广西P市性服务妇女女用安全套干预效果评估
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摘要
研究背景和意义
近三十年来,人们的性观念及性行为发生巨大变化,由此导致一系列性传播疾病(以下简称“性病”)重新成为我国必须面对的重要公共卫生问题。商业性行为是影响我国性病流行的主要危险行为之一,性服务妇女是影响性病流行的主要人群。
目前预防性病最有效的方法是以安全套为代表的、具有避孕和防病双重功效的“屏障(barrier)"保护方法。现在使用的安全套包括男用安全套(以下简称男套)和女用安全套(以下简称女套)两类。尽管男套在我国经过近20年的推广取得了相当成效,但仅依靠单一推广男套在性服务妇女中实现“100%性行为使用安全套”仍旧存在一定困难。女套是针对男套存在的问题设计的、由女性放入阴道使用的另外一类屏障性防病避孕产品。目前我国对女套的研究非常有限,特别是在性服务妇女中将女套加入现有的单一男套干预后的预防效果更是一个尚待认识的问题。
目的
评估在已有男套干预基础上加入女套的2年干预对P市性服务妇女女套接受性和保护性行为产生的效果,并探讨影响干预效果的因素。
方法
整个研究包括女套干预设计实施和效果评估两个部分。
干预主要通过到性服务场所出访的方式,对性服务场所中工作的妇女进行女套知识、使用技能教育,并为愿意尝试女套的妇女免费发放美国产第一代女套(干预第二年还提供国产凤康女套)。干预为期两年分三个阶段实施,包括各6个月的女套引入基础干预阶段和持续干预阶段、12个月的常规干预阶段。研究采用多学科方法评估干预过程和效果相关信息,包括：(1)干预前、干预三个阶段后共4次横断面问卷调查,调查对象为在干预区域性服务场所中工作的16岁及以上且调查前30天有过性行为的妇女,每次调查覆盖70-80%的此类妇女;(2)通过每个横断面调查收集的个人特征码前后匹配情况识别多次参加调查的对象；(3)人类学观察和访谈收集干预实施过程等资料。通过比较干预前后4个横断面和“被随访”的性服务妇女个人在女套累积使用率、调查前半年女套认可程度、调查前30天女套使用情况以及调查前30天有保护性行为比例的变化,分析这些变化与接受干预水平和其他影响因素的关系。
结果
干预前后4次横断面调查人数为152-155人,4次横断面调查中一共有112人至少有2次调查的个人特征码匹配,每个断面的调查中均有30-40%的性服务妇女个人特征码能与既往调查相匹配。以干预前“基线”调查的155名对象组建“固定队列”中,共有65名对象在干预后三次调查中至少被随访一次。
1.调查对象的基本特征
4次横断面调查中,性服务妇女平均年龄在32.5-34岁之间,80%以上已婚,2/3以上来自湖南和湖北两省。每次调查中约有1/3的妇女来自出租屋,来自发廊和宾馆内的美容按摩厅的妇女比例均在20%-40%间波动。妇女第一次性行为的中位年龄19-20岁,开始从事性服务的中位年龄在27-28岁。90%以上的妇女怀过孕,2/3的妇女做过人工流产,但是有20-30%的妇女尚未生过孩子。
4次横断面调查中个人特征码匹配2次、3次和4次妇女分别有69、28和15人,匹配的首次参加调查的妇女的平均年龄在33岁以上,大于237名无匹配者的首次参加调查的平均年龄(30.9岁)。匹配妇女44%来自出租屋,高于无匹配的妇女(29%)。
2.干预实施和调查对象对干预的接受
2年中工作人员一共对55家性服务场所进行了490次出访,其中一半以上的出访发放了女套。发放美国产一代女套近2000只,国产凤康女套约640只,男套发放近20000只。第一年干预出访约320次,是第二年出访次数的2倍。出租屋类场所在第一年和第二年干预中的平均出访次数(10.5次、5.3次)高于发廊(5.6次、3.6次)和宾馆类场所(5.8次、2.8次)。
干预6个月后,近70%的妇女报告接受过女套干预,能明确认识干预工具(以“见过翻板图”为标识)的妇女占48%,报告自己练习过女套使用的妇女占24%。干预12个月和24个月后,以上3个比例分别为72%、63%、34%和78%、67%、22%。
3.干预前后女套接受性水平变化
横断面调查的结果显示,干预前有不到1/3的妇女听说过女套但没有人用过女套,干预后约90%的调查对象听说过女套。干预6个月、12个月和24个月三个调查时点上30-40%的妇女报告至少尝试使用过1次女套,其中50-70%的妇女用过女套2次及以上。三次干预后调查中均有近10%的对象在调查前30天用过女套。与感情性伴或客人调查前30天性行为中使用女套的平均比例为1-3%,远低于使用男套的平均比例(感情性伴：30%-42%；客人：88%-92%)。大约30-40%的妇女在干预后三个调查时点上报告,在调查前半年里她们把女套当作备用的或者经常使用的预防方法(下文称“认可女套”)
