【作者】 张彩霞；

【导师】 姜宝法；

【作者基本信息】 山东大学 ， 流行病与卫生统计学， 2017， 硕士

【摘要】 研究背景自2007年开始,异性性接触已成为我国HIV/AIDS传播的主要方式。全国艾滋病疫情报告显示,2007年至2017年,经异性性接触感染的新发病例所占的构成比已从38.9%上升到67.9%。异性性传播病例中50岁以上人群的比例从2008年的19.3%上升到2014年的36.1%。有研究表明中国大多数感染HIV的50岁以上人群都有与大龄女性性工作者(older female sex workers,OFSWs)发生性行为的历史,因此OFSWs是重要的研究和干预对象。促进女性性工作者(female sex workers,FSWs)安全套的使用一直是研究和干预的重点,以往的研究多是单独从FSWs的角度探讨安全套使用的影响因素,如FSWs文化水平低、劝说能力不足、未进行过HIV/AIDS检测、多个性伴等,其中最主要的原因是性伴拒绝使用。而无论是从FSWs还是从性伴的角度进行研究都不能完全说明为什么FSWs与一部分性伴使用安全套,而与其他的性伴不使用安全套。因此本文利用两水平logistic回归模型对OFSWs和性伴两个水平同时进行研究,全面的分析和探索OFSWs性行为中安全套使用的影响因素。由于职业的原因,OFSWs与普通人群有着不一样的社会网络结构。对于OFSWs而言,社会网络是促进HIV/STDs传播的媒介,但也是阻止HIV/STDs传播的潜在途径,如社会支持网络。我们之前对OFSWs的社会支持网络研究已表明获得较大的情感和物质支持可以减少其发生不安全性行为的概率,因此对OFSWs的社会支持(物质支持和情感支持)来源和支持力度情况进行全面细致的分析并比较不同特征OFSWs的社会支持来源是否不同,有助于我们更加清楚的了解OFSWs这个群体的社会支持网络情况,发现OFSWs的主要社会支持来源和潜在社会支持来源,为干预对象的发现和干预措施的提出提供新的思路和方向。研究目的1探索青岛市OFSWs与不同性伴之间安全套使用情况,采用两水平logistic回归模型结合OFSWs水平和性伴水平分析其影响因素;2利用对应分析图展示OFSWs的11种社会支持来源对OFSWs的物质支持和情感支持以及支持力度情况,并比较不同特征的OFSWs的社会支持情况,为相关干预对象的发现和干预措施的提出提供理论和数据支持。研究方法本研究采用同伴推动抽样法(respondent-driven sampling,RDS)于2014年3月-6月在青岛市及其辖区内招募OFSWs。采用计算机辅助问卷调查(computer assisted personal interviewing,CAPI)获取 OFSWs 的信息,包括一般人口学特征、性工作相关信息、梅毒生物学检测、性网络情况、社会支持网络情况。采用两水平logistic回归模型从OFSWs及其性伴两水平分析安全套使用的影响因素;采用对应分析展示不同社会支持网络成员对OFSWs的物质支持和情感支持的力度情况以及t/F检验比较不同特征OFSWs的社会支持情况。研究结果1 OFSWs基本信息本研究共招募到420名OFSWs,平均年龄为(42.6±6.3)岁,主要为汉族、离婚/丧偶者、外地户籍、初中及以下文化水平。OFSWs中独自一人居住的占31.7%;86.4%的OFSWs月收入占家庭月总收入的50%以上;在30岁及以后才开始从事性工作的OFSWs占76.90%;从事性工作行业的原因中经济原因占42.14%,离婚/丧偶的占17.14%。OFSWs的艾滋病相关知识知晓率为66.7%;接受过艾滋病服务帮助的占91.90%;对使用安全套的态度得分为(10.83±2.52)分;认同安全套是预防性病/艾滋最有效的方式的占97.4%;自我报告做过艾滋病检测的占75%;自我报告吸过毒的占18.33%;自我报告近半年来遭受过暴力的占47.62%;自我报告最近一次商业性行为安全套使用率为73.81%,最近一个月安全套坚持使用率为33.33%;最近一次与客人未使用安全套的主要原因有客人要求不戴套、给的钱多、无法勃起和熟客关系。OFSWs既往梅毒患病率为29.8%,梅毒现患率为8.6%。2 OFSWs安全套使用影响因素通过询问OFSWs,获得了 2100名性网络成员的信息。空模型结果显示,OFSWs与不同性伴之间安全套使用情况存在差异(t=4.77,P=0.001)。两水平logistic回归分析结果显示,OFSWs水平:文化水平为初中(OR=1.448,95%CI:1.053～1.990)、高中及以上(OR=2.309,95%CI:1.242-4.291)、认同安全套的预防功能(OR=2.001,95%CI:1.271～3.152)的OFSWs安全套使用率较高;对使用安全套的态度得分越高(OR=0.80,95%CI:0.750～0.853)、既往感染梅毒(OR=0.668,95%CI:0.487～0.917)的OFSWs安全套使用率较低。性伴水平:OFSWs的熟客和一般客人安全套使用率高于其男朋友(OR=13.807,95%CI:7.614～25.036;OR=25.974,95%CI:13.810～48.852);在发廊、桑拿、歌舞厅等公共娱乐场所进行性行为(OR=1.627,95%CI:1.140～2.321)的性伴安全套使用率较非固定场所的OFSWs高。3 OFSWs社会网络和支持情况本次研究对象OFSWs的社会支持网络成员中同行朋友的比例最大,非同行朋友的比例次之。本研究将社会支持分为物质支持和情感支持两类,此次研究对象的物质支持大于情感支持。通过对应分析图可以看到OFSWs的物质支持最可靠的来源是男朋友(非)(无商业性交易的男朋友)、家庭其他成员、非家庭成员亲戚以及非同行朋友,即亲人和非同行朋友;OFSWs的情感支持最可靠的来源是家庭其他成员、无商业性交易的男朋友、同行朋友;OFSWs最亲近和最信任的人是无商业性交易的男朋友和家庭其他成员;而最不亲近和不信任的是老板。经过t/F检验,初中及以上文化水平的OFSWs的社会支持力度大于小学及以下的;公共娱乐场所的OFSWs社会支持力度大于非固定场所的,不吸毒的OFSWs的社会支持力度大于吸毒的,最近一次商业性行为中使用安全套和最近一个月坚持使用安全套的OFSWs的社会支持大于未使用和未坚持使用的,且具有统计学差异。通过对应分析图可以看到初中及以上文化水平和非固定场所的OFSWs社会支持来源主要是非同行朋友;不使用安全套、吸毒的OFSWs的社会支持来源主要是商业性伴(熟客和有商业性交易的男朋友);小学及以下文化水平和公共娱乐场所的OFSWs的社会支持来源主要是同行朋友。结论及建议1青岛市OFSWs平均年龄为42.6岁,大部分OFSWs是因为经济原因在30岁以后被迫进入性工作行业,绝大多数OFSWs是家里的主要经济来源。OFSWs的安全套使用率仍然较低,最近一个月的安全套坚持使用率远小于最近一次安全套使用率,因此对于OFSWs仍需加强她们对安全套的认识和使用率,即只有坚持使用安全套才能预防HIV/AIDS传播。2 OFSWs安全套使用情况受自身及其性伴的共同影响,在今后的防控工作中要对OFSWs及其性伴同时进行干预,重点关注对象为文化水平低、性行为场所不固定、既往感染梅毒的OFSWs及其男朋友、熟客等固定性伴。3 OFSWs的社会支持网络成员的主要构成是同行朋友和非同行朋友,但OFSWs的社会支持最可靠的来源还是没有商业性行为的男朋友、家庭其他成员,而同行朋友是潜在的社会支持者,OFSWs最不信任和不亲近的是老板、领班。加强OFSWs与老板、领班和同行朋友的关系将是重要的干预方向。商业性伴(熟客和有商业性性行为的男朋友)是吸毒、未使用安全套的OFSWs的主要社会支持来源,而商业性伴是AIDS/STDs传播的主要桥梁人群,因此商业性伴支持者(熟客和有商业性性行为的男朋友)是今后预防AIDS/STDs传播的主要干预对象和人群。采取措施改变OFSWs与不同性伴之间的安全套使用情况,加强自我保护意识将是工作的重点。更多还原

