| BackgroundIn the recent years, with sustained and rapid growth of the incidence of sexually transmitted diseases (STD) in China, it has become a major public health problem and aroused great concern. Foreign related data display that it is also an important auxiliary factor of HIV communication. The reported incidences of STD in Shanghai, eastern China have ranked first in the country since1997and reached up to316.59/10in2000, also Shanghai is one of the largest metropolitan areas in China where the HIV/AIDS transmission route is largely attributed to heterosexual contact. Therefore, to understand the epidemiological characteristics among STD patients is urgently needed for providing a basis for formulating STD/AIDS preventive interventions.It was reported that a lot of STD patients with the characteristics of low level of related knowledge, high incidence of unsafe sex,and low frequency of condom use. Affected by social discrimination, the burden of disease and other factors, the physical and mental health status, the life quality of STD patients was affected to some extent. Whether the STD patients can accept standardized and timely treatment is essential to the patients’ treatment and prognosis, as well as the prevention and control of epidemic speed of STD.Because the KAP statuses about STD/AIDS are sensitive issue areas involving personal privacy, many patients will intentionally concealed their high-risk sexual behaviors,it is difficult to avoid non-response bias, reporting bias by using traditional direct questioning method. To avoid the defects of traditional survey methods, Warner proposed the first randomized response technique, Warner Model(Two related problems model) in1965. In1967, Simmons improved on the Warner model, proposed the two unrelated model,named Simmons model.Objectives1. Design the questionnaire on epidemiological characteristics for patients with STD, QECP-STD, for the understanding of epidemiological characteristics patients with STD (including STD related knowledge, attitudes, high risk behaviors, health seeking behaviors, treatment satisfaction, mental health status and quality of life conditions, etc.). KAP, SCL-90, DLQI parts from QECP-STD will be evaluated on reliability and validity for the future investigations in similar populations. 2. To assess STD related knowledge, attitudes, risk communication behaviors, health seeking behaviors, treatment satisfaction, mental health status and quality of life conditions and to explore the influencing factors and the influencing path, to offer targeted, feasible intervention strategies and measures for STD patients.3. Try to use the the relatively insensitive to or low sensitive questions to discriminate and forecast the occurrence condition of sensitive high-risk behaviors.4. Use the RRT survey methods to survey STD related high-risk attitudes and behaviors, compare the results which from RRT models and from traditional anonymous self-administered survey method and anonymous interview survey method, to investigate the validity and the feasibility of RRT among STD patients.Methods1. Investigation on the epidemiological characteristics of STD patientsThe study samples included a total of519clinically diagnosed STD patients systematic randomly selected from three different types of hospitals in Shanghai city and Wuxi city from2010to2011. The contents included general demographic characteristics (including birth date, gender, household registration status, educational level, socio-economic status, occupation, the diagnosis and types of STD, and disease stage), STD/AIDS-related knowledge, attitudes, high-risk behaviors intention and high-risk behaviors (including non-marital sex, sex partners, condom use, etc.), seeking behaviors(seek medical attention orientation, improper seeking behaviors, referral experience, clinics spend, etc.), treatment satisfaction, mental health status, quality of life conditions and so on.2. Investigation on survey methodologyThe study samples included a total of623clinically diagnosed STD patients systematic randomly selected from three different types of hospitals in Shanghai city and Wuxi city from2011to2012. These outpatient STD patients were simple randomly divided into four groups A, B, C, and D. The two related problems model (Warner model) and the numeric variables unrelated model, the two unrelated problems model (Simmons model) and the numeric variables unrelated mode, the anonymous face to face interview method, the anonymous self-administered survey method were used in group A, B, C, and D respectively.The contents included general demographic characteristics(gender, household registration status, education level, age, marital status, etc.), some high risk attitudes and behaviors (premarital sex, extramarital sex, commercial sex, having sex even after suspected of being infected with STD, attitudes towards premarital sex and extramarital sex, the number of non-marital sexual partners),etc.3. Data collation and analysisAfter the questionnaires had been collated, Epidata3.02software was used for the establishment of database, SPSS17.0, SAS9.1and Amos20.0software were used for statistical analysis.Compositions of rates and constituent ratios were analyzed by chi-square test, the trend analysis’s of rates were used by the Cochran Armitage trend tes, the t-test, analysis of variance, linear regression analysis were used for normal distribution variables, ank sum test, rank correlation analysis were used for skewed distribution variables, multiple regression, multivariate logistic regression analysis, path analysis, discriminant analysis, structural equation modeling and the RRT model Probabilistic Inference formula were also used for different research purposes and data.Main Results1. The vast majority of patients were young adults, male, married and from towns, the average score of the STD-related knowledge was25.41±4.87, STD patients had relatively low recognition rates on the occurrence of parts of STD, clinical characteristics, the possibility of infection during incubation period, self-protection, the ability of sexually transmitted diseases, rational drug use, indirect transmission pathways of daily life and some routes of transmission such as mosquito bites.2. Only22.2%and63.0%of patients were opposed to premarital sex and extramarital sex, males were significantly lower than female.Factors that affect the overall attitudes situation related to STD in order of importance were STD knowledge score, gender, STD history (negative factor), it showed that through improving STD patients’cognitive level may cause attitudes tend to be more actively.75.8%of the patients had premarital sex,57.1%of patients had extramarital sex,77.5%of the patients had more than2sexual partners. Factors that affect the overall status of high-risk behaviors among STD patients in order of importance were gender (negative factor), marital status, age (negative factor), non-marital sex attitude scores (negative factor), STD