在个人特征码匹配的112名对象中,75%的妇女对女套的认可程度在其参与与的间隔最长的两次调查间呈上升趋势。在“固定队列”中至少被随访1次的对象(n=65)其女套认可程度在干预后三次调查中呈上升趋势。
4.干预前后保护性行为水平的变化
干预前,调查对象报告与所有性伴在调查前30天的性行为中全部使用安全套(简称“全部用套”)的比例为42.6%,77.3%的妇女报告调查前30天与客人全部用套,33.3%的妇女与感情性伴全部用套。在于预后的三次调查中,调查前30天与所有性伴全部用套的妇女比例比干预前提高了2.4-6.4个百分点,与客人全部用套的妇女比例提高了6.2-10.2个百分点,但与感情性伴全部用套的妇女比例变化不大且无规律。
在个人特征码匹配的112名对象中,一半以上的妇女在间隔时间最长的两次时点间,调查前30天与客人或者与感情性伴使用安全套的比例维持不变。“固定队列”中65位至少被随访1次的对象在干预前后这两个比例亦未看出明确的变化趋势。
5.影响性服务妇女女套接受性及保护性行为的因素
5.1定量问卷资料分析结果
在单因素分析中,女套接受性指标“是否使用过女套”、“调查前半年是否认可女套”和性服务妇女的年龄、婚姻状态、场所类型以及接受干预各项指标的关联在干预后3次调查中均有统计学显著性。但在多因素Logistic回归模型中,控制了年龄、场所类型、性伴类型和男套使用水平的影响后,妇女接受干预程度越高,使用过女套的比例越大(调整OR在3.5-8.0之间),同时认可女套比例也更高(调整OR在3.4-9.0之间)。年龄可能是另一个与女套接受性有关的独立影响因素。年龄大于30岁的性服务妇女在干预24个月后的调查中认可女套的可能性约是年龄小于等于30岁组的3倍(调整的OR=3.3,95%CI:1.1～9.4)
在保护性行为上,“调查前30天性行为是否全部使用安全套”在单因素分析中主要与性服务妇女的场所类型、年龄、婚姻状态、生育健康史、性伴类型和性伴人数等变量有统计学上的关联。多因素Logistic回归模型中,控制了年龄、场所类型和性伴类型的影响后,接受干预程度和“调查前30天性行为是否全部使用安全套”在干预6个月和12个月时关联无统计学显著性,但在干预24个月调查中妇女接受干预程度越高,调查前30天全部用套的比例越大(调整OR=1.9,95%CI：1.1～3.5)。来自出租屋、年龄大于30岁和有感情性伴的性服务妇女在调查前30天性行为中全部用套的可能性较低。
5.2定性人类学资料分析结果
大部分性服务妇女在接触女套之初对其外观和使用方法持消极看法,但也有妇女认可女套保护女性的作用,愿意学习使用。在实际使用中男性注重女套是否能增加性愉悦感,妇女则更关注女套的安全性。同时,中、青年性服务妇女在安全套使用的意愿和能力的差别、所处场所规则和场所内接受干预机会的差别可能造成女套接受性的不同。此外,妇女学习和摸索女套使用时,一般更愿意与感情性伴首次尝试,对女套熟悉以后,更多则在与客人的性行为中使用。
另一方面,工作人员与妇女的信任关系是干预实施的基础,性服务场所工作时间与干预时间的吻合性、场所开展干预的空间、场所老板的态度和场所内妇女复杂性等都可能影响组织干预的难易程度和妇女干预接受的机会。
结论
在广西P市这样一个开展男套推广工作十余年并取得一定成效的地区,将女套加入原有男套干预2年后显示,有一定比例的性服务妇女逐步将女套整合到预防行为中。女套接受性不仅与接受干预程度有关,同时还受到性服务妇女年龄和所处场所的共同影响。工作人员与妇女的信任关系、场所的复杂性影响着干预实施的难易程度及性服务妇女接受干预的机会。
Background and significance
China's a drastic change in sexual norms and behaviors over that past three decades has been accompanied by the expansion of sexually transmitted infections (STIs) including HIV/AIDS epidemics which become an important issue of public health. Commercial sex is the one of mainly influential risk behaviors in the STIs epidemics. Female sex workers (hereinafter referred to as FSWs or women) are the key population in that issue.
