More than seven thousand cases of AIDS were reported in Thailand by the end of 1993. As for HIV infection, one in 70 persons were infected, giving a total of approximately 800,000 persons infected with the virus^4. These figures indicate the rapid spread of HIV since the detection of the first AIDS case in 1984. Today, HIV has become a pandemic -- affecting women and men in high risk groups as well as the public at large including children. Figure 1 shows the sharp increase in HIV prevalence amongst several groups.

Alarmingly, 65 per cent of those already infected are young people in the 15-34 age group who are the economically most productive section of the population.

As a response to the gravity of the epidemic and the concern for its dramatic impact, the

Government of Thailand began its AIDS campaign in 1987 with the establishment of the country’s National AIDS Programme. It initially viewed HIV/AIDS as a problem affecting drug users and sex workers, thereby targeting only these groups in its campaigns. However, as HIV infection spreads beyond the high risk groups, the government recognized that HIV/AIDS can only be prevented and controlled through mobilizing multiple sectors of society.

The National AIDS Prevention Control Committee was therefore established in 1991 with the Prime Minister as Chairman of this policy making body at the national level.  The Committee has representatives from various agencies including government, NGOs and the private sector. Currently, the  National AIDS Prevention and Control Plan serves as a framework for coordinated AIDS prevention and control throughout the nation. This framework serves to control further transmission through:

1. public information and education (targetting all sectors of society)
2. medical treatment and care
3. human rights work
4. social support
5. research and evaluation programmes.

Information and education programmes only slowly increased public awareness of HIV/AIDS during the first six years of the HIV pandemic in Thailand. It was not until 1993 that the impact of the National AIDS Programme on  behaviour was clearly seen. The projection done in 1991 estimated that by the year 2000 there would be 2-4 million people infected with HIV. However, a recent projection by the same core group of researchers found that behavioural change has occurred and by the year 2000 the estimated HIV population would be only 1-2 million.

Examples of changes in behaviour include an increase in condom use from under 100 million pieces per year to over 150 million pieces per year, and a lower frequency of commercial sex visits among the male population. This is to a large extent the result of, among other things, a huge increase in the  government budget to the AIDS programme now totalling US$45 million for government and NGO activities, and changes in strategies; from education/ information guided by one ministry to education/information including motivation building and social skills training for prevention and compassion by many ministries.

AIDS and the Factory Workers

For more than a decade, Thailand has experienced rapid development in the industrial sector, resulting in a significant increase in the total number of people involved in this sector.  As HIV infection is most prevalent among labourers (see Box 1) AIDS will have a growing impact on the economy.

 Furthermore, even though living and working together is not a factor in the spread of HIV/AIDS, when a worker is infected, factory administrators, managers and employees need to have correct information on the transmission and prevention of the disease.  They also need to develop correct attitudes about the disease so that they live and work together with people with HIV/AIDS without prejudice.

A large number of factory workers, especially those in the 15-24 age group, live in dormitories near the factories where sources of entertainment are limited. In such situations, alcohol and sex provide alternative entertainment -- a lifestyle that exacerbates the transmission of HIV. Because they are the most economically productive and in their prime reproductive ages, failure to educate them on HIV/AIDS will have a dramatic impact. Hence, it is essential that these workers are given information on HIV/AIDS and how the disease is transmitted and that they develop positive attitudes to help eliminate discrimination towards those with HIV/AIDS.

In spite of policies and guidelines formulated under the National AIDS Committee, there were previously no models for providing or disseminating information to Thai labourers about HIV/AIDS. Moreover, no studies had been undertaken to see if the educational media available were appropriate for labourers.

It was for the above reasons that the Thai Government requested support from the UNICEF, Thailand Office to undertake a project on AIDS Prevention through Health Education and Non-Formal Counselling.

Thai Red Cross Society

Since the diagnosis of the first AIDS case in Thailand by Dr Praphan Phanuphak, the founding director of the Thai Red Cross Programme on AIDS, the Thai Red Cross Society (TRCS) has been a leading NGO in addressing the problems and issues associated with HIV/AIDS. Its close working relationship with the government in this area has resulted in effective national policy development and programme implementation.