【Abstract】 BackgroundHeterosexual contact has become the main transmission way of HIV/AIDS in China since 2007.The National AIDS/STDs report showed that the proportion of new cases with heterosexual contact infection has risen from 38.9%in 2007 to 67.9%in 2017.In the case of heterosexual transmission,the age group(≥50 years old)rose from 19.3%in 2008 to 36.1%in 2014.Studies have shown that the majority of elderly people infected with HIV in China(age≥50)had history of sexual behavior with older female sex workers(OFSWs),so OFSWs are important subjects for research and intervention.Condom use of female sex workers(FSWs)has always been the focus of research and intervention.The Previous research explored influencing factors of condoms use from the perspective of FSWs,such as low level of FSWs,lack of persuasion,lack of HIV/AIDS testing,multiple sexual partners,etc.The most important reason was sexual partners refused to use.Whether from the perspective of FSWs or sexual partners can not fully explain why FSWs used condoms with some partners,but do not use condoms with other partners.Therefore,this paper uses two-level of logistic regression to study both OFSWs and sexual partners at the same time,and comprehensively analyzed and explored the influencing factors of condom use among OFSWs.Due to professional reasons,OFSWs has a different social network structure with the general population.For OFSWs,social networks are vectors that promote the spread of HIV/STDs,but are potential ways to prevent the spread of HIV/STDs,such as social support networks.Prior study has shown that greater emotional and material support can reduce the probability of unsafe sex of OFSWs,therefore comprehensive and detailed analysis the source and support of OFSWs’ social support(material support and emotional support)and comparison social support sources of different characteristics of OFSWs,to help us to better understand the community of OFSWs social support network,to found the main source of social support and potential social support of OFSWs.Two provide new ideas and directions for the discovery intervention subjects and intervention works.Objectives1 To explore the use of condoms between OFSWs with different sexual partners in Qingdao,the two-levels logistic regression model combined with OFSWs level and sexual partners level was used to analyze the influencing factors.2 To display the material support,emotional support and support strength of OFSWs from 11 kinds of social support sources through the corresponding analysis chart of the corresponding analysis.To compare the social support of OFSWs with different characteristics.To provide theoretical and data support for the discovery of intervention objects and proposing of interventions measures.MethodsIn this study,respondent-driven sampling(RDS)was used to recruit OFSWs in Qingdao from March to June 2014.The computerized personal interviewing(CAPI)was used to obtain information of OFSWs,including