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

背景资料：我们建议进行一项早期研究，以制定干预措施，解决自我报告的“异常阴道分泌物”（AVD）这一全球范围内尤其是南亚地区高度流行的综合征的公共卫生问题。AVD是一个公共卫生问题，因为它可能是性传播感染的信号，如淋病、衣原体或滴虫病，或内源性生殖道感染，如细菌性阴道病或念珠菌病。世界卫生组织提倡使用AVD的综合征管理指南（在综合征指南中称为阴道分泌物综合征），该指南遵循逐步方法，在实验室设施不可用的低资源环境中检测和管理感染。然而，现在公认的是，综合征的方法是一个穷人的预测感染，特别是性传播的和流程图导致相当多的抗生素治疗。此外，在南亚，有复杂的文化和心理社会因素与AVD的投诉有关。它可能与传统的阿育吠陀信仰有关的重要性体液。AVD意味着由于各种身体和心理社会原因，如虚弱、忧虑、“骨骼融化”和“性滥交”，导致重要体液的流失，印度、孟加拉国和斯里兰卡的妇女在不同的研究中表示了这一点。印度和巴基斯坦的研究发现，AVD与心理健康问题（大多数是轻度和中度问题）之间存在很强的关联，这些问题可能与妇女经历的压力，社会冲突，性别劣势，贫困和婚姻不和有关。事实上，有人认为，AVD是南亚妇女痛苦的一种文化习惯用语，在那里寻求心理健康护理是耻辱的。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，印度一般人群中高达30%的妇女和孟加拉国近50%的孕妇报告了这一情况。因此，在这些情况下，其管理应该是医疗保健的优先事项。随着（a）细菌性阴道病、念珠菌病和滴虫病的快速诊断或护理点检测的可用性，（B）在初级保健环境中进行精神健康筛查的有效工具和（c）精神保健的分级护理模式已证明是成功的（由受过训练的非专业医护人员为有轻微精神健康问题的病人提供基本的心理辅导，而医生和专科医生则负责处理严重的个案），亚洲需要转型。我们在这项研究中的目的是开发一种干预措施，将这三个要素（以及衣原体和淋病的分子检测评估为性风险）整合在一种新的风险评估工具或协议中，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。研究方法：使用定性研究方法，我们将探讨AVD的看法和目前的做法，在社区和卫生工作者中的妇女谁是他们最寻求AVD。将与卫生系统的其他利益攸关方进行访谈，包括医务人员、妇女健康专家、心理健康专家和实验室工作人员，以了解卫生系统在实验室和病人管理程序运作方面的需求。我们将与一小组选定的当地专家和卫生部门工作人员密切合作，制定修订后的评估工具，并在20名卫生工作者（通过与妇女和卫生部门工作人员协商确定）和40名患有AVD的妇女中实施，这些妇女将在3个月和6个月时接受随访。将分析其结果（自我报告的AVD、感染和心理健康），并使用利益相关者访谈进行最终过程评价，从而制定干预试点计划纲要。

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.