以社区为基础有效发现和管理艾滋病感染者/病人的模式探讨
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摘要
研究目的
以社区为基础开展VCT/PITC服务,建立有效发现及管理艾滋病感染者／病人的新的的系统模式。健全社区范围内VCT服务网络,包括在综合医院、产前门诊、妇产科、性病和结核病门诊等开展VCT服务和PITC服务,加强社区卫生服务中心开展VCT服务和PITC服务能力建设及提供技术支持。研究方法
采用定量调查和定性调查相结合的方法。
1、定量调查,采用横断面研究,利用随机整群抽样方法,于2009年5月对湖北省襄樊市(屏襄门社区和王府街社区)和十堰市(二堰桥社区和擂鼓街社区)共1192名居民进行面对而问卷调查。将收集的资料用Epidata3.0软件建库,采用正版SPSS15.0软件分析。采用x2检验、单因素二项分类非条件Logistic回归分析和多因素二项分类非条件Logistic回归分析方法,对资料结果进行了分析。
2、定性调查,以个人访谈形式,现场访谈了湖北省艾滋病高流行地区十堰市和襄樊市医疗卫生保健机构人员11人。包括疾控中心有关领导、妇幼保健院有关领导、医院院长、VCT室有关负责人、VCT室咨询员、社区卫生服务站站长、社区卫生服务站工作人员。并在襄樊市和十堰市各组织了一场小组讨论。襄樊讨论组由6人组成,包括疾控中心有关领导1人、医院院长1人、VCT室咨询员1人、社区卫生服务站站长1人、社区卫生服务站工作人员1人。十堰讨论组由5人组成,包括疾控中心有关领导1人、妇幼保健院有关领导1人、VCT室有关负责人1人、社区卫生服务站站长1人、社区卫生服务站工作人员1人。
研究结果
一、定量调查结果。
1、社区居民关于艾滋病有关知识的知晓情况：60.3%的人认为艾滋病是由人类免疫缺陷病毒(HIV)所引起的病毒性传染病；56.5%的人认为目前艾滋病不能治愈；73.0%的人认为目前艾滋病目前能预防；对于何种方式能传播艾滋病,13.2%的做出了错误回答,认为“和艾滋病人一起吃饭”、“共用被褥”或“咳嗽、打喷嚏”有可能传播艾滋病,17.1%的人不清楚什么方式能传播艾滋病,69.7%的人做出了正确回答,认为“性接触”、“共用注射器静脉吸毒”、“共用牙刷、剃须刀”、“母婴传播”、“输入未经艾滋病病毒检测的血液或血液制品”可传播艾滋病；对于预防艾滋病的正确方法,13.6%的人做出了错误回答,认为应该“将艾滋病人隔离起来,保护大家”、“尽量远离艾滋病人,不与他们同桌吃饭”,17.9%的人不知道如何预防艾滋病,68.5%的人认为“不吸毒”、“正规途径无偿献血”、“洁身自好、正确使用安全套”、“不到非正规场所打耳洞、纹身、拔牙等”、“治疗时使用经严格消毒的注射器及医疗器械”可以预防艾滋病；29.6%的人表示知道“四免一关怀”政策。
2、社区居民对VCT/PITC服务的知晓及利用情况：26.3%的人曾听说过VCT/PITC服务,4.9%的人曾经到相关机构进行过自愿咨询检测,年龄越小,家住襄樊市、文化程度越高,艾滋病VCT和PITC服务的知晓率越高；文化程度越高、家庭人均月收入越低,艾滋病VCT和PITC服务的利用率越高。
3、社区有关艾滋病防治及VCT和PITC服务的开展情况：36.9%的人曾接受过预防艾滋病的宣传活动：如有艾滋病防治的讲座,50.3%的人表示会去参加,30.1%的人不会去参加,19.6%的人不清楚自己是否会去参加；35.1%的人表示自己所在的社区举办过防治艾滋病VCT和PITC服务知识的宣传活动,29.9%的人表示自己所在社区没有举办过防治艾滋病VCT和PITC服务知识的宣传活动,34.9%的人不清楚自己所在社区是否举办过防治艾滋病VCT和PITC服务知识的宣传活动。
二、定性调查结果。
目前,大部分社区为居民都建立了健康档案,但艾滋病病人或感染者的档案目前都由疾控中心统一管理。居民健康档案建立的时间还不长,档案形式和管理手段都还需要进一步完善。
基本上还未开展以社区为基础的VCT/PITC服务。以社区开展VCT/PITC服务既有优势又存在可克服的困难：
1、社区医疗保健体系并未完全成熟,基本上还未开展VCT和PITC服务,即便开展将存在居民担心泄漏隐私的问题,目前我国VCT和PITC服务基本由疾控部门承担,而各疾控的服务流程基本上比较规范,群众对疾控的工作也比较认可,同时疾控部门对这项工作也积累了丰富的经验,对社区今后开展此项工作有重大指导意义。
2、VCT和PITC服务普遍存在经费和技术支持不到位的问题,社区现有人员目前还不能胜任VCT和PITC服务工作。