The TRCS Programme on AIDS officially started in December 1989. All activities under this programme are guided by the following principles:

• Given support, HIV-positive people can live positive and meaningful lives.
• People infected with HIV have the same rights as do other members of   society.
• Discrimination against people with HIV is unjust and inhumane.
• The general population must be educated on HIV/AIDS as well as acceptance and care for HIV-infected persons.

Because of its successful record, the task of managing the project on AIDS Prevention through Health Education and Non-formal Counselling was given to the Thai Red Cross Society (TRCS) Programme on AIDS. Collaborating with the various implementing agencies consisting of provincial labour departments, universities and teachers’ colleges, TRCS initiated the project in 1991.

The Project

The emphasis of this project is to:

1. Provide youth working in factories with knowledge of HIV/AIDS and its  prevention.
2. To promote non-discriminatory attitudes and treatment towards those  infected with HIV/AIDS.

The project was made up of three major activities:  (1)  the development of appropriate educational materials for the target group;  (2)  training of trainers;  (3)  training of youth factory workers.

These activities were undertaken in two stages, beginning with a pilot phase in Khon Kaen province before the expansion to other provinces.

The Pilot Phase

Khon Kaen province in the northeastern region was chosen as the location for the pilot project for three reasons. First, statistics show that the HIV prevalence in this region is comparatively low. With intervention, it is expected that the spread of HIV can be controlled. Second, Khon Kaen is the home of more than 200 factories with more than 1,000 workers each. Third, the majority of these workers are youth below the age of 24, a group at particular risk for HIV, and whose special needs for HIV/AIDS education and information have not been met.

Educational Materials

Development of educational materials involved two separate activities which were undertaken concurrently in Bangkok and Khon Kaen. While the team in Bangkok put in efforts to develop training models, activities in Khon Kaen concentrated on the development of supplementary educational materials such as comic books, posters and leaflets.  (See Annex 1).
A working group consisting of members of the TRCS Programme on AIDS, and social workers of the TRCS and Chulalongkorn Hospital was established to review existing educational materials and training models for HIV/AIDS prevention. "We reviewed a large number of available posters, pamphlets, flipcharts, cassettes, videos and training manuals. We came to the conclusion that the existing training package could not meet the needs of the factory workers. So we had to develop an appropriate training package" said Dr Jean Barry who headed the team of four experts. Two training models were developed based on these materials. The first was for a one-day training of eight hours while the other was for an eight hour training carried out over two days. These models were then tested with factory workers from various provinces working in Bangkok. Comments and lessons learnt from the test were incorporated into the final training model which allows for active participation of trainees. However, depending on the level of education of the workers, the package is adapted to suit the workers’ level of literacy and awareness of HIV/AIDS.

Concurrent with the development of the training model in Bangkok, a team at the Khon Kaen University, headed by Dr Chuanchom Sakondhavat, developed supplementary educational materials to be used in this project. "The message in the materials should be appropriate to those reading them. In this case, factory workers, their families and their communities are the target groups. They should be able to easily understand the message and at the same time should enjoy reading them" said Dr Sakondhavat. The objective of these materials is for the factory owners and trained workers to distribute them to other workers and then to the community.

Development of the educational materials started with two one-day seminars for 100 factory owners/managers on HIV/AIDS and its prevention. At these seminars, participants were informed how AIDS education would benefit both factories and workers. Then, after contacting selected factories from those represented at the seminars and obtaining agreement from the owners/managers of these factories, a mini-survey was conducted with 300 workers, both pre- and post-intervention trials, to determine their level of awareness and knowledge of HIV/AIDS and high risk behaviour as well as their attitudes  related to HIV/AIDS. Subsequently, a series of in-depth interviews with 16 workers and focus group discussions with 8 groups were conducted to find out their possible motivation for prevention and their acceptance of interventions. The individuals interviewed in the post-intervention trial were not necessarily the same persons interviewed in the pre-intervention trial. The data collected were then used as a baseline for evaluating change after the interventions and to modify the intervention strategies and education content.

