Case Study: Operation Lighthouse

Context for Operation Lighthouse
India is now home to the second largest population of HIV infected individuals with prevalence rates as high as 50% among certain high-risk populations. The national prevalence rate is closer to 1% though incidence is escalating among high-risk groups such as sex workers, truckers, migrant laborers, and men who have sex with men. Sex and HIV/AIDS are considered taboo discussion topics in India and there is a reluctance to speak about or purchase condoms. Despite some education efforts, there remains a general lack of awareness about HIV and AIDS in the general population and many high-risk group members deny they are vulnerable.

It is in this context that USAID approached PSI/India to develop a large Interpersonal Communication (IPC) intervention to target high-risk groups located in 12 Indian ports. The challenge was daunting considering the geographic and linguistic diversity of the country. A series of formative assessments were undertaken, an action plan was developed, and this was followed by implementation. The impact of the program is repeatedly measured, and when necessary, corrective action is taken to make appropriate improvements.

Operation Lighthouse
Operation Lighthouse (OPL) is a comprehensive and integrated program that includes interpersonal, mid and mass media communications, product and service promotion and provision strategies, as well as advocacy to target groups whose behavior place them at a high risk for HIV acquisition. These high risk groups include commercial sex workers, truck drivers and helpers, fisherman, migrant laborers, and people who load and unload trucks (loaders and downloaders.) The desired behaviors promoted by Operation Lighthouse include: reducing the number of non-spousal sex partners; increasing condom use with non-spousal sex partners; an increase in the treatment of Sexually Transmitted Infections (STIs) and undergoing voluntary counseling and testing (VCT).

Selecting the IPC Strategy
Interpersonal communication was chosen as an appropriate technique to address HIV/AIDS among high-risk groups as the prime focus of OPL is to motivate high risk groups to adopt preventive behavior. PSI/India also wanted to explore the effectiveness of utilizing interpersonal communication activities combined with mid media and some mass media. Interpersonal communication has been proven to be effective in inspiring positive behavior change, although its cost-effectiveness is currently being assessed in India. PSI/India's strategy was to combine the IPC with mid and mass media and measure which channels were the most cost-effective in bringing about behavior change and subsequently reinvest in those interventions.

Formative Research
Operation Lighthouse conducted mapping exercises to identify and prioritize target groups on the basis of risk and also to select best locations where each risk group could be targeted. These mapping techniques helped to define the geographic boundaries of the intervention and to identify the numbers of people in each potential target population. Formative assessments were also conducted to identify exactly which target populations were most at risk as a result of their high risk behaviors. For example, in an assessment of informal workers, migrant workers, who were responsible for loading and unloading trucks were found to be separated from their wives for long periods of time and were, therefore, likely engage in transactional sex. The formal port workers, however, were not prioritized as a target population because they were found to return home each evening and were, therefore, less likely to engage in transactional sex. The results of the formative research allowed Operation Lighthouse to focus on the appropriate risk groups in an effective and efficient manner.

The different target populations assessed during the formative research phase are reached by OPL. For example: migrant laborers, transport workers (truck drivers and their assistants), loaders, down loaders, sex workers, MSM, Central Industrial security force personnel, formal and informal port workers and fishermen.

A behavior impact survey baseline was done in the beginning of the project for each target population. This not only provided data with which to compare progress, but it also provided insight into the selection of Operation Lighthouse's themes and messages. Additional research was also conducted to gain insight into the lifestyles and behavioral patterns of the target populations. For example, research was conducted to find out the number of trips different truck drivers took and who they had sex with when traveling. This assessment provided a clear picture of the risk behaviors, behavioral patterns, and media habits of the target populations. The intervention design was directly influenced by these research findings.

Program Structure
Field offices were established in each of the 12 port cities. Ports were selected as the geographical focus of the program because a variety of high risk groups congregate there. The ports in which OPL set up offices include Kandla, Bombay, Vashi, Goa, Mangalore, Chennai, Tuticorin, Cochin, Vizag, Calcutta, Haldia, and Paradip. These are the major ports that cover the states on the coastal area of India. From an implementation and managerial standpoint, the number of ports was restricted to twelve, so that resources were not spread too thin. Across the 12 ports, OPL operates in ten languages.

Establishing field offices also meant that OPL staff could more easily work on site and be focused on the different layers of the intervention. Interpersonal communications, outreach work, mid-media, VCTC/STI services and promotions, telephone help-lines, and condom sales and promotions are all activities that occur out of the field offices. A staff support network was set up so that each region had a regional program manager.