3、国家有关艾滋病防治政策落实不到位,“四免一关怀”等政策由于各种原因有时并没有切实执行。
4、访谈中普遍反映VCT工作由当地疾控集中掌管,实际工作中存在管理与实际工作脱节的问题,经费、人力、技术支持等分别由不同的单位负责,存在沟通困难的问题,如果发展以社区为基础的VCT和PITC服务,仍应由疾控中心集中指导,但应适当下放权力到社区,各上级职能部门之间也应加强沟通。
5、各社区医疗卫生服务中心由于地理位置和历史发展等原因存在区域差别很大、发展极不平衡的现象,有的社区卫生服务站已建设得相当完善,建立了妇幼、慢病、老年疾病防治等科室,对辖区居民建立了健康档案并规范管理,社区医疗卫生保健人员对业务相当熟悉,对国家的“四免一关怀”等政策也非常了解,艾滋病防治工作也开展的比较全面,除了对辖区居民的卫生宣传外,还深入娱乐场所进行宣传、发放安全套等,比如襄樊市屏襄门卫生服务站；有的则刚刚成立,各方面工作都在起步阶段,医疗人员都是借调过来的,对业务并不熟悉,对国家的“四免一关怀”等政策了解并不多,艾滋病防治工作仅限于宣传层面,比如十堰市景山花园卫生服务站,因此,应发展社区之间的“传、帮、带”对口工作关系,发展好的积极辅助刚起步的,尽量减少这种差距,发展好的也可以暂时帮刚起步的分担工作任务,启动跨社区的医疗合作。研究结论
以社区开展VCT/PITC服务是切实可行的,我们有必要利用社区特有的经济和文化背景,积极开展多种形式的艾滋病相关知识(包括VCT/PITC服务)的健康教育。开展以社区为基础的VCT/PITC服务,以增加VCT/PITC服务的可及性和利用率。通过促进社区居民健康档案的建立,在社区设立VCT和PITC门诊,开展以社区为基础的VCT和PITC外展服务,三条途径来实现有效早发现；在社区建立“爱心家园”来实现有效管理,即建立以社区为基础的模式来有效发现和管理艾滋病感染者／病人。
研究创新
首次建立了以社区为基础的有效发现和管理艾滋病感染者／病人的管理模式。
Research objective
To develop community-based VCT/PITC service and establish a new systemic model detecting and managing People Living With HIV/AIDS(PLWHA) effectively in areas with high HIV prevalence.
Research methods
Both quantitative and qualitative methods were adopted. Random sampling in cluster was used to select those 1192 study subjects and face to face interview was carried out adopting anonymous questionnaires. Qualitative research methods were adopted including personal interview and panel discussion. In areas with high HIV prevalence of Hubei Province,China,Xiangfan City and Shiyan City,11 Medical and health services staffs were interviewed,and 6 experts and members of the project team,Xiangfan City, and 5 experts and members of the project team, Shiyan City, were organized to discuss in panel.
Research results
Quantitative result:26.3% of those subjects had heard of and 4.9% had used of VCT/PITC service. There were not only advantages but also difficulties that can be overcome to develop community-based VCT/PITC service.