Results showed that although most workers were aware of HIV/AIDS, many were misinformed about how HIV is transmitted; misinformation ranged from the belief that HIV is transmitted through sharing a bathroom to sharing food. Attitudes towards those with HIV/AIDS were generally negative. For these workers, accepting information on HIV/AIDS has two main motivation: they know it has no cure and they are concerned for family members and friends. Messages on HIV/AIDS were well accepted. In surveying the available HIV/AIDS information materials, workers’ preference showed that video and comic books were the best method of HIV/AIDS education. Reading comic books makes the readers feel like they are doing some leisure-time reading rather than reading textbooks. "Comic books reduce stress" was a response from one participant.

The Message

HIV/AIDS information was the focus of the curriculum developed by the staff of the Social Welfare Unit of Chulalongkorn Hospital during the pilot project and the first year of the project.  Components focusing on non-discrimination and living with people with HIV/AIDS, in keeping with national HIV/AIDS education trends, were added at the start of the second year.  To reflect the continuing need to evoke behaviour change in the target population, educational approaches were changed. Currently, curricula take a "life skills" approach which concentrate on the building of important decision-making skills. These skills combined with knowledge on sexual and reproductive health make the issues at hand personal to the individual and, therefore, it is hoped that the target individuals will change their behaviour when their personal health choices are involved. If the project continues and is upscaled, there have been calls for the curriculum to have a greater focus on women’s empowerment and negotiating skills.

Involvement of Entertainers

Until this project was initiated, popular entertainers who can greatly influence the behaviour of youth, distanced themselves from any association with HIV/AIDS. "Fear that any association with the disease would bring negative publicity was the reason for their non-involvement" says Dr Werasit Sittitrai. Persuasion on his part finally succeeded in creating an innovation in itself -- the participation of filmstars, and singers in the development of materials.
With the willingness of entertainers to participate in HIV/AIDS prevention, a calendar portraying several entertainers presenting HIV/AIDS messages was developed. Darapapyon, a movie star magazine, provided the promotional photographs and arranged for all the necessary approval from the entertainers featured.

Nationwide Distribution of IEC Materials

Encouraged by the development process and the effectiveness of the educational materials, the Office of the Prime Minister suggested the use of the  materials throughout the country. Action plans for production and distribution of educational materials to factories in the provinces targeted under this project were developed by the Ministry of Interior and Office of Provincial Industry. A grant of US$250,000 to implement the action plans was provided by the Government.

Today, a large number of government agencies and local NGOs are using the educational materials developed by this project. In addition, flipcharts have been requested by the National AIDS Programmes in Laos and Cambodia.

Training for Non-Formal Counsellors

The project aims to reach youth factory workers through a group of trained co-workers. The idea behind this strategy is to allow youth workers to learn about HIV/AIDS and to seek counselling in a comfortable environment. This strategy will likely lead to programme sustainability.

Workers chosen to become non-formal counsellors receive training on HIV/AIDS, how it is transmitted and ways to prevent infection.  They also learn how to use the flipchart as a tool in educating their co-workers and friends. Most important, these non-formal counsellors are trained to effectively communicate the message and to provide basic counselling.

Training consist of a 1-day (8 hours) workshop. The model and teaching methodology encourage active participation from the trainees.  Only two hours in the one-day training is allocated for lectures on HIV/AIDS, its prevention and on how to use the flipchart. The rest of the day is devoted to small-group discussion, role playing, games and group presentations.  Special attention is given to role playing on communicating or imparting knowledge to others and on counselling. The participatory technique is proven to be popular with the trainees. "In the beginning, the workers are shy and do not talk much. But after a few icebreakers, they were able to participate actively" says a trainer from the Drug Prevention Centre, Ubonratchathani Teacher Training College.

The selection of trainees is done by factory managers.  Selection criteria includes:  lively personalities; ability to communicate well with peer workers; and leadership qualities. Trainers noticed that being chosen to participate in the workshop was a source of pride and confidence to most of these workers.  "Receiving a certificate at the end of the workshop is very good for the workers’ morale and self-esteem. It is also a motivation for them to spread the knowledge they had gained" explained a factory manager.