general demographic characteristics,sex work-related information,syphilis biology detection information,sexual network information,and social support networks information.The two levels logistic regression model was used to analyze the influencing factors of condom use from OFSWs level and their sexual partners’ level.Corresponding analysis was used to show the material support and emotional support of OFSWs and the social support of different OFSWs.Results1 The characteristics of OFSWsA total of 420 OFSWs were recruited in this study,with an average age of(42.6±6.3)years,most of them were Han ethnics,divorced or widowed,were migrants(without registered household in Qingdao),with junior middle school or lower education.There were 133 OFSWs(31.7%)living alone;86.4%OFSWs’monthly income accounted for more than 50%of the total monthly income of the family;76.90%began to engage in sex work when they were at the age of 30 or older;42.14%engaged in sex work industry for economic reasons,17.14%for divorce/widowed.66.7%knew the knowledge about AIDS transmission;91.90%received AIDS service help;the attitude towards condom using was(10.83 ±2.22)points;97.4%agreed with that condom is the most effective way to prevent STDs/AIDS;75%self reported having HIV testing;18.33%self reported using drugs;47.62%reported suffering violence nearly six months;73.81%self reported using condom in their last commercial sex behavior,33.33%reported having consistent condoms use in every commercial transaction during last month;the main reasons for not using condoms with the guests in the last commercial transaction included refusing to use,giving more money,could not erection and regular customers.Previous syphilis prevalence rate of OFSWs was 29.8%,syphilis prevalence rate was 8.6%.2 Influencing factors of condom useInformation of 2100 network members was obtained by asking OFSWs.The percentage of condom use was different among different sexual partners of OFSWs(t=4.77,P=0.001).Two levels of logistic model analysis showed that,OFSWs with junior middle school education level(OR=1.448,95%CI:1.053-1.990),high school education level or above(OR=2.309,95%CI:1.242--4.291),approving prevention function of condom(OR=2.001,95%CI:1.271-3.152)had higher rate of condom use.OFSWs with higher score of attitude on condom use(OR=0.80,95%CI:0.750-0.853),syphilis infections in the past(OR=0.668,95%CI:0.487-0.917)had lower rate of condom use.For sexual partners,the rate of condom use among OFSWs’regular and general partners were higher than that of OFSWs’ boyfriends(OR=13.807,95%CI:7.614～25.036;OR=25.974,95%CI:13.810～48.852).Sexual partners having sexual behavior on salon、sauna、dancing halls and other places of entertainment(OR=0.50,95%CI:0.37～0.67)had higher rate of condom use.3 OFSWs’ social networks and supportFrom this study,we concluded that the largest proportion of the social support network members of OFSWs were peer friends,the second largest proportion was non-peer friends.This study divided social support into material support and emotional support,and the material support of OFSWs was greater than emotional support.Through the corresponding analysis chart,we found that the most