促进云南农村妇女孕早.doc

促进云南农村妇女孕早、中期艾滋病自愿咨询检测综合干预研究【摘要】目的 探索适合云南农村地区的孕产妇艾滋病病毒（HIV）自愿咨询检测（VCT）干预措施，促进农村孕妇尽早获得HIV自愿咨询检测，有效预防艾滋病母婴传播。方法 采用流行病学准实验研究方法，2005年12月，选择属于艾滋病中度流行地区的腾冲县作为研究地点,根据离县城较远和较近、经济状况相近等条件，选取4个乡，作为研究点。基线调查包括入户面对面地对孕28周至产后3个月农村妇女223人、相关社区人群310人问卷调查，辅以孕产妇个人深入访谈，并收集相关统计数据。根据基线调查结果, 随机抽取2个乡作为干预乡，与之配对的2个乡作为对照乡，对照乡按省及县里统一要求开展孕产妇VCT促进工作，干预乡除按统一要求开展工作外, 实施9个月的综合干预措施。针对基线调查中影响孕妇HIV自愿咨询检测的因素制定综合性干预措施，具体内容包括：采用参与性方法培训乡村干部和乡村医生，以各村村干部和村医生为主力，开展丰富多彩的参与性社区健康教育活动，开发适合农村地区预防艾滋病母婴传播的参与性健康教育材料和方式， 利用孕产妇保健手册宣传艾滋病母婴传播知识，乡妇幼专干和村医生共同讨论形成“定时、定点、乡村医生进村”的孕妇采血和送检流程，在医疗保健机构产前门诊为产检孕妇常规提供HIV自愿咨询检测服务。2006年11月，以基线调查人群的纳入标准和样本量为依据，实施终末效果评估。分别将基线资料和终末资料进行对比，使用t检验、2检验、方差分析及Logistic回归等统计分析方法，分析干预组和对照组孕产妇HIV检测率、知识、态度的变化，以及社区相关人群知识、态度的变化。结果 基线调查的结果显示，孕妇HIV检测率和怀孕28周前自愿咨询检测率总体水平较低（33%和15.2%），干预组与对照组孕妇HIV检测率及知识、态度关键指标可比性较好。影响孕产妇接受HIV检测的因素主要是认为检测没有必要；其次是对检测相关知识信息不足，如担心收费贵、不知道到哪里检测等。多因素Logistic回归分析显示：产检时接受过艾滋病宣教，知晓孕产妇艾滋病咨询和初筛检测是免费的以及知晓HIV检测地点与孕产妇获得检测有相关性。干预后干预组孕妇HIV检测率、孕28周前自愿咨询检测率分别从59.0%、15.0%上升到96.8%、83.0%，而对照组相应指标分别从55.7%、15.5%上升到80.6%、36.6%，综合干预措施对促进孕妇28周前获得自愿咨询检测有更明显的作用。干预组孕产妇艾滋病核心知识指标明显高于干预前（2 = 32.84，0.01），对照组核心知识指标干预前后变化无统计学意义（2 = 0.04，0.05）。干预后干预组孕产妇对艾滋病及HIV检测的态度均发生了正向变化（2 = 4.0419.52，0.05），对照组孕产妇态度变化无统计学意义（2 = 0.012.72，0.05）。干预组调查的112名孕产妇中有72.3%近1年内参加了乡村级各种形式的艾滋病健康教育活动，达172人次，而对照组112名孕产妇中仅38人（33.9%）接受了包括阅读健康教育材料在内的健康教育，为62人次。综合干预措施显著增加了干预组乡村干部和普通育龄妇女艾滋病核心知识和综合知识，乡村医生的核心知识和丈夫的综合知识也分别得到提高，但婆婆的各项知识无明显变化。乡村干部、普通育龄妇女、乡村医生、丈夫和婆婆的VCT重要知识信息干预后都得到明显增加，婆婆、育龄妇女、乡村医生和乡村干部对孕妇进行HIV检测的认可程度也明显增强，并改善了他们对感染HIV的道德判别态度。对照组各类人群干预前后核心知识、VCT重要知识信息水平没有得到提高，对艾滋病和检测的态度也基本无变化。结论 参与性社区健康教育活动配合方便可及的孕妇VCT服务的综合性干预措施，有效地提高了农村妇女孕早、中期的HIV自愿咨询检测率，增加了孕产妇及社区群众艾滋病及预防艾滋病母婴传播知识，并部分改变了社区相关人群对艾滋病病人及HIV感染者的态度。【关键词】 孕产妇；艾滋病；自愿咨询检测；干预Comprehensive intervention on improving pregnant women in uptake of voluntary counselling and testing for HIV in the first and middle trimester in rural Yunnan【ABSTRACT】OBJECTIVES To explore effective interventions to promote voluntary counselling and testing （VCT） for Human Immunodeficiency Virus （HIV） among rural pregnant women in rural YUNNAN，so as to improve the pregnant women to obtain VCT early and prevent mother-to-child transmission of HIV successfully.METHODS Quasi-experiment was applied in this study. According to the distances from townships to the county centre and economic situation, four townships were chosen from Tengchong County, one district with middle degree of HIV epidemic in YUNNAN, as our study sites. Baseline survey was conducted on 223 rural women after 28 weeks gestation and with infants aged 3 months or less and 310 related people in villages of the 4 study sites in Nov, 2005. At the same time, data on HIV testing and maternal health was also collected. Based on the survey, 2 townships were randomized assign to the intervention group, and the 2 matching township went into the control group. Routine VCT was implemented in the control group as governmental requirements. Nine months comprehensive interventions and routine VCT were conducted in the intervention group.Based on the survey findings, comprehensive interventions were made, including: Training village cadres and village doctors by participatory approaches, Village cadres and doctors playing main roles in conducting multiple participatory community health education, Developing Participatory PMTCT health