The program model involves developing single themes and focusing all resources on those themes for three to six months. The themes can also be reintroduced at later time points if needed. Some of the focus themes have included:

• Increasing risk perception of unprotected sex with non-spousal partners
• Increasing risk perception of having multiple partners
• Creating awareness about asymptomatic HIV carriers
• Motivating correct and consistent condom usage
• STIs are caused due to unprotected sex with an infected partner
• Benefits of VCT

The theme approach allows for resources to be focused on clear and measurable behavioral objectives. It also allows for a multitude of activities to be developed so that messages can be repetitively reinforced, but through different channels. Training modules, support materials, and a media campaign (street theatre, posters, billboards, or regional mass media) are all prepared with a focus on a single theme. The content of the materials are based on formative assessments and pre-testing.

During a three-month campaign on a single theme, such as treatment of STIs from a medical practitioner, a typical member of a target population will:

• See a street theatre performance
• Have a one on one meeting with an interpersonal communicator
• Observe a demonstration of how to put on a condom
• Be referred by Operational Lighthouse outreach worker to STI clinic
• Be given a pamphlet illustrating the different types of STIs

All materials are pre-tested with the target groups, and the progress of the intervention is tracked closely through monitoring and evaluation, allowing evaluators to make the link between the intervention and any resulting behavior change. Each type of activity is tracked to see which one has the most impact on the behavior of target group members. Ideally, each member of the target population would be reached six or seven times through several different channels. Another advantage of this approach is that by focusing on specific geographic areas, it is easier to concentrate resources and create multiple opportunities to reach the target populations.

Designing Message Content
All the messages created for each theme are based on formative assessments. The Communications team at the core office handles the conceptualization and development of key themes. The outreach work under OPL is called the Integrated Behaviour Change Communications Approach. Monthly feedback from the Interpersonal Communicators (IPCs), who interact with target groups to carry out intervention activities, also contributes to the content of program messages. Once quarterly themes are selected the corresponding messages are developed collaboratively by the core office managers, the research and communication managers, and the training and materials development contractors.

Operation Lighthouse Staff
The staff motivation level is high and the turn-over rate low. The Interpersonal Communicators (IPCs) are full-time, paid professionals. Many of them come from the NGO sector and have Masters Degrees in Social Work. The product promotion team members are also full-time, paid staff, although they tend to have lower education levels. The majority of the outreach staff are men with the exception of the sex worker IPCs who are primarily women. The fact that IPCs are paid rather than work as volunteers increases their commitment to PSI and their dedication towards the program. Since the IPCs are hired and trained especially for the outreach work and are not drawn directly from target populations, they are not peer educators. They are hired based on their education and qualifications.

Operation Lighthouse divides its field staff into three teams. The "Behavior Change Communications Team" that deals with behavior change related themes such as: HIV risk with non-commercial partner or partner reduction. The "Services Promotion Team" aims at motivating individuals to go for VCT and to seek STI treatment. The "Visibility, Accessibility and, Touch Team" is focused on improving correct condom use and reducing the stigma associated with condoms.

Evidence-Based Program Design
Operation Lighthouse prides itself on its evidence-based decision-making. In addition to the formative research that informed the initial design of the project, Operation Lighthouse incorporates continual qualitative and quantitative assessments into their program design. Research provides the basis for every aspect of the project and use of the monitoring and evaluation data is a top priority among project managers.

Monthly review meetings are held in the core office to evaluate research priorities. The program design is continuously tweaked as new data become available. This allows the program to focus on the strategies that are working best. For example, research identified condom access as a barrier to their use. Based on this finding, strategies were developed to increase and ensure condom availability in the non-traditional outlets. In another instance, before starting the VCT promotion campaign, positive deviants, or members of high risk groups who had chosen to get tested prior to the initiation of Operation Lighthouse were studied to find out what motivated them to adopt positive behaviors. The results of this research also helped inform message content.

Mid and Mass Media Support Materials
A wide range of games, activities, street theater [PDF], and support materials such as cue cards and flip charts are continually created for Operation Lighthouse. New materials are produced for each of the quarterly themes. The use of these support materials enhances participation in the IPC inspired discussions and dialogues and helps to encourage behavior change, the fundamental goal of Operation Lighthouse.