The workshops are mostly conducted on Sundays, hence, working hours are not affected. Although this arrangement works out well with the factory owners/managers, it discourages the workers from attending the workshop because Sunday is a holiday. Two alternatives are suggested to overcome this problem. The workshop can be conducted on a working day instead of Sunday but factory owners/managers may not be happy with this alternative. The other choice is to provide incentives to the workers to come on a Sunday.

To facilitate sharing of information and counselling, peer counsellors are given an assortment of educational materials to assist them in talking with others. This assortment includes flipcharts, comic books, information booklets, videos and posters.

Follow-up at Factories after Training

As this project was meant to  create a substantial number of non-formal counsellors, it was expected that follow-up activities in the factories would not be structured. Evaluations indicate that knowledge on HIV/AIDS prevention and counselling was shared by the trained workers with their peers, friends, family members and neighbours. Such sharing takes place informally during lunch break, in residential halls provided by the factories, at home, and during get togethers with friends. At factories, workers are exposed to educational materials such as calendars and posters. Workers sometimes get such information through cassettes played in the factories. In certain factories, materials are made available to workers. However, factories do not carry out seminars or exhibits as follow-up to the workshop.

Often, trained workers are inhibited about striking up conversations on HIV/AIDS with their peers. On the other hand, their peers tend to be the ones to break the ice. They know that their friends have recently attended a special training and have many questions on what the training was about. This, of course, makes the task of initiating conversations on HIV/AIDS prevention easy for those trained. Some of the peer counsellors stated that the educational  media have proven to be ice breakers as well. One woman working in a distillery stated that her family saw the instructional flipchart on a table at home and then proceeded to ask questions about the contents of the flipchart.

On the other hand, surveys found that two-fifths of the peer counsellors preferred not to use any educational materials while sharing HIV/AIDS information with others. This may be due to the natural way in which casual conversations are started. Workers would seldom carry the educational materials with them on the chance that they might have an opportunity to talk with someone about HIV/AIDS. The conversations which  incorporated educational materials generally took place in the worker’s home or residence where the educational media were at hand.

Interviews with both factory managers and workers indicate that employees are more aware of HIV/AIDS and how it is transmitted after the project intervention. Most of the workers take more caution with regard to their sexual behaviour. "It is now a matter of life and death" says an untrained male worker in a liquor factory. They often remind each other to protect themselves.  The influence of alcohol, however, is a problem among factory workers.  A worker in a sugar manufacturing factory stated that "the problem arises when we have too much to drink. We will forget everything".

The interviews also found that those who did not participate in the training are also interested in training. Asked why they wanted to know more about HIV/AIDS, a range of reasons were given and are quoted in Box 5.

Towards Programme Sustainability

To ensure the sustainability of the project, the capacity of local agencies to implement and coordinate project activities was strengthened through training of trainers and also through networking among agencies.

Training of Trainers

Recruitment of trainers was done by the TRCS and the Ministry of Education. In most provinces, the trainers are teachers from the local Teacher Training Colleges. At these colleges, there exist centres which provide information on various health issues, making incorporation of HIV/AIDS prevention activities a logical and practical step. Hence, these colleges are the best agencies to work with because they already have the experience in health education.

Trainers from the various provinces were initially trained in Khon Kaen province. Later, refresher training was held in Bangkok. These trainees were trained by a team comprised of the social workers who were involved in the development of the training manual, two-three resource persons and two assistants who are familiar with provincial dialects. At the 2-day training, prospective trainers received information on HIV/AIDS and how to conduct the training for factory owners and workers using the educational material package developed by the TRCS. The one day training also teaches trainers how to liaise with the provincial labour department and factories in follow-up activities such as distribution of materials, monitoring and evaluation. Such skills are important for the sustainability of project.

Networking among Agencies

Step 1: The Secretary General of the TRCS writes to the Governor in the specific province.

Step2: Upon approval from the Governor’s office, a social welfare worker of the TRCS, Bangkok visits the province to hold meetings with the Governor, TRCS chapter, and Labour Department to inform them of the objectives of the project as well as to seek their support in  project implementation.

