risk perception and 1.7 percent report moderate risk perception. 222

20 6.3 Factors creating vulnerability at place of destination HIV infection is associated with specific risk including behavior where there is risk of infection and secondly situations where there is a risk of HIV infection. While the first is a measure of individual s inability to control risk of infection, the latter refers to the macro level community based factors that increases risk to infection. When individuals are displaced internally or across borders, their vulnerability to HIV infection can increase because social support mechanisms are disrupted, health services may become inaccessible, gender discrimination may exist and so on and so forth. In the context of HIV/AIDS, besides the lack of knowledge, it is the lack of control over social and economic circumstances that precipitates individuals to engage in risk behaviors leading to transmission of infection. This section presents data on the second part namely vulnerability factors at the place of destination. Disruption of individuals from families and communities due to mobility can lead to increase in susceptibility and vulnerability to HIV infection. At the place of destination, the bridge populations become a part of a unique social sphere that is different from the social world they occupy at their place of origin. The norms on social and sexual behaviors may be different at the place of destination and the groups away from the constraints of normative behaviors applicable at their place of origin may display a certain permissiveness to risk behavior. The social norms prevalent at their place of origin are no longer enforcing on them and they operate on a varied set of normative behaviors. The gender norms of the patriarchal nature of Indian society creates an environment of permissiveness with regard to increased risk in the form of addictions, sexual behaviors both at place of origin and destination. United Nations population 223

21 Division (2006) states Despite stereotypes and common assumptions it is neither migrants nor migration per se that increase the risks of HIV transmission: it is the trying conditions and hardships that many face throughout the migration experience that makes them more vulnerable to infection. Apart from the rural-urban dimension, the environment at the place of destination can lead to certain behaviors which may put them at increased risk. Navi Mumbai is an area of long standing trade route. APMC and the truck terminus are locations of growing trade and are well connected to various parts of the country through roadways and rail network. Away from their families, the two subgroups occupy a space marked by a unique culture of work, comradeship and relationship networks both related to work and personal life. On being asked if there are any factors at the place of destination that creates vulnerability to the epidemic, the respondents have listed the following. The response being a multiple choice, response the respondents reported more than one factor. Overall data shows that respondents have listed easy availability of sexual partner (87.5 percent), alcohol consumption (83.4 percent) and separation from regula r partner (82.1 percent) as major factors that make them vulnerable to HIV infection. The township of Vashi has numerous bars within 2 km radius of the APMC market. Peer pressure ( 38.0 percent) followed by limited health services (36.9 percent) have also b een stated as factors contributing to the vulnerability of this bridge population. 224

22 TABLE 6.7 PERCENTAGE DISTRIBUTION OF FACTORS CREATING VULNERABILITY AT PLACE OF DESTINATION AMONG THE RESPONDENT GROUPS Variable Truck Drivers Mathadi Workers Total Separation regular partner Consumption alcohol from of 78.8 (246) 85.6 (255) 82.1 (501) 85.3 (266) 81.5 (243) 83.4 (509) Easily accessible 84.9 (265) 90.3 (269) 87.5 (534) sex networks Limited access to 40.1 (125) 33.6 (100) 36.9 (225) health services Peer pressure 37.5 (117) 38.6 (115) 38.0 (232) Any other 0.6 (2) 1.3 (4) 1.0 (6) Total (312) (298) (610) Figures in parentheses represent actual number The respondents opinion provides an interesting insight into the factors creating vulnerability for the two groups. There are some respondents who do not agree that there are vulnerability factors at the place of destination. They opine that with increasing awareness, there are changes in behavior patterns of people working at APMC. 225

23 Some responses shared are : I agree that there are some factors that puts drivers at risk, but now with more information on this disease, the danger is reducing. People know that they have to take care otherwise they will get sick. Ttruck driver from Rajasthan Now there is lot of information. People know and they have changed their behavior. Not so much at risk now. In the market other people are also in risk people working in offices, banks, truck drivers not just the workers. Mathadi Mukadham Though consumption of alcohol is acknowledged as very common among the two sub groups, some respondents think that not everybody engages in risk behavior as they aware of the risk factors and consume alcohol within their limits. Some of the respondents report that they do not feel that being away from their place of origin creates vulnerability. No. That is not correct, not everybody goes out, drinks % drink. But out of that 50 % limit their drinks. Only 10 % go to bars. So we cannot talk workers in general. Mathadi worker No definitely. We are from Hyderabad. We go back home in week s time. But drivers from north they are away from home for a long time. They are at risk, drivers who travel for couple of months. Long distance drivers leave home, go to Dhabha, have risk 226