Support materials help facilitate and enhance discussions between IPCs and high risk group members. The more high quality the discussion and the more pertinent it is to the experience of the participant, the more likely the interaction will result in behavior change.

PSI/India developed a flip chart which contained high quality glossy photographs of characters in real-life dramatic situations related to a specific theme. This intervention tool looks like a story board with each image advancing the story. A dialog which corresponded with the photo sequence was pre-recorded on audio cassettes and played during the interaction, or in certain circumstances, the script was read by the interpersonal communicators. To facilitate discussion, the participants are asked about the behaviors of the characters and what should happen next.

Operation Lighthouse also uses what it calls the "surround and engage approach." Posters, banners, and wall paintings, which convey the current theme, are placed in and around intervention sites. The concise messages are designed to reinforce the messages of the interpersonal communicators. Mapping techniques were utilized to identify locations for ideal poster placement in and around the target group location to best access each target population.

Operation Lighthouse also provides take-home support materials to its participants. Leaflets with illustrations that recap the theme messages and provide the target populations with information for health care service access are also distributed during all outreach activities and events. Often they are simply placed on tables for people to take in areas where staff has set up to answer questions.

Street theatre groups were hired or created by Operation Lighthouse. IPCs worked closely with these groups to assist in the development of their dramas. The leaders of the drama groups also attend the trainings conducted on each new theme. Puppet and magic shows and stories based on traditional folklore were all used to attract the attention of the target populations and convey HIV risk reduction messages.

The creative materials that are designed truly address the needs of a given target group population. It was discovered, for example, that the sex workers targeted by Operation Lighthouse had a very limited understanding of reproductive health. Special materials, therefore, were developed for them. One such product was a cardboard daisy that appeared to be a beautiful flower on the outside, but when opened, revealed worms on the inside. This simple material proved to be useful in communicating to the women that they could have no symptoms and still be infected with an STI, which, in turn, greatly increased their chances of being infected with HIV. The use of this material resulted in an increase in demand for screening for STIs.

Links to Services
Operation Lighthouse also works to link members of its target audience to the appropriate healthcare services. The primary services linked to Operation Lighthouse are: VCT and STI treatment. The goals of OPL's VCT and STI treatment work involve creating a demand for and promoting these services aggressively and sees a direct link between the service promotion and demand. Both the promotion and the uptake of services are tracked closely, and all VCT and STI service clients are asked from where he/she has been referred.

Service linkage is also promoted through time limited promotional schemes such as giving discount coupons to members of high risk groups. The coupons are all colored differently. Each color denotes the source of the coupon, such as an IPC session, a street theatre performance, or a product promotion team. Ultimately, at one point, a friendly competition emerged among the different groups promoting the services to see which had the greatest success in encouraging people to utilize the services. Furthermore, using this technique also allows Operation Lighthouse researchers to accurately monitor which activities are the most likely to encourage participants to seek treatment.

Under OPL there are STI rotating clinics in four port locations: Kandla, Kolkata, Haldia, and Paradip. The service promotions teams in these locations promote the Saadhan rotating clinics for STIs. This team focuses on discussing STI causation and severity with clients. In eight other ports, OPL has VCT-only clinics, hence the service teams in these areas promote VCT only.
However, in some of these clinics there are doctors who prescribe medicines for STIs. For example, in the VCT clinic within the Bombay red light district program, where OPL primarily works with commercial sex workers, STIs are given more focus.

Consumer research identified that the target groups wanted VCT services that were warm and professional. Ensuring that VCT services are of high quality, both in terms of service provision and ensuring that clients are treated fairly and with respect, also helps encourage service usage. All clinics follow standardized protocols and were designed and promoted as warm and professional services. Mystery client studies were implemented to ensure quality. Strict quality assurance measures were implemented to ensure reliability of HIV test reports at the VCT Center.

Operation Lighthouse is in the process of augmenting the establishment of VCT services in the project's catchment areas to focus even more on risk reduction and behavior change. Support materials have been developed for counselors to help high risk clients develop their own "personalized risk development plan." A series of cards are presented by the counselors that allow their clients to identify their risk behavior category and to choose the behavior change they felt most comfortable with. Behavior change can range from abstinence, to choosing masturbation rather than sex, to reducing the number of new partners, to correct and consistent condom use, and reducing their alcohol intake.

To increase STI services utilization private doctors in Mumbai were made members of and were marketed as part of the "Key Clinics" franchise. These doctors were trained to provide high quality STI services targeting mainly male clients of sex workers.