Step 3: The social welfare worker then holds a meeting with factory owners/managers in the province to inform them of the same. In addition, the owners/managers are also provided with information on HIV transmission and ways to prevent infection. Support from factory managers is vital in ensuring that factory workers will participate in the project. During these visits, educational materials are also distributed to the factories.
Step 4: The Department of Labour organizes the training and coordinates  involvement of trainers from the Teacher Training College.

Step 5: The initial training workshop in every province is conducted by the training team from Bangkok with assistance provided by local trainers. This is done so that the prospective trainers can observe how training workshops should be conducted before conducting them on their own.

Step 6: As the coordinating agency at the provincial level, personnel from the Department of Labour visit factories to monitor follow-up activities after workers are trained. Support from the provincial labour office in organizing training workshops and monitoring activities in the factory facilitates project implementation. In line with the government’s commitment to the fight against HIV/AIDS, an officer is assigned in each provincial Labour Department to coordinate HIV/AIDS activities in the province.

Achievements

The achievements attained by the project are summarized below:
 

1. Youth working in factories have been marginalized in efforts to educate the public on HIV/AIDS. This project was the first initiative to systematically provide HIV/AIDS education to this group.
2. Materials developed under the project have successfully met the needs of the target group and are now widely distributed in factories in Thailand. These materials are being used by government agencies as well as other  NGOs working in the same field.
3. Several government agencies and NGOs in Indochina have developed context-specific materials based on the materials developed by the TRCS.
4. From a pilot project in one province, this project has expanded to reach 12,885 youth working in factories in 20 provinces.
5. The project has built capacity at the provincial level through its network of resource persons and collaborating agencies. The network is an important factor in ensuring project sustainability.

Innovation as it was Implemented

The Programme on AIDS, Thai Red Cross Society and UNICEF both advocate a community-based approach to interventions undertaken or sponsored by each agency.  This means that the implementing agency must attempt to make use of existing infrastructure, i.e. facilities, services, installations and equipment existing within the organization or to incorporate the use of the existing infrastructure within the local community.  Therefore, there was no capital input for the project.

The estimates for costs of the recurrent input were taken from the project proposal and the final liquidation accountings for the third year⁵  of the project.  The third year was chosen as representative of the project costs because it was the most complete year to date in terms of preparation, materials produced, number of provinces targeted and the balanced representation of provinces with either high or low levels of factory based labour.  The total cost of the recurrent input are broken down in Table 1.

Table 1.  Recurrent Inputs: The Third Year (1993-1994)
 

Item	Budget  required   (Baht)	Budget Available & Received  (Baht)	Budget Received $ US
Personnel - supervisors,  administrators, counsellors, trainers, etc	506,100.00	495,553.00	19,822.12
Administrative support (personnel, office space, equipment)	0.00	0.00	0.00
Supplies - education materials	1,315,860.00	1,288,439.00	51,537.56
Supplies	67,480.00	66,074.00	2,642.96
Project management	134,960.00	132,147.00	5,285.88
Recurrent training - outreach training	3,880,100.00	3,799,247.00	151,969.88
Transportation(driver and vehicle)	0.00	0.00	0.00
Communication - telephone, electricity, water, fax,	67,480.00	66,074.00	2,642.96
Other operating inputs:  monitoring, evaluation,  data processing, and  report	101,220.00	103,026.00	4,121.04
Sub-total	6,073,200.00	5,950,560.00	238,022.40

In order to make a closer examination of the expenditures necessary for the projects or those which may be cut, a list of project activities and outputs have been drawn up in Table 2.

Identification of a "Minimalist Package"

Because of the community-based approach advocated, intervention programmes already tends to take a minimalist approach.  However, there are still two areas where costs may be reduced or cut out completely.  The first of these is in the area of IEC materials development.