education material to meet the need in rural areas, Disseminating knowledge about PMTCT using Maternal health handbook, “Working procedures of blood collection and transferring for HIV testing of pregnant by entering villages on fixed locations in fixed time” being made up by rural maternal and child health personnel and village doctors, Providing routine VCT for HIV services for prenatal health women in antennal clinics.Evaluation survey was conducted in December 2006. The enrolling standard and sample size of surveyed subjects were as same as baseline survey. The evaluation data and baseline data were analysis using t-test, Chi-square test, variance analysis and logistic regression. The effectiveness of comprehensive interventions was evaluated by changes of HIV testing rate, knowledge and attitudes of subjects.RESULTS The baseline survey showed that the HIV testing rate of pregnant women and the rate of VCT for HIV among pregnant women before 28 weeks gestation were both low, which were 33% and 15.2% respectively. The key indicators were balanced between the intervention group and the control group. The main correlate associated with not accepting HIV testing was “Pregnant women had the concept of unnecessary to take HIV testing”. The following correlate was “knowing little about VCT, such as worrying about high fees for VCT and not knowing where to access HIV testing”. Multivariate logistic regression analysis indicated that having received HIV/AIDS education during prenatal healthcare, knowing counseling and screening test for HIV expense and where to get the test were associated with HIV testing for pregnant women.After the intervention, the HIV testing rate of pregnant women and the rate of VCT for HIV among pregnant women before 28 weeks gestations were increased from 59.0% and 15.0% to 96.8% and 83.0%, respectively in intervention group. However, the corresponding rates in control group only rose from 55.7% and 15.5% to 80.6% and 36.6%, respectively. The knowledge level of core indicators after intervention were higher than before（2=32.84，0.01）,and attitude to VCT for HIV had changed positively （2=0.04，0.05）among surveyed pregnant women and new mothers in the intervention group. But in the control group, the knowledge level of core indicators and attitude to VCT had no significant difference at the same time（2=0.012.72，0.05）. In nearly one year, 72.3% of 112 surveyed pregnant women and new mothers participated in community health education, reaching 172 person-times in the intervention group. However there were only 33.9% of subjects in the control group, 62 person-times.The comprehensive intervention significantly increased knowledge level of core indicators and general knowledge of HIV/AIDS among village cadres and women of childbearing age. The core indicators scores of village doctors and the general knowledge scores of husbands were also both improved. However, the knowledge of mothers in law of pregnant women was not different before and after intervention. After the intervention, knowledge and information on VCT for HIV and the acception of HIV testing for pregnant women had been increased significantly among community related people. And the intervention changed their moral attitude of discrimination to HIV infection in the intervention g