Encountering & Overcoming Obstacles
The development of Operation Lighthouse has been a learning process, and a number of obstacles were encountered along the way. The fact, however, that Operation Lighthouse does monthly monitoring and evaluation has allowed them to quickly identify obstacles and make the necessary program adjustments to overcome them. The promotion of Voluntary Counseling and Testing presented a number of obstacles to Operation Lighthouse. The high risk target populations were unaware of the service and their risk perception was low. To address this, Operation Lighthouse developed a communication campaign that highlighted the advantages of early testing: early access to treatment; improving quality of life; having the opportunity to plan for the future; and having newfound opportunity to protect themselves in the future. The campaign was successful in increasing demand for testing among the target populations.

Research identified that police harassment of sex workers was preventing sex workers from having confidence in and collaborating with the project. The police threatened the women with arrest primarily because they were looking for bribes and free sex. Research provided insights into the problem and a strategy was devised to increase awareness of the problem within the red light district community. A dialog was opened between the project and the police and legal awareness sessions for the sex workers were organized. Though the harassment of the police was not entirely eliminated, because Operation Lighthouse was willing to address the issue, the sex workers gained more faith in the project.

Research found that despite an increase in sex worker condom negotiation skills, about a quarter of the male clients still refused to use condoms. Some of the sex workers were reluctant to give up the income from those clients and accepted to have unprotected sex. The female condom was presented as an alternative to sex workers with clients who refused to use condoms. This tactic proved successful, and the sex workers were able to maintain their income and protect themselves from HIV/AIDS.

The reluctance to buy condoms even if they are readily available was identified as an important obstacle for condom use among male target group members. An event to address this was developed called "Pocket Mein Packet." Men were encouraged to purchase condoms and keep the condoms with them at all times. Those who produced the condoms when asked were eligible for a drawing for prizes. This strategy helped them get over their embarrassment in buying condoms and to carry condoms with them all the time.

IPC Trainings
Quarterly participatory training sessions are conducted for the IPCs. At the training sessions, the new themes, surrounding issues, and support materials are introduced. Training can be costly, especially when it is done several times during a year, but Operation Lighthouse has found these trainings to be fundamental to motivate and stimulate the IPCs. Though it is challenging to develop new trainings for each new theme and message, the approach helps keep the IPCs focused on the specific issues at hand.

Operation Lighthouse's training strategy was originally focused on presenting facts about HIV and AIDS. However, they found that focusing on sexual risk behaviors and personal risk assessments was more successful. Rather than being trained to initiate conversations with questions such as, "What do you know about HIV?" the IPCs were taught to focus more on questions such as, "What habits do you have which put you at risk for infection?" The training functions on a need-to-know basis. At each training the IPCs are given only the information they need to address the new theme. They are also given certain skills training like body language and voice modulation, and are trained on how to use the materials, what questions to expect, and how to answer them correctly. This differs from a more traditional approach to training in which IPCs are given a lot of information at one time and possibly a refresher course several years later.

The trainings proved to be successful in building confidence and skill levels of the IPCs. The single theme approach greatly contributed to this. Since only the messages of the new theme are introduced at each training, there is ample time to build the capacity of IPCs to communicate effectively.

The core office works closely with its training contractor, Training Resources & Media Production (TRAMP), to develop the theme concepts into actual messages and identify areas in which IPC communication skills need improvement. TRAMP was selected to do the training because of its experience with participatory approaches to training. The IPCs are given ample opportunity in the training sessions to practice using the materials and develop their skills for stimulating discussions through inter-active methods. Operation Lighthouse staff then works to coordinate these messages and training activities with the mid media materials produced by local mid-media teams so that the messages and materials blend seamlessly together.

The geographical spread and cultural diversity have presented quite a challenge to developing effective training. Having a competent central trainer will help ensure consistent quality of the training, but this single person may not have the necessary linguistic knowledge to help the IPCs communicate with their target populations in the most effective manner. Plans are currently underway to identify trainers on a regional basis. In the south, INSA, a training agency has been appointed to train the IPCs from southern ports. Until a similar organization is contracted in other areas, special attention is being given to the development of a common vocabulary in the regional languages that would be used by the IPCs and in the mid and mass media.

Operation Lighthouse's 250 IPCs are trained at least four times a year. Each of the trainings cost about $7800. This includes the cost of the development of the support materials development, travel of the IPCs, trainers and their stay.