Advantages and problems in the community-based model:
A community is where the residents dwell in and are familiar with. Thus, the community-based VCT/PITC services have better convenience and availability.
We learned in the interviews that some people had the awareness of and demands for receiving counseling and testing after high-risk behaviors but could get no help due to the lack of knowledge about where and how to take these services. "Those residents who need the service would easy to find them", if we developed the community-based VCT/PITC services near to them.
The residents in the same community often have the same life styles and cultural backgrounds, better understanding and also more likely to trust each other. It had been shown that a role model or valued member of the community declaring that he or she had a test was important in reducing stigma and increasing the uptake of HIV test.
If we establish community-based model to detect and then manage people living with HIV/AIDS effectively, information on the seropositives could be acquired more quickly and detailedly. And it can save traffic, time, manpower and other costs, and attains higher social benefits of governmental investment.
The community health service network had been basically shaped in China. Parts of the community health service stations were well-established, with the ability to undertake HIV/AIDS prevention and control. Moreover, it had established health files for the residents with good management. The community health care personnel were adept at handling their everyday business and knew well of governmental "Four Frees and One Care" policy on the PLWHA. They developed not only health education but also behavioral intervention such as distributing condoms at amusement places. Pingxiangmen community health Service Station had set a good example of that.
We expected the community-based model had quite a few advantages. But our investigation disclosed there were also some problems in the model.
The conditions of developing the community-based VCT/PITC services in China were not quite mature or there were almost no community-based VCT/PITC services. Even if government develops such services, the residents would refuse to receive for worrying about "acquaintances would leak their privacy". Community-based AIDS prevention and treatment business was still being at a promotional level. A majority of people knew little of VCT/PITC service (awareness rate was 26.3%). And the uptake rate was also in a low stage. Only 4.9% of the population had ever used of the service. It discloses the low efficiency of our health education, and neither the quantity nor the quality of the health education was good enough. As knowledge affects attitude, and attitude affects behavior, we should make full use of the cultural and economic community advantages to develop excellent health education.
VCT/PITC services were centralized in the charge of Centers for Disease Control and Prevention (CDC) and with detached administration and execution. The funding, manpower and technology were managed by different sections respectively. If the subordinate department met with difficulties, they had to submit their reports to several supervising authorities. It made the subordinate department and the supervising authorities difficult to communicate. CDC should decentralize to some extent if we develop the community-based VCT/PITC services in future. However, CDC should still centralizedly guide but not manage the other institutes. At the same time, the supervising sections in CDC should strengthen communicating with each other.
In China, there were widespread problems for lack of funds and technical supports in VCT/PITC services. Some of community healthcare staff was not quite qualified for their business. Highly unbalanced developments with regional differences were key problem among the existing community healthcare institutions. Part of them had been well developed, competent to their work, but the other had just been set up. Even some of the latter healthcare staff were on secondment, not familiar with the business. Therefore we should establish "help with" responsive working relationships between the well-developed and the just been set up. And cross-community medical co-operation was necessary. Accordingly, the gaps should be minimized.
It was viable to develop community-based business on fighting against HIV/AIDS depending on all social sectors under the governmental guidance, although there were lots of the existing difficulties.
Research conclusion
Community-based VCT/PITC service hadn't been developed. It's viable to develop community-based VCT/PITC service. So can elevate the availability and use rate of VCT/PITC service to detect and then manage People Living With HIV/AIDS (PLWHA) effectively. Health education should be strengthened and community-based VCT/PITC service should be developed. We plan to develop the community-based VCT/PITC services through three paths, including Strengthening managing the health files, community-based VCT/PITC clinics and workplace VCT/PITC services. Then we establish the community HIV health care centers constituted of 8 sectors to provide an overall management. Thus, we can detect and then manage PLWHA effectively with a new systemic community-based model.
So can elevate the availability and use rate of VCT/PITC service to detect and manage People Living With HIV/AIDS (PLWHA) effectively.
Research originalities
There were almost no community-based VCT and PITC services in China. The availability and use rate were low. We explore how to ste up a community-based model to detect and manage People Living With HIV/AIDS (PLWHA) effectively.