IEC Materials

When examining the results of a survey conducted to evaluate the trained factory workers’ performances and assess the sexual behaviour of the trained versus the untrained factory workers, it was found that the workers who underwent training as non-formal counsellors either chose to talk with their friends without any educational materials or tended to use either the flipchart or the comic books given to them during their training.  These same workers tended not to use posters, calendars, pamphlets/booklets, video tapes or audio cassette tapes when talking to their friends about HIV/AIDS.  These latter materials, however should not be undervalued in importance.  They may play a significant role in maintaining worker interest in the topic of HIV/AIDS and in motivating the trained workers to continue their education efforts both in the workplace and at home.  These materials are important additions to the factory’s health information resources as they are another confidential (through self-study) source for workers to obtain additional information on HIV/AIDS.  In upscaling the project, it may be possible to coopt many similar materials from other programmes or, at least, share the education materials costs with other interventions in which these materials may be appropriate.

Collaboration with Government Agencies

Another area where costs may be significantly reduced may come from enlisting greater cooperation and support from government agencies as mentioned in the section on managerial requirements.  In that section it is stated that in some provinces there was a great deal of cooperation from the Provincial Department of Labour and the Provincial Department of Industry while in others there was very little cooperation.  The level of cooperation tended to depend on whether the departments had already initiated or were in the process of planning their own interventions on the one hand or are open to and seeking ideas and assistance in planning and implementing interventions on the other.  In either case the departments’ programming efforts fall under the National AIDS Prevention and Control Plan which calls on all ministries to be responsible for conducting HIV/AIDS interventions in their respective sectors.

Previously (1991-1993) national AIDS programming funds were under the supervision of the Office of the Prime Minister which delegated funds to each ministry for its own sectoral HIV/AIDS programming. Currently, the Ministry of Public Health is the Secretariat of the National AIDS Prevention and Control Committee which means that this ministry is in control of all national AIDS  programming funds.  Therefore, any governmental or non-governmental agency seeking national funds for interventions, etc. must submit a proposal to the Ministry of Public Health or the local Provincial Office of Public Health for its approval.  The result has been that the process of obtaining funds has become extremely competitive and is considered too difficult and time consuming by many agencies.  If a greater multisectoral approach were taken, national and other funds as well as programming could be shared among governmental and non-governmental agencies.

When this project was initiated, the idea of greater multisectoral cooperation had not yet come into play, and many governmental and non-governmental agencies, continue to maintain independent programming.  Moreover, it would be difficult to now turn back the clock and attain greater cooperation after local projects have already been initiated.  Tacit cooperation would have to be obtained from the government agencies at the highest levels before this would be possible.

One possible way of doing this would be to incorporate this project into one of the programmes under the Fourth Country Programme of Co-operation between the Royal Thai Government and the United Nations Children’s Fund, HIV/AIDS Programme Plan of Operations, 1994-1998.  This programme is "designed as a collaboration between non-government organizations, the government and other allies..." (Plan of Operations, pg. 1) and has the tacit approval of various government agencies, non-governmental organizations, the Buddhist clergy and United Nations agencies.  The interventions under the Plan are initiated by various non-governmental organizations with the collaboration of appropriate government agencies in all regions of Thailand.  As the projects continue over a five year period, the government agencies will assume greater responsibility for the programming and management of the projects.  The costs for the projects are expected to be absorbed into the government funding cycle lending sustainability to the projects after capacity building among the government agencies has been achieved.

With this in mind, it may be possible to incorporate the project into the second component of the project HIV/AIDS Education for Out-of-School Youth under the Fourth Country Programme which focuses on youth in the workplace and in the non-formal sector.  If this is possible, the Provincial Departments of Labour can be responsible for project implementation during the first year of upscaling the project.  In subsequent years, additional responsibilities may be given to the Department of Labour and other government agencies.

We can assume that the third year funding for training of factory owners/managers (average per training) would be $4,000 and the estimated cost of training for factory owners/managers (average per province) with government agency involvement would be $0.00.