24 behavior, Turbe also red light district (RLD). They have risk. Drivers who go back home often are not at risk.on day of rest, drivers have fun, for time pass. They go to cinema, rest, have beer and sleep off. But they have no other addictions. Some people may get undue influenced by friends. If a person thinks about his health he will be ok. Even if he has relation he uses condoms he will be ok. Truck driver from Hyderabad Comparison of the vulnerability factors across the two subgroups of Truck drivers and Mathadi workers Separation from regular partner The most commonly cited post-migration characteristic affecting sexual behavior is separation from a regular sexual partner/spouse (Sanders and Sambo, 1991). There is anthropological evidence in East Africa that adultery by husbands and wives is tolerated if the husbands are away for a long period of time, even if not acknowledged explicitly (Caldwell, Caldwell and Quiggin, 1989: Lurie et al. 1997; Romero-Daza, 1994). Among the respondent group of truck drivers, a majority of the respondents report that being away from their regular partner creates grounds for vulnerability (78.8 percent) while a similar trend can be seen among the mathadi workers (85.6 percent). Drivers being away from home, having lot of freedom, both these things puts us in danger. People develop habits that put them in danger. Truck driver from Gujarat 227

25 Women working here also sometimes take advantage of man who earn and have house here. There is also more freedom here than in village. Mathadi worker from Koperkhairne Cross tabulation with age groups shows an interesting observation. Among the truck drivers, the proportion of respondents stating separation from regular partners as a vulnerability factor remains nearly the same while in the group of mathadi workers the proportion of respondents reporting this factor increases with increase in age group. In the age group years 62.0 percent report this factor as creating vulnerability while 90.0 percent in age group years, 89.5 percent in years report the same. The Pearson chi-square is and p =.000. Thus the correlation between age and separation from regular partner as a major vulnerability factor is significant at 99 percent level of confidence. Among the group of truck drivers, the data does not show statistical correlation. TABLE 6.8 CROSS TABULATION OF AGE GROUP WITH SEPARATION FROM REGULAR PARTNER Variable Respondent Age Total types years years years years Separation from regular partner Truck drivers Mathadi workers 78.9 (75) 82.1 (115) 71.9 (41) 75.0 (15) 78.8 (246) 62.0 (31) 90.0 (117) 89.0 (73) 89.5 (34) 85.0 (255) Figures in parentheses represent actual number 228

26 A similar trend can be observed among mathadi workers across marital status. The proportion of married mathadi workers stating separation from regular partner as a major factor creating vulnerability is higher (88.7 percent) as compared to unmarried mathadi workers (65.3 percent). The Pearson Chi-square is and p =.000. Thus the correlation between marital status and separation from regular partner is significant at 99 percent level of confidence. For the respondent group of truck drivers, the data does not show much difference across the marital status percent of married drivers state this factor as creating vulnerability and 78.6 percent unmarried respondent reports the same. TABLE 6.9 CROSS TABULATION OF MARITAL STATUS WITH SEPARATION FROM REGULAR PARTNER Variable Respondent Marital status Total types Unmarried Married Divorced Widowed Separation Truck from regular partner drivers 78.6 (24) 80.0 (38) 50.0 (3) 75.0 (1) 78.8 (66) Mathadi workers 65.3 (32) 88.7 (212) 75.0 (3) (8) 85.0 (255) Figures in parentheses represent actual number Consumption of alcohol The Nation Institutes of Health (NIH) Off ice of AIDS Research has identified alcohol use, abuse, and dependence as an important factor in the spread of HIV both here and abroad. Individuals who abuse alcohol are more likely to become infected and to infect others. NIH 2004 Plan for HIV-Related Research states that "High priority is being given to research to understand the phenomenon of addiction itself, as well as the complex 229

27 interaction of alcohol use, drug use, and poor impulse control, and to develop effective interventions from that knowledge base". Both biomedical and behavioral research is looking at correlation between alcohol consumption and HIV/AIDS. In addition to creating vulnerability in terms of inconsistent condom use and other risk behavior under the influence of alcohol, there is a second dimension to this correlation whereby alcohol consumption reduces the immunity of the body and leads to increased suspect ability to opportunistic infections and progression towards the state of AIDS. A majority of truck drivers report consumption of alcohol as the main factor for creating vulnerability (85.3 percent) while a nearly equal proportion of mathadi workers report the same (81.5 percent). People do drink. Mostly every one drinks. Those who wear mala do not drink or eat non vegetarian. But when family is not her and there is no one to talk, workers get tired. They go out and drink. About 40 percent workers have their family in village. Earlier more number of workers had family in village. They used to sleep here in godown itself. But now many workers have got rooms here. Those who stay here without family are at risk. Mathadi Mukadham We do lot of hard work and our bones hurt at the end of the day. Many people feel the need to drink at night Mathadi worker 230