以社区为基础开展VCT/PITC服务,建立有效发现及管理艾滋病感染者／病人的新的的系统模式。健全社区范围内VCT服务网络,包括在综合医院、产前门诊、妇产科、性病和结核病门诊等开展VCT服务和PITC服务,加强社区卫生服务中心开展VCT服务和PITC服务能力建设及提供技术支持。研究方法
采用定量调查和定性调查相结合的方法。
1、定量调查,采用横断面研究,利用随机整群抽样方法,于2009年5月对湖北省襄樊市(屏襄门社区和王府街社区)和十堰市(二堰桥社区和擂鼓街社区)共1192名居民进行面对而问卷调查。将收集的资料用Epidata3.0软件建库,采用正版SPSS15.0软件分析。采用x2检验、单因素二项分类非条件Logistic回归分析和多因素二项分类非条件Logistic回归分析方法,对资料结果进行了分析。
2、定性调查,以个人访谈形式,现场访谈了湖北省艾滋病高流行地区十堰市和襄樊市医疗卫生保健机构人员11人。包括疾控中心有关领导、妇幼保健院有关领导、医院院长、VCT室有关负责人、VCT室咨询员、社区卫生服务站站长、社区卫生服务站工作人员。并在襄樊市和十堰市各组织了一场小组讨论。襄樊讨论组由6人组成,包括疾控中心有关领导1人、医院院长1人、VCT室咨询员1人、社区卫生服务站站长1人、社区卫生服务站工作人员1人。十堰讨论组由5人组成,包括疾控中心有关领导1人、妇幼保健院有关领导1人、VCT室有关负责人1人、社区卫生服务站站长1人、社区卫生服务站工作人员1人。
研究结果
一、定量调查结果。
1、社区居民关于艾滋病有关知识的知晓情况：60.3%的人认为艾滋病是由人类免疫缺陷病毒(HIV)所引起的病毒性传染病；56.5%的人认为目前艾滋病不能治愈；73.0%的人认为目前艾滋病目前能预防；对于何种方式能传播艾滋病,13.2%的做出了错误回答,认为“和艾滋病人一起吃饭”、“共用被褥”或“咳嗽、打喷嚏”有可能传播艾滋病,17.1%的人不清楚什么方式能传播艾滋病,69.7%的人做出了正确回答,认为“性接触”、“共用注射器静脉吸毒”、“共用牙刷、剃须刀”、“母婴传播”、“输入未经艾滋病病毒检测的血液或血液制品”可传播艾滋病；对于预防艾滋病的正确方法,13.6%的人做出了错误回答,认为应该“将艾滋病人隔离起来,保护大家”、“尽量远离艾滋病人,不与他们同桌吃饭”,17.9%的人不知道如何预防艾滋病,68.5%的人认为“不吸毒”、“正规途径无偿献血”、“洁身自好、正确使用安全套”、“不到非正规场所打耳洞、纹身、拔牙等”、“治疗时使用经严格消毒的注射器及医疗器械”可以预防艾滋病；29.6%的人表示知道“四免一关怀”政策。
2、社区居民对VCT/PITC服务的知晓及利用情况：26.3%的人曾听说过VCT/PITC服务,4.9%的人曾经到相关机构进行过自愿咨询检测,年龄越小,家住襄樊市、文化程度越高,艾滋病VCT和PITC服务的知晓率越高；文化程度越高、家庭人均月收入越低,艾滋病VCT和PITC服务的利用率越高。
3、社区有关艾滋病防治及VCT和PITC服务的开展情况：36.9%的人曾接受过预防艾滋病的宣传活动：如有艾滋病防治的讲座,50.3%的人表示会去参加,30.1%的人不会去参加,19.6%的人不清楚自己是否会去参加；35.1%的人表示自己所在的社区举办过防治艾滋病VCT和PITC服务知识的宣传活动,29.9%的人表示自己所在社区没有举办过防治艾滋病VCT和PITC服务知识的宣传活动,34.9%的人不清楚自己所在社区是否举办过防治艾滋病VCT和PITC服务知识的宣传活动。
二、定性调查结果。
目前,大部分社区为居民都建立了健康档案,但艾滋病病人或感染者的档案目前都由疾控中心统一管理。居民健康档案建立的时间还不长,档案形式和管理手段都还需要进一步完善。
基本上还未开展以社区为基础的VCT/PITC服务。以社区开展VCT/PITC服务既有优势又存在可克服的困难：
1、社区医疗保健体系并未完全成熟,基本上还未开展VCT和PITC服务,即便开展将存在居民担心泄漏隐私的问题,目前我国VCT和PITC服务基本由疾控部门承担,而各疾控的服务流程基本上比较规范,群众对疾控的工作也比较认可,同时疾控部门对这项工作也积累了丰富的经验,对社区今后开展此项工作有重大指导意义。
2、VCT和PITC服务普遍存在经费和技术支持不到位的问题,社区现有人员目前还不能胜任VCT和PITC服务工作。
