Development of an intervention for improved management of self-reported abnormal vaginal discharge by women in rural north India.

制定干预措施，以改善印度北部农村妇女自我报告的异常阴道分泌物的管理。

• 批准号: MR/T026979/1
• 负责人: Meenakshi Gautham
• 金额: $ 19.32万
• 依托单位: London School of Hygiene & Tropical Medicine
• 依托单位国家: 英国
• 项目类别: Research Grant
• 财政年份: 2021
• 资助国家: 英国
• 起止时间: 2021 至 无数据
• 项目状态: 已结题
• 来源: https://gtr.ukri.org/projects?ref=MR%2FT026979%2F1
• 关键词: Development; intervention; improved; management; self

Background: We propose an early phase study to develop an intervention to address the public health issue of self-reported 'abnormal vaginal discharge'(AVD), a highly prevalent syndrome worldwide and in South Asia in particular. AVD is a public health concern as it may signal a sexually transmitted infection like gonorrhoea, chlamydia or trichomoniasis, or an endogenous reproductive tract infection like bacterial vaginosis or candida. The World Health organization has advocated use of syndromic management guidelines for AVD (referred to as vaginal discharge syndrome in the syndromic guidelines) which follows a stepwise approach to detect and manage infections in low resource settings where laboratory facilities are unavailable. However it is now accepted that the syndromic approach is a poor predictor of infections, especially the sexually transmitted ones and the flowcharts lead to considerable over treatment with antibiotics. Moreover in South Asia, there are complex cultural and psychosocial factors associated with the complaint of an AVD. It may be linked with traditional Ayurvedic beliefs about the importance of bodily fluids. AVD signifies the loss of vital bodily fluids resulting from various physical and psychosocial causes like weakness, worry, 'melting of bones' and 'sexual promiscuity', as expressed by women in different studies in India, Bangladesh and Sri Lanka. Studies in India and Pakistan have found strong associations between AVD and mental health problems (mostly mild and moderate ones) that could be linked with stress, social conflicts, gender disadvantage, poverty and marital discord that women experience. In fact it has been suggested that AVD is a cultural idiom of distress among women in S.Asia where seeking care for mental health is stigmatised. AVD is a common reproductive complaint of women in India, Bangladesh, Nepal and Sri Lanka, reported by up to 30% women in the general population in India and nearly 50% of pregnant women in Bangladesh. So its management should be a healthcare priority in these settings.With the availability of (a) Rapid Diagnostics or Point of Care tests for bacterial vaginosis, candida and trichomoniasis, (b) validated tools for mental health screening in primary care setting and (c) proven success of a stepped care model of mental healthcare (in which trained lay health workers provide a basic level of psychosocial counselling to patients with mild mental health problems and doctors and specialists manage the severe cases), the management of AVD in S. Asia calls for a transformation. Our aim in this study is to develop an intervention that integrates these three elements (together with molecular testing for chlamydia and gonorrhoea for those assessed to be at sexual risk) in a novel risk assessment tool or protocol and compare this revised tool with syndromic management in a future trial. Methods: Using qualitative research methods we will explore AVD perceptions and current practices amongst women in the community and health workers who are most sought by them for AVD. Interviews with other stakeholders in the health system including medical officers, women's health specialists, mental health experts and laboratory staff will be conducted to understand health system needs with respect to operationalising the laboratory and patient management procedures. Working closely with a small group of selected local experts and health department staff, we will develop the revised assessment tool and implement this with 20 health workers (identified through consultations with women and health department staff) and 40 women presenting with an AVD, who will be followed up at 3 and 6 months. Their outcomes (self-reported AVD, infections and mental health) will be analysed and a final process evaluation using stakeholder interviews will lead to an outline of a plan for piloting the intervention.

背景：我们建议进行一项早期研究，以制定一项干预措施，以解决自我报告的“阴道分泌物异常”（AVD）的公共卫生问题，这是一种在世界范围内，特别是在南亚非常普遍的综合征。AVD是一个公共卫生问题，因为它可能是淋病、衣原体病或滴虫病等性传播感染的信号，也可能是细菌性阴道病或念珠菌病等内源性生殖道感染的信号。世界卫生组织提倡使用AVD综合征管理指南（在综合征指南中称为阴道分泌物综合征），该指南遵循一种分步方法，在缺乏实验室设施的资源匮乏环境中发现和管理感染。然而，现在人们接受的观点是，综合征方法不能很好地预测感染，尤其是性传播感染，而且流程图会导致相当大的抗生素过度治疗。此外，在南亚，有复杂的文化和社会心理因素与AVD的主诉有关。这可能与传统阿育吠陀关于体液重要性的信仰有关。在印度、孟加拉国和斯里兰卡进行的不同研究中，妇女表示，AVD是指由于各种身体和社会心理原因造成的重要体液流失，如虚弱、担忧、“骨头融化”和“滥交”。印度和巴基斯坦的研究发现，AVD和精神健康问题（大多是轻度和中度的）之间存在很强的联系，而精神健康问题可能与女性所经历的压力、社会冲突、性别劣势、贫困和婚姻不和谐有关。事实上，有人认为，在寻求心理健康治疗被污名化的亚洲，AVD是一种对女性痛苦的文化习语。AVD是印度、孟加拉国、尼泊尔和斯里兰卡妇女常见的生殖疾病，在印度的普通人群中有高达30%的妇女报告患有AVD，在孟加拉国有近50%的孕妇报告患有AVD。因此，在这些环境中，其管理应该是医疗保健的优先事项。有了(a)细菌性阴道病、念珠菌病和滴虫病的快速诊断或即时检测，(b)在初级保健机构中进行精神健康筛查的有效工具，以及(c)精神保健分步护理模式（训练有素的非专业卫生工作者向轻度精神健康问题患者提供基本的心理社会咨询，医生和专家管理重症病例），东南亚的AVD管理需要转型。我们在这项研究中的目的是开发一种干预措施，将这三种因素（连同衣原体和淋病的分子检测，用于评估有性风险的人）整合到一种新的风险评估工具或方案中，并在未来的试验中将这种修订后的工具与综合征管理进行比较。方法：采用定性研究方法，我们将探讨社区妇女和卫生工作者对AVD的看法和目前的做法，她们最寻求AVD。将与卫生系统中的其他利益攸关方进行面谈，包括医务官员、妇女卫生专家、精神卫生专家和实验室工作人员，以了解卫生系统在实验室运作和患者管理程序方面的需求。我们将与选定的一小群当地专家和卫生部门工作人员密切合作，开发修订后的评估工具，并在20名卫生工作人员（通过与妇女和卫生部门工作人员协商确定）和40名患有急性口炎的妇女中实施，将在3个月和6个月时对她们进行随访。将分析其结果（自我报告的AVD、感染和心理健康），并利用利益攸关方访谈进行最后的过程评估，从而制定一项试点干预计划大纲。