Multipurpose barrier methods have been the most effective preventive devices for STIs to date, which provide the dual protection against unwanted pregnancy and the transmission of sexually transmitted disease. Now the condom includes the male condom (MC) and the female condom (FC). Though male condom (MC) has been promoted efficiently for more than a decade in China, there remains some obstacles to achieve "100%Condom Use" among FSWs only through MC-only intervention. FC is an intravaginal barrier method that is designed for overcoming drawbacks of MC. However, to date there have been very few studies about FC acceptability and use in China, or about the potential effects of integrating FC into the existing MC promotion.
Objectives
The objectives of this study were to evaluate the effects of FC inclusion in MC promotion efforts through examination of FC acceptability and overall rates of protected sex among FSWs in P city, Guangxi province.
Methods
This study included the design and implementation of an FC intervention and evaluation of outcomes.
The FC intervention was implemented mainly through outreach to sex-work establishments, delivering FC knowledge, training the skill and providing free FC1(also including domestic Phoenurse FC at the second year) among women working in sex establishments. The FC intervention was designed as a three-phase program with two6-month phases of introductive intervention and a12-month phrase of routine intervention.
Interdisciplinary methods were used to evaluate FC intervention, including:(1)Four serial cross-sectional surveys of FSWs at baseline (pre-intervention), at6months,12months and at24months post-intervention were conducted. Women working in the targeted establishments who were16years or older and sexually active in the prior30days were eligible for the survey at any time point. All cross-sectional surveys were designed to recruit70%to80%of the total estimated women working in the targeted sex establishments.(2)The cohort was consisted of the women who were followed in three post-intervention cross-sectional surveys by matching their unique ID between surveys.(3)Ethnographic observations and interviews were conducted prior to, during and post intervention for collecting the data of the intervention implementation process. The proportions of ever used FC, FC recognition in last6months, FC uptake and overall protected sex in last30days among FSWs in pre-and post-intervention surveys were be compared. The associations between the outcomes and the levels of accepted intervention and other influential factors were also explored.
Results
There were about152to155women participated in each cross-sectional survey. Aggregately112women's unique ID codes were matched between at least two surveys. Thirty to forty percentages of women in each cross-sectional survey were matched to the prior surveys. In the fixed cohort based on the pre-intervention survey as the baseline,65participants were followed at least once in the three post-intervention surveys.
1. Characteristics of participants
At the four cross-sectional surveys, the mean age of participants ranged from32.5to34years old. Eighty percentages of women were married and2/3originated from Hunan or Hubei province. Approximately one third of participants worked in the boarding houses, and20-40%of these women worked in hairdresser/massage parlors and hotel-based massage, beauty and sauna parlors, respectively. The median age of first sexual experience and initiating sex work was19to20years old and27to28 years old. Ninety percentages of participants had experienced pregnancy, and2/3had an abortion. However, Twenty to thirty percentages of FSWs had no children.
The number of women whose unique personal ID codes were matched among2\3\4surveys was69,28and15. The mean age of these women at "baseline" survey was over33years old, and the mean age of women with non-matched ID codes was30.9years old. The proportion of women from boarding houses among whom with matched ID code and with non-matched ID code were44%and29%.
2. Intervention implementation and participation
The staff conducted nearly490outreach encounters to55establishments during the24months of three intervention phrases, and in half of these outreach, FC was delivered. More than2000FC with first generation (FC1),640domestic-made Phoenurse FC and20000MC were delivered in all. The times of outreach in the first year were about320, which was the double times in the second year. Mean times of outreach to the boarding houses during two years (in the first year:10.5; in the second year:5.3) was higher than the hairdresser (in the first year:5.6; in the second year:3.6) and hotel-based massage, beauty and sauna parlors (in the first year:5.8; in the second year:2.8).
About70%of FSWs reported having participated in FC intervention activities, forty eight percentages having recognized the intervention tool (the flip chart as the mark) and24%having practiced FC insertion by herself at6months post-intervention survey. These three proportions were72%,63%,34%and78%,67%,22%at post-intervention12-month and24-month surveys, respectively.