history, personal monthly income and so on.3. The average SCL-90total score was136.19±40.25, the average socres of depression, anxiety, psychosis were higher than the norm of Chinese adults, depression and anxiety symptoms among female patients were more severe; SCL-90total scores were negatively correlated with age. Each SCL-90symptom score of the patients in typical clinical symptoms period was higher than which in the other clinical stages except hostile (P<0.05). There was a significant difference on the average SCL-90total scores among the patients with different types of STD, the psychological status of patients with genital herpes and syphilis was relatively poor.The quality of life in aspects of sex life, treatment, study and work, psychological and physiological was severely affected, The average DLQI total score was9.96±6.14,43.2%of patients reported severe or above effects on the impact of quality of life, the overall quality of life among STD outpatients was poorer than acne, vitiligo and other skin diseases; DLQI total scores were negatively correlated with age; Each DLQI symptom score of the patients in typical clinical symptoms period was higher than which in the other clinical stages except sex life and treatment (P<0.05). Female, unmarried, younger patients had lower life quality level than male, married, elder patients respectively. There was a significant difference on the average DLQI total scores among the patients with different types of STD, the life quality status of patients with genital herpes and gonorrhea was relatively poor.There was incomplete positive correlation between SCL-90total score and DLQI score, The multivariate analysis showed that if patients had more severe psychological symptoms on psychosis, sleep and diet, depression, paranoia, might get the higher DLQI total scores.The results of path analysis showed that the direct influencing factors of life quality included age, number of symptoms, cognitive status of STD, mental health status,etc, the indirect influencing factors included household registration status, age, number of symptoms, education level, cognitive status of STD,etc.4. We found that there had been a considerable proportion of improper health-seeking behaviors among STD outpatients, for example, treatment delay rate accounted for51.4%,Average initial treatment interval accounted up to8days, only69.0%of patients notified or would notify their regular sexual partners,34.8%of the patients’ regular sexual partners did not go to seek diagnosis and treatment,25.8%of patients used drugs by themselves without a diagnosis;8.7%of the patients had been to undocumented clinics for diagnosis and treatment of STD;9.2%of the patients had been to undocumented pharmacies to buy drugs for STD treatment. The influencing factors of improper health seeking behaviors included gender, knowledge of STD prevention and treatment, household categories, education levels, income levels, self-reported infection routes, the distance to visiting hospitals.5. By using Warner model and Simmons model, we got the higher positive rates on the incidence rates of extramarital sex, commercial sex and negative rate on attitude towards extramarital sex compared with traditional anonymous self-administered survey method and anonymous interview survey method, these questions were always contrary to the traditional moral values and the rule of law norms. By using the numeric variables unrelated model, we estimated that the average number of non-marital sexual partners among STD patients had also been significantly higher than the results of the two traditional methods. It showed that the RRT models could protect the privacy of these respondents effectively and control reporting bias to some extent, improve the validity level on the investigation of highly sensitive issues.The two RRT models were acceptable, but may need to be improved by simplifying sampling and random response process, they both received high efficiency rates, indicating good feasibilities in the process of investigation.Discriminant analysis prediction models including the extramarital sex behavior model among the married patients, the commercial sex behavior model and the premarital sex behavior model among STD patients which had been constructed in this study were validated.Conclusions and Suggestions1. The level of cognitive rates among rural, married, older, less educated, lower income patients was relatively low, so they should be considered as focused populations for STD prevention education activities. Interventions should be designed by the forms of radio and television, free consultation, etc.2. The interventions on STD-related attitudes should focus on male patients, patients from rural areas, patients with lower education level or STD history.as well as those who were not infected by their own spouses. The intervention design on high-risk behaviors should also be based on the KAP and demographic characteristics of patients, for ensample, strengthening the safe sex and self-protection skills educations for the younger, higher education students population, unmarried urban youth, unmarried occupational groups with high income levels. Among those older patients, patients from rural areas or with lower education, lower income levels, it should not only strengthen the skills training on the proper use of condoms, but also guide them to identify and select a safe medical practices.3. Psychological health screening, the assessment on quality of life, psychological intervention, knowledge and skills training on improving the quality of life should be carried out simultaneously with clinical treatments, targeted intervention programs should be combined with age, marital status gender, type of disease, clinical stage, etc.4. Strengthening the education of STD prevention&treatment knowledge and improving service availability were key links to reduce treatment delays; Promoting partner notification and regular sexual partners’ diagnosis and treatment should focus on male patients, especially them through which non-marital sex infection routes, as well as patients with lower education levels. It was recommended to conduct targeted psychological counseling and intervention, and to improve the awareness and skills of partner notification;the health administrative departments should strengthen the supervision and management on prescription drug sales, as well as the education on the norms of medication in urban areas, strengthen the institutional supervision and management of STD clinics in rural areas.5. The RRT models could protect the privacy of these respondents effectively and control reporting bias to some extent, improve the validity level on the investigation of highly sensitive issues.By investigating insensitive or low sensitive questionss to construct discriminant analysis model to predict highly sensitive issues may be a good choice when RRT is difficult to implement. |
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