28 Yes, men do out for drinking. They know that they have to be safe but after drinking they may lose consciousness and may not use condoms. Lot of people knows smoking is bad, but they do smoke. Mathadi Mukadham Among the group of truck drivers, the data show that as income level increases, the proportion of respondents reporting alcohol consumption also increases. The Pearson Chi- square is and p =.037. Thus the correlation between income and alcohol consumption is significant at 95 percent level of confidence. Such a trend is not seen among the mathadi workers percent of respondents in less than Rs. 10,000 report this factor as important factor creating vulnerability while 78.8 percent in Rs. 10,001 20,000 report the same Easy accessibility to sexual network Sex work is widespread in India, and occurs on a much larger scale than in many other countries. Women often get involved in sex work due to poverty, marital break-up or because they are forced into it. In India, sexual transmission is the primary driver of epidemic HIV prevalence rates are high among sex workers and their clients. In Mumbai, which has a larger brothel-based sex industry than any other area of India, HIV prevalence among sex workers has remained very high for the last many years. National Behavioral Surveillance Survey (2006) has brought out that male STD patients are largely clients of sex workers and this bridge group will drive the epidemic forward. The majority of male clients are seasonal economic migrants from rural to urban centers and other neighboring states in search of work during the lean period. While staying in urban areas they have the opportunity to visit FSWs and the risk of contracting HIV infection. 231

29 When they return to their families they transmit the infection to their wives, which further gets transmitted to their children. The infection thus spreads from the core group population to the rest of the low risk general population and from urban centers to many villages. Though sexual activity outside marriage is generally proscribed, there has always been considerable laxity in favor of men. Several avenues, primarily commercial sex networks, are available for men seeking premarital and extramarital sexual relations. Besides female sex workers, there are non-commercial partners known as regular partners. They may be women working in the market area, shops, dhabhas etc. The two subgroups may engage in sexual relations with regular partner under the assumption that since they are not engaged in sex work, they would not be carriers of infection. Cultural taboos on open discussion of sexual matters have constrained avenues for acquiring knowledge about safe sexual practices and the means for practicing safe sex. Thus multiple partners, inconsistent condom use, homosexual relations may create a nexus of sexual relation creating grounds for vulnerability to HIV/AIDS for the study groups at APMC and Truck terminus. A large proportion of truck drivers report easy accessibility to sexual network as a factor creating vulnerability (84.9 percent) while a similar large proportion of mathadi workers report the same (90.3 percent). There are many bars within two km. radius of the APMC market and truck terminus. Besides female sex workers, there is a network of sexual relations formed within the workplace. 232

30 Being away from home gives us freedom to do what we want, do not care, men do not fear for self or family, risk of getting HIV is more. Truck driver from Tamil Nadu no entertainment, have to wait for supply for four or more days, sitting ideally with no means of passing time, some people drink while others go outside. Truck driver from Karnataka On being asked regarding the meeting point with the partners, the data shows interesting information. For the truck drivers, the data report 11.5 percent of respondents report meeting their sexual partner at APMC market, 3.1 percent at truck terminus, and 7.0 percent at bar, 16.1 percent at friend s place, 4.7 percent at Dhabha and 10.9 percent at highway roads. For the mathadi workers, a huge proportion of respondents report meeting their sexual partner at APMC market (55.1 percent), 11.0 percent at bar, 2.5 percent at Dhabha, 5.1 percent at friend s place Limited access to health services One of the challenges to scale up HIV/AIDS response is to meet the potential increase in the epidemic in terms of health facilities and services. Particularly for the mobile and hard to reach population, access to health service remains a lacuna. Being on the move, unfamiliarity with the health care providers at the place of destination, not able to maintain regular follow ups due to mobility reasons are some factors that create vulnerability in the context of HIV/AIDS. Limited access to health services as a factor creating vulnerability has been reported by 40.1 percent of truck drivers and 33.6 percent of mathadi workers. The Mathadi Board 233