3. FC acceptability
One third of FSWs had heard of but no one had used FC at baseline. At the6-month,12-month and24-month post-intervention surveys, more than90%of FSWs reported knowing about FC, and30%-40%of FSWs have used FC at least one time, and50%-70%of them had used FC more than once. The proportion of women having used FC during the prior30days remained at about10%at three post-intervention surveys. The mean proportion of protected sex by FC ranges from1%to3%with primary and paying partners in the last30days at each post-intervention cross-sectional survey, which was lower than the proportions using MC (with primary partners:30%-42%; with paying partners:88%-92%).30%-40%FSWs reported they considered FC as an backup protection method or regularly used it in the last6 months at6months,12and24months post-intervention surveys.
Seventy five percentages of women's levels of FC recognition in last6months increased between two surveys that their interval was longest among112women whose ID codes were matched. The levels of FC recognition in last6months in the fixed cohort (N=65) showed a clear growth trend in four serial surveys.
4. The level of protected sex before and after intervention
At the baseline survey,42.6%of the participants reported100%protected sex with all types of partners in the last30days. This proportion with clients and the primary partner was77.3%and33.3%, respectively. After intervention, this proportion had increased by (2.4%to6.4%) at the three post-intervention surveys. The proportion of women reported100%protected sex with clients increased by (6.2%to10.2%), but this proportion with the primary partner was stable at each post-intervention surveys.
The trend of the level of protected sex in the last30days was not obviously between two surveys that their interval was longest among112women and in the fixed cohort.
5. Factors associated with FC acceptability, protected sex and intervention implementation.
5.1Quantitative assessment
The indicators of FC acceptability,"ever having used FC" and "FC recognition in last six months " were associated with age, marriage status, establishment types and participation in intervention in the univariate analysis. Better participation in the intervention was consistently associated with ever having used FC (adjusted OR ranges from3.5to8.0) and recognized FC (adjusted OR ranges from3.4to9.0) in the last6months at three post-intervention surveys, controlling for age, establishment and sex partner and the level of protected sex by MC. Age may be an independent factor associated with FC acceptability, that is older than30years old was associated with recognized FC (adjusted OR=3.3,95%CI:1.1-9.4).
As to the level of protected sex,"having100%protected sex in the last30days" was associated with establishment types, age, marriage status, reproductive history, sex partner types and number of sex partners in the univariate analysis. After adjustments for age, establishment and sex partner types, women who better participated in the intervention were more likely to have100%protected sex in the last30days at24month post-intervention survey (adjusted OR=1.9,95%CI:1.1-3.5), however we did not find the association at6month or12month post-intervention survey. Being from boarding house, older than30years old and having primary partner less likely to have100%protected sex in the last30days.
5.2Qualitative assessment
Most of women had a negative attitude towards the FC appearance and usage, but some women recognized the FC's protection and were willing to learn how to use it. Men were pay attention to whether the FC increases sexual joy, but women emphasized the safety of FC. The difference between middle-aged women and youth women on the willingness and ability of using condom, the rule of sex establishments, the chance of accepted intervention in establishment may associate with FC acceptability. In addition, some women were more likely to first try FC with primary partners than with paying partners when they were learning the skill. If they were familiar with FC, they were more likely to sustain FC use with paying partners.
On the other hand, good relationship with FSWs was the basic of intervention implementation. The match between FSWs'working time and intervention time, the room in the establishment for intervention, the boss's attitude towards intervention and the complexity of women in the sex establishments may associated with difficulty of implementing intervention and the chance of accepted intervention.
Conclusions
After two-year FC intervention along with MC promotion among FSWs in P city, where the MC promotion progress had been made during the last10years, a considerable proportion of women accepted FC as a prevention method.The FC acceptability was not only associated with the level of accepted intervention,but also varied by women's age and establishments. Moreover, the difficulty of intervention implementation and the chance of women accepted intervention were influenced by the relationship between outreach workers and FSWs and the complexity of the sex establishments.
