同伴推动抽样法和基于场所的抽样方法在女性性工作者中的比较研究
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摘要
背景：性病艾滋病的流行已经是全球重要的公共卫生问题。在我国和世界多数地区,性病艾滋病的流行常常集中在具有高风险行为的隐匿人群中,如女性性工作者(female sex worker, FSWs),男男性行为者(men who have sex with men)和静脉注射吸毒者(injecting drug users, IDU)o获得这些人群的准确信息对了解性病艾滋病的流行情况、流行趋势、制定和评价合理的干预措施都具有重要意义。常用于这些人群的抽样方法有基于场所的抽样方法和同伴推动抽样法(Respondent-driven sampling, RDS)。RDS最早于1994年由Heckthorn等对传统的链式推举法改良而来,其应用已经越来越广泛,但目前将RDS与其他方法做比较从而对RDS进行实证评价的研究尚不多。
目的：本研究同时在FSWs人群中应用RDS方法和一种基于场所的方法,通过比较这两种方法获得的FSWs人群的特征,对RDS做出评价,并为当地的监测和防治工作提供参考信息。
方法：于2009年10月至2010年1月,在广西壮族自治区柳州市FSWs人群中同时开展两个平行的横断面调查,一边应用RDS方法,由7名种子开始,利用FSWs人群的社会网络由同伴招募研究对象；另一边应用一种基于场所的方法-PLACE (Priorities for Local AIDS Control Efforts, PLACE),通过调查社区和场所知情人获得一个场所抽样框架,从中抽取一定数量的场所,然后从这些场所招募研究对象。通过面对面问卷调查收集人口学特征、性行为、毒品使用、性工作等信息,采集调查对象的手指血进行梅毒螺旋体特异性抗体检测。RDS调查的数据采用专门的分析工具进行总体率的点估计和区间估计。PLACE数据根据抽样策略和场所及个体水平参加调查的比例产生相应的抽样权重,在分析中对数据进行加权分析。通过比较两个方法获得的FSWs特征指标估计值的置信区间是否重叠来判断有无统计学差异。
结果：RDS共招募583名合格的FSWs, PLACE共招募161名合格的FSWs。RDS与PLACE发现了明显不同的FSWs人群特征。RDS仅招募到2.5%(95%CI1.4,3.8)居住在郊县的FSW,而49.7%(95%CI49.3,50.1) PLACE FSWs居住在郊县。RDS发现了7.6%(95%CI3.3,12.5)在最近6个月里只通过电话招揽客人的FSWs和更多的在公园、街头等户外场所招揽客人的FSWs,而PLACE没有发现只通过电话招揽客人的FSWs。与基于娱乐场所的FSWs相比,只通过电话招和在公园、街头等户外场所招揽客人的FSWs的梅毒快速检测结果阳性率更高,安全套使用率较低,曾在性工作场所内接触过HIV防治活动也较少。79.4%(95%CI68.8,90.1)的PLACE FSWs曾在性工作场所内接触过HIV防治活动,明显高于RDS FSWs (48.2%,95%CI42.7,53.2)。PLACE FSWs中的梅毒快速检测结果阳性率为24.0%(95%CI13.2,34.8),明显高于RDS FSWs的阳性率(8.6%,95%CI5.3,12.8)。当去除PLACE郊县的FSWs后,RDS FSWs与PLACE市区FSWs的梅毒总体阳性率不再有显著差别。PLACE郊县FSWs的梅毒快速检测结果阳性率最高,为34.4%(95%CI17.0,51.8)。
结论：由于缺乏一个金标准,因此很难对两方法获得的FSWs样本的代表性做出评价。在针对隐匿人群的调查和监测中,更重要的是能够接触到目标人群的各个部分。在柳州市区,RDS发现了更为隐蔽的只通过电话招揽客人的FSWs,而PLACE没有发现这部分FSWs。因此,在常规采用基于场所的方法开展HIV/STIs监测和干预活动的地区,可在前期调查中了解本地性行业的变化动态,如果相当一部分FSWs只是通过电话、网络等更隐匿的方式招揽客人,则可采取基于场所的方法和RDS相结合的方法,获得更广泛多样的FSWs样本,为监测活动提供更准确的数据,从而为制定防治项目和干预政策提供更丰富的信息。但是,RDS在郊区环境下的适用性尚需进一步研究。郊县的梅毒流行情况更加严重,需要加强干预活动。电话和站街FSWs更加隐匿,感染性病艾滋病的风险也更高,需要采取针对性的措施加强干预工作。
Backgroud:Globally, HIV/STIs epidemic is a very important public health problem. Many hidden populations with high risk behaviors, such as female sex workers (FSWs), men who have sex with men (MSM) and injecting drug users (IDU), have been disproportionately affected by the HIV/STIs epidemics in many parts of the world including China. Accurate and precise data on the behaviors in these at-risk populations is critical for understanding and tracking the direction of the epidemic, planning and evaluating effective intervention responses. Methods commonly used for sampling these populations include venue-based sampling and respondent-driven sampling (RDS). RDS was modified from chain-referral sampling and first introduced by Heckthorn in1994. It has been increasingly applied in recent years. But few empirical research have evaluated RDS in concurrent comparison with other methods.