3、国家有关艾滋病防治政策落实不到位,“四免一关怀”等政策由于各种原因有时并没有切实执行。
4、访谈中普遍反映VCT工作由当地疾控集中掌管,实际工作中存在管理与实际工作脱节的问题,经费、人力、技术支持等分别由不同的单位负责,存在沟通困难的问题,如果发展以社区为基础的VCT和PITC服务,仍应由疾控中心集中指导,但应适当下放权力到社区,各上级职能部门之间也应加强沟通。
5、各社区医疗卫生服务中心由于地理位置和历史发展等原因存在区域差别很大、发展极不平衡的现象,有的社区卫生服务站已建设得相当完善,建立了妇幼、慢病、老年疾病防治等科室,对辖区居民建立了健康档案并规范管理,社区医疗卫生保健人员对业务相当熟悉,对国家的“四免一关怀”等政策也非常了解,艾滋病防治工作也开展的比较全面,除了对辖区居民的卫生宣传外,还深入娱乐场所进行宣传、发放安全套等,比如襄樊市屏襄门卫生服务站；有的则刚刚成立,各方面工作都在起步阶段,医疗人员都是借调过来的,对业务并不熟悉,对国家的“四免一关怀”等政策了解并不多,艾滋病防治工作仅限于宣传层面,比如十堰市景山花园卫生服务站,因此,应发展社区之间的“传、帮、带”对口工作关系,发展好的积极辅助刚起步的,尽量减少这种差距,发展好的也可以暂时帮刚起步的分担工作任务,启动跨社区的医疗合作。研究结论
以社区开展VCT/PITC服务是切实可行的,我们有必要利用社区特有的经济和文化背景,积极开展多种形式的艾滋病相关知识(包括VCT/PITC服务)的健康教育。开展以社区为基础的VCT/PITC服务,以增加VCT/PITC服务的可及性和利用率。通过促进社区居民健康档案的建立,在社区设立VCT和PITC门诊,开展以社区为基础的VCT和PITC外展服务,三条途径来实现有效早发现；在社区建立“爱心家园”来实现有效管理,即建立以社区为基础的模式来有效发现和管理艾滋病感染者／病人。
研究创新
首次建立了以社区为基础的有效发现和管理艾滋病感染者／病人的管理模式。
Research objective
To develop community-based VCT/PITC service and establish a new systemic model detecting and managing People Living With HIV/AIDS(PLWHA) effectively in areas with high HIV prevalence.
Research methods
Both quantitative and qualitative methods were adopted. Random sampling in cluster was used to select those 1192 study subjects and face to face interview was carried out adopting anonymous questionnaires. Qualitative research methods were adopted including personal interview and panel discussion. In areas with high HIV prevalence of Hubei Province,China,Xiangfan City and Shiyan City,11 Medical and health services staffs were interviewed,and 6 experts and members of the project team,Xiangfan City, and 5 experts and members of the project team, Shiyan City, were organized to discuss in panel.
Research results
Quantitative result:26.3% of those subjects had heard of and 4.9% had used of VCT/PITC service. There were not only advantages but also difficulties that can be overcome to develop community-based VCT/PITC service.