近三十年来,人们的性观念及性行为发生巨大变化,由此导致一系列性传播疾病(以下简称“性病”)重新成为我国必须面对的重要公共卫生问题。商业性行为是影响我国性病流行的主要危险行为之一,性服务妇女是影响性病流行的主要人群。
目前预防性病最有效的方法是以安全套为代表的、具有避孕和防病双重功效的“屏障(barrier)"保护方法。现在使用的安全套包括男用安全套(以下简称男套)和女用安全套(以下简称女套)两类。尽管男套在我国经过近20年的推广取得了相当成效,但仅依靠单一推广男套在性服务妇女中实现“100%性行为使用安全套”仍旧存在一定困难。女套是针对男套存在的问题设计的、由女性放入阴道使用的另外一类屏障性防病避孕产品。目前我国对女套的研究非常有限,特别是在性服务妇女中将女套加入现有的单一男套干预后的预防效果更是一个尚待认识的问题。
目的
评估在已有男套干预基础上加入女套的2年干预对P市性服务妇女女套接受性和保护性行为产生的效果,并探讨影响干预效果的因素。
方法
整个研究包括女套干预设计实施和效果评估两个部分。
干预主要通过到性服务场所出访的方式,对性服务场所中工作的妇女进行女套知识、使用技能教育,并为愿意尝试女套的妇女免费发放美国产第一代女套(干预第二年还提供国产凤康女套)。干预为期两年分三个阶段实施,包括各6个月的女套引入基础干预阶段和持续干预阶段、12个月的常规干预阶段。研究采用多学科方法评估干预过程和效果相关信息,包括：(1)干预前、干预三个阶段后共4次横断面问卷调查,调查对象为在干预区域性服务场所中工作的16岁及以上且调查前30天有过性行为的妇女,每次调查覆盖70-80%的此类妇女;(2)通过每个横断面调查收集的个人特征码前后匹配情况识别多次参加调查的对象；(3)人类学观察和访谈收集干预实施过程等资料。通过比较干预前后4个横断面和“被随访”的性服务妇女个人在女套累积使用率、调查前半年女套认可程度、调查前30天女套使用情况以及调查前30天有保护性行为比例的变化,分析这些变化与接受干预水平和其他影响因素的关系。
结果
干预前后4次横断面调查人数为152-155人,4次横断面调查中一共有112人至少有2次调查的个人特征码匹配,每个断面的调查中均有30-40%的性服务妇女个人特征码能与既往调查相匹配。以干预前“基线”调查的155名对象组建“固定队列”中,共有65名对象在干预后三次调查中至少被随访一次。
1.调查对象的基本特征
4次横断面调查中,性服务妇女平均年龄在32.5-34岁之间,80%以上已婚,2/3以上来自湖南和湖北两省。每次调查中约有1/3的妇女来自出租屋,来自发廊和宾馆内的美容按摩厅的妇女比例均在20%-40%间波动。妇女第一次性行为的中位年龄19-20岁,开始从事性服务的中位年龄在27-28岁。90%以上的妇女怀过孕,2/3的妇女做过人工流产,但是有20-30%的妇女尚未生过孩子。
4次横断面调查中个人特征码匹配2次、3次和4次妇女分别有69、28和15人,匹配的首次参加调查的妇女的平均年龄在33岁以上,大于237名无匹配者的首次参加调查的平均年龄(30.9岁)。匹配妇女44%来自出租屋,高于无匹配的妇女(29%)。
2.干预实施和调查对象对干预的接受
2年中工作人员一共对55家性服务场所进行了490次出访,其中一半以上的出访发放了女套。发放美国产一代女套近2000只,国产凤康女套约640只,男套发放近20000只。第一年干预出访约320次,是第二年出访次数的2倍。出租屋类场所在第一年和第二年干预中的平均出访次数(10.5次、5.3次)高于发廊(5.6次、3.6次)和宾馆类场所(5.8次、2.8次)。
干预6个月后,近70%的妇女报告接受过女套干预,能明确认识干预工具(以“见过翻板图”为标识)的妇女占48%,报告自己练习过女套使用的妇女占24%。干预12个月和24个月后,以上3个比例分别为72%、63%、34%和78%、67%、22%。
3.干预前后女套接受性水平变化
横断面调查的结果显示,干预前有不到1/3的妇女听说过女套但没有人用过女套,干预后约90%的调查对象听说过女套。干预6个月、12个月和24个月三个调查时点上30-40%的妇女报告至少尝试使用过1次女套,其中50-70%的妇女用过女套2次及以上。三次干预后调查中均有近10%的对象在调查前30天用过女套。与感情性伴或客人调查前30天性行为中使用女套的平均比例为1-3%,远低于使用男套的平均比例(感情性伴：30%-42%；客人：88%-92%)。大约30-40%的妇女在干预后三个调查时点上报告,在调查前半年里她们把女套当作备用的或者经常使用的预防方法(下文称“认可女套”)
在个人特征码匹配的112名对象中,75%的妇女对女套的认可程度在其参与与的间隔最长的两次调查间呈上升趋势。在“固定队列”中至少被随访1次的对象(n=65)其女套认可程度在干预后三次调查中呈上升趋势。
4.干预前后保护性行为水平的变化
干预前,调查对象报告与所有性伴在调查前30天的性行为中全部使用安全套(简称“全部用套”)的比例为42.6%,77.3%的妇女报告调查前30天与客人全部用套,33.3%的妇女与感情性伴全部用套。在于预后的三次调查中,调查前30天与所有性伴全部用套的妇女比例比干预前提高了2.4-6.4个百分点,与客人全部用套的妇女比例提高了6.2-10.2个百分点,但与感情性伴全部用套的妇女比例变化不大且无规律。
在个人特征码匹配的112名对象中,一半以上的妇女在间隔时间最长的两次时点间,调查前30天与客人或者与感情性伴使用安全套的比例维持不变。“固定队列”中65位至少被随访1次的对象在干预前后这两个比例亦未看出明确的变化趋势。
5.影响性服务妇女女套接受性及保护性行为的因素
5.1定量问卷资料分析结果