Objectives:To evaluate RDS through concurrent implementation and comparison of two sampling method, RDS and a venue-based sampling method, among FSWs. And to provide information for local HIV/STIs control efforts.
Method:From October2009through January2010, two cross-sectional studies using RDS and a venue-based sampling method called "PLACE"(Priorities for Local AIDS Control Efforts, PLACE) respectively were simultaneously conducted among FSWs in Liuzhou city, Guangxi Zhuang Autonomous Region. RDS sampling process started with seven seeds and participants were referred by peers through FSWs' social networks. For PLACE, a venue sampling frame was constructed through interviews with community and venue informants. A subset of venues was sampled from the sampling frame and participants were recruited at selected venues. Information on socio-demographic characteristics, sexual behaviors, drug use behaviors and sex work were collected through face-to-face interviews. Syphilis rapid test was employed to test Treponemal pallidum specific antibodies using finger-prick whole blood specimens. RDS data was analyzed using Respondent-driven sampling analysis tool to produce adjusted population propotions and confidence intervals. PLACE data was weighted incorporating sampling strategies and participation rate at venue and individual level to generate population estimates. Overlaps in confidence intervals around each of the two samples'population estimates were compared to examine significant differences at a significance level of5%.
Results:A total of583and161eligible FSWs were recuited in RDS and PLACE respectively. The two methods found significant different population characteristics. RDS only recruited2.5%(95%CI1.4,3.8) FSWs who resided in rural counties, while49.7%(95%CI49.3,50.1) PLACE FSWs resided in rural counties. RDS found a group of FSWs who only solicited though telephone in the past six months and a greater proportion of FSWs who solicited at public outdoor venues. RDS estimated that telephone-based FSWs accounted for7.6%(95%CI3.3,12.5) of the total FSWs population. In contrast, PLACE did not find any FSWs who only solicited through telephone. Compared with FSWs based in establishments, FSWs who only solicited through telephone or at public outdoor venues had higher rate of a positive syphilis rapid test results, relatively lower rate of condom usage, and less exposure to HIV prevention activites at sex work venues.79.4%(95%CI68.8,90.1) PLACE FSWs had experienced HIV prevention activities at sex work venues, which was considerably higher than that among RDS FSWs (48.2%,95%CI42.7,53.2). The overall prevalence rate of a positive syphilis rapid test was24.0%(95%CI13.2,34.8) among PLACE FSWs, which was significantly higher than that among RDS FSWs (8.6%,95%CI5.3,12.8). After excluding PLACE FSWs recruited at rural counties, there was no significant difference in the overall prevalence rate of a positive syphilis rapid test between RDS FSWs and PLACE urban FSWs. The prevalence rate of a positive syphilis rapid test was the highest among rural FSWs (34.4%,95%CI17.0,51.8).
Conclusions:In the absence of a gold standard, it is difficult to judge the representativeness of the samples produced by different methods. In the surveillance and investigation of hidden populations, it is especially important to reach all segments of the target population. In urban Liuzhou, RDS found a more hidden group of FSWs who only solicited through telephone which was not found by PLACE and more FSWs who were in less contact with HIV prevention activites and services. Thus, we recommend that in areas where venue-based method is the routine practice for surveillance and intervention activities, efforts should be taken to learn the dynamics of local sex work industry. If a substantial proportion of FSWs only solicit clients through more hidden ways such as telephone or internet, findings from a hybrid method combining venue-based method and RDS could collect more accurate data for surveillance and provide more information upon which to make program and policy decisions. However, more research is needed to test the applicability of RDS in the context of rural sex work industry. More serious epidemic of syphilis in rural counties warrants more enhanced interventions. FSWs who solicited through telephone and public outdoor venues are even less accessible and at higher risk of HIV/STI. Focued interventions are urgently needed.