If a minimalist package were conducted in the twelve target provinces of the third year of operation, the approximate costs would be the following:
 

Item	Budget required ($US)
Personnel	19,822.12
Education materials	24,562.44
Project management	5,285.88
Training of TTC staff	3,280.00
Training of workers	103,969.88
Communication	2,642.96
Monitoring, evaluation, Data processing and report	4,121.04
Total	163,684.32

The average cost per training in a minimalist package can therefore be figured out as:

  US$163,684.32   = $2,153.74 per training (all inclusive)
  76 trainings

Requirements for Upscaling the Innovation

It would be impossible to estimate the costs of upscaling this project directly on a province to province basis since some of the provinces have a strong industrial base while others maintain primarily agrarian societies.  In any case, it is best to look at the number of individuals who may be reached within a one year period.  Since the target provinces in the third year of operation are fairly representative of provinces with either high or low levels of factory based  labour, the average number of workers trained may be taken as representative of the number of workers possible to train in each province in one year.  If the same training structure is adhered to in the upscaling of the project, the average number of workers trained per province will remain fairly constant since the trainers from the Centers for Preventive Medicine at the local Teacher Training Colleges all have the same limited amount of time during the year to conduct trainings, i.e. during term breaks (mid-March through mid-May and the month of October).

In the third year of operation, 76 training sessions were conducted by 10 Teacher Training Colleges in 12 provinces.  This means that an average of 6.33 trainings were conducted and an average of 316.5 workers were trained in non-formal counselling per province in that year.  As mentioned above, with a minimalist package, each training would cost approximately $2,153.74 per training.

There are 36 Teacher Training Colleges in Thailand’s 76 provinces and Bangkok, each with its own Center for Preventive Medicine.  If each Teacher Training College is fully cooperative in conducting training in their respective provinces, approximately 487.5 trainings could be held, and 24,375 workers could be trained. Assuming that each trained worker would reach 152.4 persons, approximately 3,715,263 persons could be reached through the provision of educational materials and non-formal counselling in one year.  The basic cost for this could be derived as follows:

487.5 trainings X $2,153.74/per training = $1,049,948.2

This figure, however, must be increased slightly to accommodate the greater coordinating and administrative needs of the project.  As recommended in the managerial requirements it would be necessary to hire four regional coordinators @ 15,000 baht or $600.00 per month per person.

4 coordinators X $600.00 month/person X 12 months/year = $28,800.00

Additional funds would also be necessary to train three additional staff (for primary as opposed to refresher training) at the Centers for Preventive Medicine at each Teacher Training College.

36 TTC x 3 persons x $164.00/person = $17,712.00

Therefore the total estimated cost for upscaling the project comes to $1,096,460 per year.
 

Managerial Requirements
Target Group Involvement

Initiated by the government and implemented by the Thai Red Cross Society, factory managers/owners were neither involved in the design nor in the implementation of the project. Their involvement was limited to seminars in the early stages of the project implementation. Similarly, involvement of factory workers was in the survey, interviews and focus group discussions during the pilot stage. It was only after the training that their involvement became substantial.

Literature on programme management and lessons from population related programmes continue to suggest that a "top-down" approach is ineffective. Programme success is dependent on whether the needs of the target groups are met and the extent of their involvement in programme planning, implementation, management and evaluation.  These lessons also apply to HIV/AIDS prevention programmes at the workplace.  It is crucial therefore that both managers and workers are actively involved in programme planning and implementation from the very beginning of programme formulation.

Providing Alternative Lifestyles

Lifestyles of workers can be a significant influence on their high risk behaviour. For example, although factory workers involved in the programme are more aware of HIV/AIDS and its devastating consequences, and are more cautious of their sexual behaviour, such caution prevails only when these workers are sober. The influence of alcohol is a problem among factory workers as summarized by a worker "the problem arises when we have too much to drink. We forget everything". Because there are few sources of entertainment in industrial areas in the provinces, workers resort to drinking during their leisure time which often leads to unprotected sex.

The lifestyles of workers, often overlooked in programme design, cannot be ignored. The influence of lifestyles on workers’ behaviour that may increase the likelihood of HIV infection has given urgency to understanding how workers spend their leisure time and how they would spend their time, should other opportunities be available.

A Holistic Approach

The project realized that the concerns of youth with regard to their reproductive health is not limited to HIV/AIDS. They are also concerned about contraceptives, other sexually related diseases, relationships and responsibilities. Having a holistic understanding of reproductive health is likely to enhance young people's comprehension of HIV/AIDS and its prevention, hence making HIV/AIDS prevention projects more effective.