在单因素分析中,女套接受性指标“是否使用过女套”、“调查前半年是否认可女套”和性服务妇女的年龄、婚姻状态、场所类型以及接受干预各项指标的关联在干预后3次调查中均有统计学显著性。但在多因素Logistic回归模型中,控制了年龄、场所类型、性伴类型和男套使用水平的影响后,妇女接受干预程度越高,使用过女套的比例越大(调整OR在3.5-8.0之间),同时认可女套比例也更高(调整OR在3.4-9.0之间)。年龄可能是另一个与女套接受性有关的独立影响因素。年龄大于30岁的性服务妇女在干预24个月后的调查中认可女套的可能性约是年龄小于等于30岁组的3倍(调整的OR=3.3,95%CI:1.1～9.4)
在保护性行为上,“调查前30天性行为是否全部使用安全套”在单因素分析中主要与性服务妇女的场所类型、年龄、婚姻状态、生育健康史、性伴类型和性伴人数等变量有统计学上的关联。多因素Logistic回归模型中,控制了年龄、场所类型和性伴类型的影响后,接受干预程度和“调查前30天性行为是否全部使用安全套”在干预6个月和12个月时关联无统计学显著性,但在干预24个月调查中妇女接受干预程度越高,调查前30天全部用套的比例越大(调整OR=1.9,95%CI：1.1～3.5)。来自出租屋、年龄大于30岁和有感情性伴的性服务妇女在调查前30天性行为中全部用套的可能性较低。
5.2定性人类学资料分析结果
大部分性服务妇女在接触女套之初对其外观和使用方法持消极看法,但也有妇女认可女套保护女性的作用,愿意学习使用。在实际使用中男性注重女套是否能增加性愉悦感,妇女则更关注女套的安全性。同时,中、青年性服务妇女在安全套使用的意愿和能力的差别、所处场所规则和场所内接受干预机会的差别可能造成女套接受性的不同。此外,妇女学习和摸索女套使用时,一般更愿意与感情性伴首次尝试,对女套熟悉以后,更多则在与客人的性行为中使用。
另一方面,工作人员与妇女的信任关系是干预实施的基础,性服务场所工作时间与干预时间的吻合性、场所开展干预的空间、场所老板的态度和场所内妇女复杂性等都可能影响组织干预的难易程度和妇女干预接受的机会。
结论
在广西P市这样一个开展男套推广工作十余年并取得一定成效的地区,将女套加入原有男套干预2年后显示,有一定比例的性服务妇女逐步将女套整合到预防行为中。女套接受性不仅与接受干预程度有关,同时还受到性服务妇女年龄和所处场所的共同影响。工作人员与妇女的信任关系、场所的复杂性影响着干预实施的难易程度及性服务妇女接受干预的机会。
Background and significance
China's a drastic change in sexual norms and behaviors over that past three decades has been accompanied by the expansion of sexually transmitted infections (STIs) including HIV/AIDS epidemics which become an important issue of public health. Commercial sex is the one of mainly influential risk behaviors in the STIs epidemics. Female sex workers (hereinafter referred to as FSWs or women) are the key population in that issue.
Multipurpose barrier methods have been the most effective preventive devices for STIs to date, which provide the dual protection against unwanted pregnancy and the transmission of sexually transmitted disease. Now the condom includes the male condom (MC) and the female condom (FC). Though male condom (MC) has been promoted efficiently for more than a decade in China, there remains some obstacles to achieve "100%Condom Use" among FSWs only through MC-only intervention. FC is an intravaginal barrier method that is designed for overcoming drawbacks of MC. However, to date there have been very few studies about FC acceptability and use in China, or about the potential effects of integrating FC into the existing MC promotion.
Objectives
The objectives of this study were to evaluate the effects of FC inclusion in MC promotion efforts through examination of FC acceptability and overall rates of protected sex among FSWs in P city, Guangxi province.
Methods
This study included the design and implementation of an FC intervention and evaluation of outcomes.