目的：本研究同时在FSWs人群中应用RDS方法和一种基于场所的方法,通过比较这两种方法获得的FSWs人群的特征,对RDS做出评价,并为当地的监测和防治工作提供参考信息。
方法：于2009年10月至2010年1月,在广西壮族自治区柳州市FSWs人群中同时开展两个平行的横断面调查,一边应用RDS方法,由7名种子开始,利用FSWs人群的社会网络由同伴招募研究对象；另一边应用一种基于场所的方法-PLACE (Priorities for Local AIDS Control Efforts, PLACE),通过调查社区和场所知情人获得一个场所抽样框架,从中抽取一定数量的场所,然后从这些场所招募研究对象。通过面对面问卷调查收集人口学特征、性行为、毒品使用、性工作等信息,采集调查对象的手指血进行梅毒螺旋体特异性抗体检测。RDS调查的数据采用专门的分析工具进行总体率的点估计和区间估计。PLACE数据根据抽样策略和场所及个体水平参加调查的比例产生相应的抽样权重,在分析中对数据进行加权分析。通过比较两个方法获得的FSWs特征指标估计值的置信区间是否重叠来判断有无统计学差异。
结果：RDS共招募583名合格的FSWs, PLACE共招募161名合格的FSWs。RDS与PLACE发现了明显不同的FSWs人群特征。RDS仅招募到2.5%(95%CI1.4,3.8)居住在郊县的FSW,而49.7%(95%CI49.3,50.1) PLACE FSWs居住在郊县。RDS发现了7.6%(95%CI3.3,12.5)在最近6个月里只通过电话招揽客人的FSWs和更多的在公园、街头等户外场所招揽客人的FSWs,而PLACE没有发现只通过电话招揽客人的FSWs。与基于娱乐场所的FSWs相比,只通过电话招和在公园、街头等户外场所招揽客人的FSWs的梅毒快速检测结果阳性率更高,安全套使用率较低,曾在性工作场所内接触过HIV防治活动也较少。79.4%(95%CI68.8,90.1)的PLACE FSWs曾在性工作场所内接触过HIV防治活动,明显高于RDS FSWs (48.2%,95%CI42.7,53.2)。PLACE FSWs中的梅毒快速检测结果阳性率为24.0%(95%CI13.2,34.8),明显高于RDS FSWs的阳性率(8.6%,95%CI5.3,12.8)。当去除PLACE郊县的FSWs后,RDS FSWs与PLACE市区FSWs的梅毒总体阳性率不再有显著差别。PLACE郊县FSWs的梅毒快速检测结果阳性率最高,为34.4%(95%CI17.0,51.8)。
结论：由于缺乏一个金标准,因此很难对两方法获得的FSWs样本的代表性做出评价。在针对隐匿人群的调查和监测中,更重要的是能够接触到目标人群的各个部分。在柳州市区,RDS发现了更为隐蔽的只通过电话招揽客人的FSWs,而PLACE没有发现这部分FSWs。因此,在常规采用基于场所的方法开展HIV/STIs监测和干预活动的地区,可在前期调查中了解本地性行业的变化动态,如果相当一部分FSWs只是通过电话、网络等更隐匿的方式招揽客人,则可采取基于场所的方法和RDS相结合的方法,获得更广泛多样的FSWs样本,为监测活动提供更准确的数据,从而为制定防治项目和干预政策提供更丰富的信息。但是,RDS在郊区环境下的适用性尚需进一步研究。郊县的梅毒流行情况更加严重,需要加强干预活动。电话和站街FSWs更加隐匿,感染性病艾滋病的风险也更高,需要采取针对性的措施加强干预工作。
Backgroud:Globally, HIV/STIs epidemic is a very important public health problem. Many hidden populations with high risk behaviors, such as female sex workers (FSWs), men who have sex with men (MSM) and injecting drug users (IDU), have been disproportionately affected by the HIV/STIs epidemics in many parts of the world including China. Accurate and precise data on the behaviors in these at-risk populations is critical for understanding and tracking the direction of the epidemic, planning and evaluating effective intervention responses. Methods commonly used for sampling these populations include venue-based sampling and respondent-driven sampling (RDS). RDS was modified from chain-referral sampling and first introduced by Heckthorn in1994. It has been increasingly applied in recent years. But few empirical research have evaluated RDS in concurrent comparison with other methods.