31 has provided Mathadi Hospital in Kalamboli, Navi Mumbai where services are made available to workers. Many cite inability to leave work for the day to visit the hospital as a major barrier for accessing the health services provided. For minor illnesses, they visit the local health facility near Vashi. being away from family creates bad habits that puts us in lot of health problems. There is a health clinic but it is difficult to leave work and go there. Mathadi worker from Mahabaleshwar For STI people do not now where to go for treatment here in Mumbai. People who go to red light district Lal Dongar do go for treatment. Yes, men do go for treatment. There is lot of fear. They may think that their problems are signs of HIV. A. Awareness is very important. Here since new men are coming in, going home, there is risk. In village though people do not go out, still they come in danger. These men become danger to people back in village. Mathadi Mukadham If we get sick here, go to private doctors, otherwise we prefer our government hospital. For HIV testing also we prefer village. The sick man comes here, has a quarter and sleeps off. He would be fine in the morning. I did testing here but till date have not got the report. They could have posted the report. So now we do not do the testing here. The medicine here does not suit us. We have more faith in our own doctors. Many times people feel I may be positive and do not test. Truck driver from Tamil Nadu 234

32 Among the truck drivers, the data shows that as income increases, the proportion of respondents stating limited access to health services decreases. While 48.7 percent of respondents in income category of less than Rs.10, 000 report this factor, 23.1 percent in Rs. 10,001-20,000. Among the mathadi workers, the data does not show such a trend percent of respondents in less than Rs. 10,000 report this factor as creating vulnerability while 57.1 percent in Rs. 10,001-20,000 report the same. The mathadi workers have various alternatives for health seeking behavior. In addition to the Mathadi Hospital at Kalamboli, there are a number of private practitioners and government hospitals in Vashi providing health services as well as private clinics Peer pressure Peer pressure is a major factor that has emerged in the context of risk behavior and HIV/AIDS. It undermines healthy social norms and HIV prevention messages to abstain, be faithful, use a condom and delay sexual debut. Research studies posit that HIV prevention projects need to engage with peer pressure with the aim of changing harmful social norms into healthy norms. Increased communication among peer groups is one way to decrease the impact of negative peer pressure. Peer education is a further mechanism by which trained peers can role model healthy social norms and challenge a peer culture that promotes high risk sexual behavior. Living in a separate space away from families, peers form a major support group and play an important role in shaping behavior practices. Nearly an equal proportion of respondents among the truck drivers and mathadi workers report peer pressure as a factor creating vulnerability. Peer pressure has been reported by 37.5 percent of truck drivers and 38.6 percent of mathadi workers. Among the two 235

33 respondent groups there seems to be an association between increase in education level and proportion of respondents stating peer pressure as an important factor creating vulnerability. There seems to be a curvilinear relation between education and peer pressure. Among the truck drivers, the data shows that peer pressure is 47.4 among those who have not received any education, decreases to 28.8 among those having received primary education, increases to 38.8 percent among secondary education and is highest among those having received tertiary education (59.1 percent). For mathadi workers, peer pressure is 60.0 percent among those who have not received any education, decreases to 43.0 percent among those received primary education, 34.0 percent among secondary educated and is highest among those who have received tertiary education (100.0 percent). TABLE 6.10 CROSS TABULATION OF PEER PRESSURE WITH EDUCATIONAL STATUS OF RESPONDENT GROUPS Variable Respondent Education Total types None Primary Secondary Tertiary Peer pressure Truck drivers Mathadi workers 47.4 (18) 28.8 (34) 38.8 (52) 59.1 (13) 37.5 (117) 60.0 (6) 43.0 (34) 34.0 (70) (5) 38.3 (115) Figures in parentheses represent actual number 236

34 driver is always outside for work, sometimes with friends we drink, go to bar, have fun, sometimes fall in danger. Truck driver from Kolhapur When everybody goes, even we feel like going. Many times friends force us to drink, they joke and fool around with women. This is not correct, the infection can spread. Mathadi worker Many times men get influenced by their friends or people from their village, community and go out for drinks and fun. Sometimes we are able to recognize who are our true friends and we try to be with such people and sometimes we are misled. Mathadi worker 6.4 Testing of Hypotheses Hypothesis testing in statistics involves making inferences about the nature of the population on the basis of observation of a sample drawn from the population. There are three hypotheses for testing in the research study. Since the study is a comparative one, there are some statements regarding comparison of crucial parameters of the two respondent groups. T test, chi- Square test and linear regression tests have been used to test the hypotheses. 237