The FC intervention was implemented mainly through outreach to sex-work establishments, delivering FC knowledge, training the skill and providing free FC1(also including domestic Phoenurse FC at the second year) among women working in sex establishments. The FC intervention was designed as a three-phase program with two6-month phases of introductive intervention and a12-month phrase of routine intervention.
Interdisciplinary methods were used to evaluate FC intervention, including:(1)Four serial cross-sectional surveys of FSWs at baseline (pre-intervention), at6months,12months and at24months post-intervention were conducted. Women working in the targeted establishments who were16years or older and sexually active in the prior30days were eligible for the survey at any time point. All cross-sectional surveys were designed to recruit70%to80%of the total estimated women working in the targeted sex establishments.(2)The cohort was consisted of the women who were followed in three post-intervention cross-sectional surveys by matching their unique ID between surveys.(3)Ethnographic observations and interviews were conducted prior to, during and post intervention for collecting the data of the intervention implementation process. The proportions of ever used FC, FC recognition in last6months, FC uptake and overall protected sex in last30days among FSWs in pre-and post-intervention surveys were be compared. The associations between the outcomes and the levels of accepted intervention and other influential factors were also explored.
Results
There were about152to155women participated in each cross-sectional survey. Aggregately112women's unique ID codes were matched between at least two surveys. Thirty to forty percentages of women in each cross-sectional survey were matched to the prior surveys. In the fixed cohort based on the pre-intervention survey as the baseline,65participants were followed at least once in the three post-intervention surveys.
1. Characteristics of participants
At the four cross-sectional surveys, the mean age of participants ranged from32.5to34years old. Eighty percentages of women were married and2/3originated from Hunan or Hubei province. Approximately one third of participants worked in the boarding houses, and20-40%of these women worked in hairdresser/massage parlors and hotel-based massage, beauty and sauna parlors, respectively. The median age of first sexual experience and initiating sex work was19to20years old and27to28 years old. Ninety percentages of participants had experienced pregnancy, and2/3had an abortion. However, Twenty to thirty percentages of FSWs had no children.
The number of women whose unique personal ID codes were matched among2\3\4surveys was69,28and15. The mean age of these women at "baseline" survey was over33years old, and the mean age of women with non-matched ID codes was30.9years old. The proportion of women from boarding houses among whom with matched ID code and with non-matched ID code were44%and29%.
2. Intervention implementation and participation
The staff conducted nearly490outreach encounters to55establishments during the24months of three intervention phrases, and in half of these outreach, FC was delivered. More than2000FC with first generation (FC1),640domestic-made Phoenurse FC and20000MC were delivered in all. The times of outreach in the first year were about320, which was the double times in the second year. Mean times of outreach to the boarding houses during two years (in the first year:10.5; in the second year:5.3) was higher than the hairdresser (in the first year:5.6; in the second year:3.6) and hotel-based massage, beauty and sauna parlors (in the first year:5.8; in the second year:2.8).
About70%of FSWs reported having participated in FC intervention activities, forty eight percentages having recognized the intervention tool (the flip chart as the mark) and24%having practiced FC insertion by herself at6months post-intervention survey. These three proportions were72%,63%,34%and78%,67%,22%at post-intervention12-month and24-month surveys, respectively.
3. FC acceptability
One third of FSWs had heard of but no one had used FC at baseline. At the6-month,12-month and24-month post-intervention surveys, more than90%of FSWs reported knowing about FC, and30%-40%of FSWs have used FC at least one time, and50%-70%of them had used FC more than once. The proportion of women having used FC during the prior30days remained at about10%at three post-intervention surveys. The mean proportion of protected sex by FC ranges from1%to3%with primary and paying partners in the last30days at each post-intervention cross-sectional survey, which was lower than the proportions using MC (with primary partners:30%-42%; with paying partners:88%-92%).30%-40%FSWs reported they considered FC as an backup protection method or regularly used it in the last6 months at6months,12and24months post-intervention surveys.
Seventy five percentages of women's levels of FC recognition in last6months increased between two surveys that their interval was longest among112women whose ID codes were matched. The levels of FC recognition in last6months in the fixed cohort (N=65) showed a clear growth trend in four serial surveys.
4. The level of protected sex before and after intervention
At the baseline survey,42.6%of the participants reported100%protected sex with all types of partners in the last30days. This proportion with clients and the primary partner was77.3%and33.3%, respectively. After intervention, this proportion had increased by (2.4%to6.4%) at the three post-intervention surveys. The proportion of women reported100%protected sex with clients increased by (6.2%to10.2%), but this proportion with the primary partner was stable at each post-intervention surveys.