Advantages and problems in the community-based model:
A community is where the residents dwell in and are familiar with. Thus, the community-based VCT/PITC services have better convenience and availability.
We learned in the interviews that some people had the awareness of and demands for receiving counseling and testing after high-risk behaviors but could get no help due to the lack of knowledge about where and how to take these services. "Those residents who need the service would easy to find them", if we developed the community-based VCT/PITC services near to them.
The residents in the same community often have the same life styles and cultural backgrounds, better understanding and also more likely to trust each other. It had been shown that a role model or valued member of the community declaring that he or she had a test was important in reducing stigma and increasing the uptake of HIV test.
If we establish community-based model to detect and then manage people living with HIV/AIDS effectively, information on the seropositives could be acquired more quickly and detailedly. And it can save traffic, time, manpower and other costs, and attains higher social benefits of governmental investment.
The community health service network had been basically shaped in China. Parts of the community health service stations were well-established, with the ability to undertake HIV/AIDS prevention and control. Moreover, it had established health files for the residents with good management. The community health care personnel were adept at handling their everyday business and knew well of governmental "Four Frees and One Care" policy on the PLWHA. They developed not only health education but also behavioral intervention such as distributing condoms at amusement places. Pingxiangmen community health Service Station had set a good example of that.
We expected the community-based model had quite a few advantages. But our investigation disclosed there were also some problems in the model.
The conditions of developing the community-based VCT/PITC services in China were not quite mature or there were almost no community-based VCT/PITC services. Even if government develops such services, the residents would refuse to receive for worrying about "acquaintances would leak their privacy". Community-based AIDS prevention and treatment business was still being at a promotional level. A majority of people knew little of VCT/PITC service (awareness rate was 26.3%). And the uptake rate was also in a low stage. Only 4.9% of the population had ever used of the service. It discloses the low efficiency of our health education, and neither the quantity nor the quality of the health education was good enough. As knowledge affects attitude, and attitude affects behavior, we should make full use of the cultural and economic community advantages to develop excellent health education.
VCT/PITC services were centralized in the charge of Centers for Disease Control and Prevention (CDC) and with detached administration and execution. The funding, manpower and technology were managed by different sections respectively. If the subordinate department met with difficulties, they had to submit their reports to several supervising authorities. It made the subordinate department and the supervising authorities difficult to communicate. CDC should decentralize to some extent if we develop the community-based VCT/PITC services in future. However, CDC should still centralizedly guide but not manage the other institutes. At the same time, the supervising sections in CDC should strengthen communicating with each other.
In China, there were widespread problems for lack of funds and technical supports in VCT/PITC services. Some of community healthcare staff was not quite qualified for their business. Highly unbalanced developments with regional differences were key problem among the existing community healthcare institutions. Part of them had been well developed, competent to their work, but the other had just been set up. Even some of the latter healthcare staff were on secondment, not familiar with the business. Therefore we should establish "help with" responsive working relationships between the well-developed and the just been set up. And cross-community medical co-operation was necessary. Accordingly, the gaps should be minimized.
It was viable to develop community-based business on fighting against HIV/AIDS depending on all social sectors under the governmental guidance, although there were lots of the existing difficulties.
Research conclusion
Community-based VCT/PITC service hadn't been developed. It's viable to develop community-based VCT/PITC service. So can elevate the availability and use rate of VCT/PITC service to detect and then manage People Living With HIV/AIDS (PLWHA) effectively. Health education should be strengthened and community-based VCT/PITC service should be developed. We plan to develop the community-based VCT/PITC services through three paths, including Strengthening managing the health files, community-based VCT/PITC clinics and workplace VCT/PITC services. Then we establish the community HIV health care centers constituted of 8 sectors to provide an overall management. Thus, we can detect and then manage PLWHA effectively with a new systemic community-based model.
So can elevate the availability and use rate of VCT/PITC service to detect and manage People Living With HIV/AIDS (PLWHA) effectively.
Research originalities
There were almost no community-based VCT and PITC services in China. The availability and use rate were low. We explore how to ste up a community-based model to detect and manage People Living With HIV/AIDS (PLWHA) effectively.
引文
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