Objectives:To evaluate RDS through concurrent implementation and comparison of two sampling method, RDS and a venue-based sampling method, among FSWs. And to provide information for local HIV/STIs control efforts.
Method:From October2009through January2010, two cross-sectional studies using RDS and a venue-based sampling method called "PLACE"(Priorities for Local AIDS Control Efforts, PLACE) respectively were simultaneously conducted among FSWs in Liuzhou city, Guangxi Zhuang Autonomous Region. RDS sampling process started with seven seeds and participants were referred by peers through FSWs' social networks. For PLACE, a venue sampling frame was constructed through interviews with community and venue informants. A subset of venues was sampled from the sampling frame and participants were recruited at selected venues. Information on socio-demographic characteristics, sexual behaviors, drug use behaviors and sex work were collected through face-to-face interviews. Syphilis rapid test was employed to test Treponemal pallidum specific antibodies using finger-prick whole blood specimens. RDS data was analyzed using Respondent-driven sampling analysis tool to produce adjusted population propotions and confidence intervals. PLACE data was weighted incorporating sampling strategies and participation rate at venue and individual level to generate population estimates. Overlaps in confidence intervals around each of the two samples'population estimates were compared to examine significant differences at a significance level of5%.
Results:A total of583and161eligible FSWs were recuited in RDS and PLACE respectively. The two methods found significant different population characteristics. RDS only recruited2.5%(95%CI1.4,3.8) FSWs who resided in rural counties, while49.7%(95%CI49.3,50.1) PLACE FSWs resided in rural counties. RDS found a group of FSWs who only solicited though telephone in the past six months and a greater proportion of FSWs who solicited at public outdoor venues. RDS estimated that telephone-based FSWs accounted for7.6%(95%CI3.3,12.5) of the total FSWs population. In contrast, PLACE did not find any FSWs who only solicited through telephone. Compared with FSWs based in establishments, FSWs who only solicited through telephone or at public outdoor venues had higher rate of a positive syphilis rapid test results, relatively lower rate of condom usage, and less exposure to HIV prevention activites at sex work venues.79.4%(95%CI68.8,90.1) PLACE FSWs had experienced HIV prevention activities at sex work venues, which was considerably higher than that among RDS FSWs (48.2%,95%CI42.7,53.2). The overall prevalence rate of a positive syphilis rapid test was24.0%(95%CI13.2,34.8) among PLACE FSWs, which was significantly higher than that among RDS FSWs (8.6%,95%CI5.3,12.8). After excluding PLACE FSWs recruited at rural counties, there was no significant difference in the overall prevalence rate of a positive syphilis rapid test between RDS FSWs and PLACE urban FSWs. The prevalence rate of a positive syphilis rapid test was the highest among rural FSWs (34.4%,95%CI17.0,51.8).
Conclusions:In the absence of a gold standard, it is difficult to judge the representativeness of the samples produced by different methods. In the surveillance and investigation of hidden populations, it is especially important to reach all segments of the target population. In urban Liuzhou, RDS found a more hidden group of FSWs who only solicited through telephone which was not found by PLACE and more FSWs who were in less contact with HIV prevention activites and services. Thus, we recommend that in areas where venue-based method is the routine practice for surveillance and intervention activities, efforts should be taken to learn the dynamics of local sex work industry. If a substantial proportion of FSWs only solicit clients through more hidden ways such as telephone or internet, findings from a hybrid method combining venue-based method and RDS could collect more accurate data for surveillance and provide more information upon which to make program and policy decisions. However, more research is needed to test the applicability of RDS in the context of rural sex work industry. More serious epidemic of syphilis in rural counties warrants more enhanced interventions. FSWs who solicited through telephone and public outdoor venues are even less accessible and at higher risk of HIV/STI. Focued interventions are urgently needed.
引文
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