The trend of the level of protected sex in the last30days was not obviously between two surveys that their interval was longest among112women and in the fixed cohort.
5. Factors associated with FC acceptability, protected sex and intervention implementation.
5.1Quantitative assessment
The indicators of FC acceptability,"ever having used FC" and "FC recognition in last six months " were associated with age, marriage status, establishment types and participation in intervention in the univariate analysis. Better participation in the intervention was consistently associated with ever having used FC (adjusted OR ranges from3.5to8.0) and recognized FC (adjusted OR ranges from3.4to9.0) in the last6months at three post-intervention surveys, controlling for age, establishment and sex partner and the level of protected sex by MC. Age may be an independent factor associated with FC acceptability, that is older than30years old was associated with recognized FC (adjusted OR=3.3,95%CI:1.1-9.4).
As to the level of protected sex,"having100%protected sex in the last30days" was associated with establishment types, age, marriage status, reproductive history, sex partner types and number of sex partners in the univariate analysis. After adjustments for age, establishment and sex partner types, women who better participated in the intervention were more likely to have100%protected sex in the last30days at24month post-intervention survey (adjusted OR=1.9,95%CI:1.1-3.5), however we did not find the association at6month or12month post-intervention survey. Being from boarding house, older than30years old and having primary partner less likely to have100%protected sex in the last30days.
5.2Qualitative assessment
Most of women had a negative attitude towards the FC appearance and usage, but some women recognized the FC's protection and were willing to learn how to use it. Men were pay attention to whether the FC increases sexual joy, but women emphasized the safety of FC. The difference between middle-aged women and youth women on the willingness and ability of using condom, the rule of sex establishments, the chance of accepted intervention in establishment may associate with FC acceptability. In addition, some women were more likely to first try FC with primary partners than with paying partners when they were learning the skill. If they were familiar with FC, they were more likely to sustain FC use with paying partners.
On the other hand, good relationship with FSWs was the basic of intervention implementation. The match between FSWs'working time and intervention time, the room in the establishment for intervention, the boss's attitude towards intervention and the complexity of women in the sex establishments may associated with difficulty of implementing intervention and the chance of accepted intervention.
Conclusions
After two-year FC intervention along with MC promotion among FSWs in P city, where the MC promotion progress had been made during the last10years, a considerable proportion of women accepted FC as a prevention method.The FC acceptability was not only associated with the level of accepted intervention,but also varied by women's age and establishments. Moreover, the difficulty of intervention implementation and the chance of women accepted intervention were influenced by the relationship between outreach workers and FSWs and the complexity of the sex establishments.
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[1]伏圣高,孙李娜,孟晓军,等.1995-2009年国家级艾滋病哨点暗娼人群监测结果分析[J].疾病监测,2010(11)：850-853.
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[1]伏圣高,孙李娜,孟晓军,等.1995-2009年国家级艾滋病哨点暗娼人群监测结果分析[J].疾病监测,2010(11)：850-853.
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[6]Elias C, Coggins C. Acceptability research on female-controlled barrier methods to prevent heterosexual transmission of HIV:Where have we been? Where are we going?[J]. J Womens Health Gend Based Med,2001,10(2):163-173.
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[9]Fontanet A L, Saba J, Chandelying V, et al. Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom:results from a randomized controlled trial[J]. AIDS,1998,12(14):1851-1859.
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[11]Ray S, van De Wijgert J, Mason P, et al. Constraints faced by sex workers in use of female and male condoms for safer sex in urban zimbabwe[J]. J Urban Health,2001,78(4):581-592.
[12]Hoke T H, Feldblum P J, Van Damme K, et al. Temporal trends in sexually transmitted infection prevalence and condom use following introduction of the female condom to Madagascar sex workers[J]. Int J STD AIDS,2007,18(7):461-466.
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[14]徐衍,罗家洪,李晓梅,等.女用安全套在个旧市女性性工作者中的应用研究[J].中国全科医学,2009,12(5)：406-407.
[15]Sakondhavat C, Weeravatrakul Y, Benette T, et al. Consumer preference study of the female condom in a sexually active population at risk of contracting AIDS[J]. J Med Assoc Thai,2001,84(7):973-981.
[16]Lara D K, Grossman D A, Munoz J E, et al. Acceptability and use of the female condom and diaphragm among sex workers in Dominican Republic:results from a prospective study[J]. AIDS Educ Prev,2009,21(6):538-551.
[17]Mack N, Grey T G, Amsterdam A, et al. Central American sex workers'introduction of the female condom to different types of sexual partners[J]. AIDS Educ Prev,2010,22(5):466-481.
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