Supervision
At PSI's main office in Mumbai, there is one staff member who is dedicated to each Operation Lighthouse port. The core office staff includes program managers, as well as communication, research, administrative, and finance personnel. There are also technical advisors who specialize in specific public health issues such as HIV/AIDS.

The IPC coordinators in each site act as the link between the IPCs and the Communications Department in the core office. The coordinators are responsible for ensuring effective coverage, adherence to planned activities, on-going feedback to IPCs, and completing monthly reports to give feedback to the core office.

There is approximately one coordinator for every 5 IPCs. Although coordinators serve as supervisors, they also work as IPCs. Daily supervision on the ground is necessary to ensure the proper implementation of work plans and to maintain quality control.

Monitoring & Evaluation
Every month each field operation submits a quantitative and qualitative report on their activities. The report captures the numbers of people reached through the different communication channels in different locations. It also helps the field staff assess performance based on pre-established measurable targets. The reports also provide insight into whether resources have been allocated appropriately.

The qualitative report is based on IPC daily feedback that is compiled monthly. It includes lessons learned and key challenges. The report is also used to share feedback on the quality of the communications in the field and identify problems IPCs are facing. A team in the core office reviews these reports and provides feedback and guidance to the ports.

The quantitative survey, called the Output Tracking Survey, is conducted with 3,000 respondents in each of the 12 ports every month. It is a Knowledge, Attitude, and Practice (KAP) survey that provides information on the impact of program activities on the designated knowledge, attitude, and behavioral indicators that are outlined in the log frame. The survey also helps determine program reach, which is measured against monthly targets.

Because this information is generated monthly, decision-makers can act quickly when programmatic changes are necessary. For example, the Output Tracking Survey discovered that activities were not having the desired impact on motivating partner reduction. To address this problem, the decision was made to focus on this topic for six months in 2004. This strategic change was successful and subsequent surveys demonstrated a reduction in the number of partners among target group members.

Programmatic progress is measured against a set of predetermined goals that are based on previous successes, failures, and general knowledge of the target populations. If the goals are not reached the staff reassesses the situation to determine what went wrong and what supports are needed from core office in order to reach the goals. For example, one monitoring and evaluation survey demonstrated that despite the campaign messages focused on VCT, service uptake was not increasing. The core office decided to create special outreach teams in each port which only promoted VCT and STI services.

Each supporting mass media campaign is evaluated to ensure that ads are understood, relevant, distinct, persuasive, and lead to behavior change. The evaluations measure reach, recall and change in attitude and behavior. Each media channel is examined for cost-effectiveness. Examining India's budget [Excel] helps portray their media channels and research costs.

Lessons Learned

• To facilitate staff "buy-in" to the quarterly theme selections, it is important to share the rationales behind the selection with all IPC staff.
• When using a single theme approach it is possible that both IPCs and target populations will suffer message fatigue and become bored. It is important to find the right balance between good coverage and over-saturation.
• The leaflets produced did not have enough visual content and were too word oriented which proved to be a problem with low literate and illiterate members of the target populations.
• The support materials are introduced to the IPCs during their training. Adjusting to the new materials can be difficult, and could be facilitated by including sample discussion questions on the back of the visuals.
• Understanding and correct use of support materials is dependant on participating in the training, which makes the use of the materials more difficult by those who don't participate. This also makes the adoption of materials by other organizations or in new Operation Lighthouse sites more difficult.
• Language translations are best done locally, where the language is spoken.
• Regular training by skilled professionals has been beneficial in improving skills, building morale, and educating IPCs.
• A close relationship and regular contact with the training agency is important to ensure that new research findings and monitoring feedback from the field is incorporated into training content.
• Training sessions should encourage IPCs to share their experiences and focus more on building skills rather than simply introducing new theme content.
• Reliable initial assessments and monitoring of target population size and location are needed to ensure that work plans are accurate, cost-effective, and are reaching the population of concern.
• Ongoing supervision increases the chance for effective and high quality interventions.
• Repetition of themes increases impact.
• A calculated balance between decentralization of implementation with technical expertise, assistance and quality control assurances coming from a central office is necessary.
  
• The monitoring system is extremely effective in understanding the reach and depth of the on-ground interventions allowing them to be improved and strengthened as necessary.
• Ten Guiding Principles of Operation Lighthouse

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