The project has already adopted a reproductive health approach in its training workshops in light of the above. Topics on the issues of reproductive health such as STDs, RTIs, and enhancing male responsibility have been  incorporated into the existing training model.

Towards Sustainability

Prevention of HIV/AIDS must be a continuous process. A "one-time" training approach makes little impact on behavioural change and will likely end up as another awareness raising effort. What is needed is on-going information giving and counselling which can be provided only if the project is institutionalized. Without institutionalization of programmes, project implementation will begin to dissolve after the initial years, if not months, resulting in the decline of workers motivation. While technical expertise from NGOs or other agencies is required in the initial stages of project implementation, mechanisms for managers and/or peer counsellors to take responsibility for programmes must be put into place.

Creating Shared Values

While traditional values are promoted, the project does not lose sight of how sexual norms and behaviours have changed.  Much of the data for this comes from Thai Red Cross Society sponsored studies, such as Thai Sexual Behavior and the Risk of HIV Infection (1991) and the Study on Networks and Norms of Sex in Thailand: A Qualitative Research Inquiry (Draft 1994), and data collected by the Venereal Disease Division, AIDS Division and Division of Epidemiology of the Ministry of Public Health.  From these data, curricula are developed which reflect the current trends and help train the participants to make informed personal choices as well as maintaining the confidentiality and  respect of others.

Research

The project has been enriched by data collected and research findings which the Thai Red Cross Society has undertaken on its own or in collaboration with local as well as international agencies and universities. As discussed earlier, project design and material development are based on research findings.
Upscaling Issues

Strategy Shift

A few provincial labour offices have indicated interest in implementing similar projects. At this stage there is some concern that without adequate training the labour office will use inappropriate training techniques such as lectures/videos to mass audiences as used by the Ministry of Public Health.  The outcome would not be satisfactory.  Negotiations with all concerned parties to identify the most effective strategy for mass audiences but staying close to the project experience will be necessary.

Knowledge Does Not Equal Behaviour Change

Behavioural change is slow to come⁶ in spite of the high level of awareness among the general public about HIV/AIDS and its prevention, thus confirming the fact that knowledge does not necessarily result in behavioural change. Two issues can be derived from this reality:

1. 1.  Since the nature of the problem is behavioural, a behavioural model must be the foundation for programme design^7.
2. 2.  If risk information alone is inadequate for behavioural change, there is a need therefore to develop interventions that influence other factors which are equally responsible for behaviour change⁸.

While it is possible for the project to reach large numbers of people, the financial and instructional structure of the project does not allow for sustainability.  Financial sustainability can be built in by incorporating the project into the government funding cycles. Since the government is already committed to addressing other problems related to HIV/AIDS, the factory owners will have to share the responsibility.

For big companies which already have health programmes for their  employees, HIV/AIDS prevention would be a matter of incorporating the topic into the existing programme and ensuring programme effectiveness. However, for the smaller factories, a programme needs to be developed.

Building instructional sustainability may be more difficult.  After workers are trained, they will generally talk with their friends and families about HIV/AIDS only in the first six months after the training.  There is little to keep the trained workers’ interest and motivation high.  Refresher training would be a motivation but it would be costly and put an added burden on already overburdened staff.  Because the number of trained factory workers is comparatively low, there are pressures to develop new strategies to accommodate a larger number of factory workers should the project be upscaled.

Institutionalization of Training

Strategies that would involve trained workers to systematically train their co-workers should be explored.  The problem here is the Thai cultural reliance on "experts".  Even though many of the untrained workers interviewed stated that they are interested in attending training sessions by their co-workers, most of the factory owners and managers as well as public health staff involved felt that the trained workers would not be able to carry out such an endeavor without the assistance of "expert" staff.  In the words of one of the training staff, "People don’t believe the workers because they are ordinary people."  This attitude seems to be contrary to the objectives of the project.  The trained workers are considered "qualified" and are expected to educate and counsel their co-workers on an informal basis but are considered unqualified to do the same on a more structured basis.  The workers, on the other hand, feel that their peers do believe them and will come to them before they will go to a supervisor or a company nurse.  In any case, where HIV/AIDS is concerned, the dissemination of basic information can have an impact.