reliable source of material support for OFSWs were boyfriend,other family member,non-family member relatives and non-peer friends,that were relatives and non-peer friends;the most reliable source of emotional support for OFSWs were other family members,boyfriend without commercial sex,peer friends;The closest and most trusted person of OFSWs were boyfriends and other family members;and the least intimate and trusting was boss.Through the t/F test,the social support of OFSWs with junior high school and above education was greater than that of primary school and lower.Social support of OFSWs working in public entertainment places was greater than that of non-fixed places.Social support of OFSWs with non-drug using was greater than that of drug using,and social support of OFSWs with condoms using in commercial sexual behavior was greater than that of no used,with statistical difference.Through the corresponding analysis,we can see that the social support sources of OFSWs with junior high school and above education level and working in non-fixed places were mainly non-peer friends.The social support sources of OFSWs who did not use condoms and drugs were mainly commercial partners(regular and commercial Boyfriend);the social support source of OFSWs with primary school and the lower education level and working in public entertainments were mainly peer friends.Conclusions and suggestions1 OFSWs are mainly Han nationality,divorced/widowed,foreign household registration,with junior high school and lower education level in Qingdao.Most of the OFSWs are forced to enter the sex work industry for economic reasons after the age of 30,and the vast majority of OFSWs are the main source of income for their family.Condom use of OFSWs is still low,and consistent condom use in the last month is much lower than last condom use,so it is important to strengthen the awareness of OFSWs that only consistent condoms use can prevent HIV/AIDS transmission.2 OFSWs’ condom use is affected by both theirself and their partners.In the future prevention and control work,OFSWs and their partners should be intervened at the same time,focusing on OFSWs with lower education level,working in not-fixed places,previously infected syphilis and boyfriend,regular customers of OFSWs.3 The main composition members of OFSWs’ social support network were peer friends and non-peer friends,but most reliable source of social support of OFSWs are husbands,no commercial sex boyfriends,other family members,and peer friends are potential social supporters,OFSWs are least trusting and closing to boss.Strengthening OFSWs’ relationship with bosses and peer friends will be an important intervention measures.Commercial partners(regular and commercial sex boyfriends)are the main social support source for OFSWs with using drugs,non-use condoms.Commercial partners are the main bridge population for AIDS/STDs transmission,so commercial partners(regular and commercial sex boyfriend)are the main intervention population in the future prevention of AIDS/STDs spread.Taking measures to change the use of condoms between OFSWs and different partners,strengthening self-awareness will be the focus of the work.更多还原