社会资本与艾滋病防制的关系及策略研究
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摘要
背景
近些年，社会资本理论已被国外学者广泛应用于健康问题的研究。然而，我国开展社会资本与健康问题的研究较少，与艾滋病相关问题的研究尚未见报道。我国艾滋病流行形势依然严峻，防治任务十分艰巨。社会资本作为一种无形的资源，可以有机的整合艾滋病防制(艾防)工作中的物质资本和人力资本等有形的资源，降低艾防工作成本，放大艾防工作功效，成为探寻解决公共卫生问题的“第三条道路”。
目的
了解微观层面(个体水平，本论文关注高危人群)、中观层面(组织水平)和宏观层面(国家水平)的社会资本现况；分析三个层面的社会资本与艾滋病防制的关系；探讨我国艾滋病防制领域社会资本综合开发和利用的策略。方法
微观层面：2010年9月~12月，采用方便抽样的方法，使用课题组设计的问卷，在安徽省通过面对面现场问卷调查的方法收集资料。定量资料采用Epi Data3.0软件进行数据录入；使用SPSS13.0开展描述性统计分析、单因素和多因素二分类非条件logistic回归分析；使用AMOS20.0进行验证性因子分析。
中观层面：在艾滋病高、中、低流行地区各选取2个省，分别是广西壮族自治区、云南省、山西省、湖南省、吉林省和安徽省。2012年4月至11月，对6省的省级艾滋病防治委员会办公室(艾办)和成员单位的关键知情人进行问卷调查和深入访谈。在安徽省选择江淮同心工作组(工作组)和萧县孙圩子社区关怀救助小组(救助小组)两个草根组织开展案例分析。录音资料由调查员使用Word97软件转录成文本资料。使用SPSS13.0开展探索性因子分析和相关分析。
宏观层面：使用世界价值观调查、世界银行组织、联合国艾滋病规划署和世界卫生组织官方网站的既往统计资料，应用SPSS13.0开展多元线性回归分析。
结果
微观层面主要结果：(1)实际调查到女性性工作者583人、美沙酮维持治疗人员508人和男性同性性行为者(Men who Have Sex with Men，MSM)369人。前两类人群已由另两名硕士研究生完成。本论文只重点介绍MSM人群的调查结果。(2)调查的MSM人群的基本特征。超过半数(52.85%)的调查对象年龄在25岁及以下，大多数(69.92%)没有结过婚，接近半数(46.34%)的月收入在1001~2000元，绝大多数来自本地(72.90%)。(3)调查的MSM人群的社会资本现况。社会资本4个核心构成要素分别为组织参与、社会支持、信任和朋友网络。其中社会支持和信任因子高水平的比例较高，分别为68.56%和50.68%。组织参与因子情况：超过半数的调查对象没有参加任何组织(52.03%)以及没有参加过组织开展的活动(55.56%)，经常参加“社区”活动的较少占16.53%；社会支持因子：遇到困难总能得到经济上帮助的比例(17.61%)要低于总能获得精神上支持的比例(31.98%)；信任因子：调查对象表示完全信任父母\亲戚\朋友的比例最高(42.28%)，完全信任身边大多数人的比例最低(10.57%)；朋友网络因子：接近半数(48.51%)的调查对象密切交往的朋友数为≥5，密切交往的朋友职业种类以1~2种为主(72.09%)，密切交往的朋友关系种类≥3的较少(27.10%)。(4)调查的MSM人群的艾滋病防制效果。艾滋病基本知识总体知晓率为89.16%，条目2：“蚊虫叮咬会传播艾滋病吗？”的知晓率最低(74.25%)；最近六个月有偶然性伴的147人(39.84%)；最近一次性行为使用安全套的有188人(50.95%)。(5)社会资本与调查的MSM人群的艾滋病防制效果的关系。完全信任和基本信任自己父母\亲戚\朋友的调查对象知晓艾滋病基本知识的可能性分别是完全不信任的8.47倍(P=0.044)和5.54倍(P=0.015)。完全信任疾控中心工作人员的调查对象知晓艾滋病基本知识的可能性是完全不信任的8.48倍(P=0.039)。参加组织数量≥2个的调查对象最近一次性行为使用安全套的可能性是从未参加的3.27倍(P=0.002)，经常参加组织活动和“社区”活动的调查对象最近一次性行为使用安全套的可能性是从不参加的3.12倍(P<0.001)和3.27倍(P<0.001)；参加MSM志愿者组织的最近一次性行为使用安全套的可能性是不参加的3.10倍。密切交往的朋友职业种类和关系种类越多最近一次性行为安全套使用的可能性就越大。遇到困难不能完全得到精神支持的调查对象拥有偶然性伴的可能性是总能得到支持的1.96倍(P=0.008)。(6)社会资本对三类高危人群艾滋病防制影响的总体情况。社会资本测量条目对艾滋病防制效果的影响因高危人群而异。
中观层面主要结果：(1)问卷调查了6省艾办及成员单位关键知情人79人，深入访谈关键知情人89人。(2)调查地区艾办及成员单位社会资本现况。本研究从网络与参与、规范、信任、共同语言和共同愿景5个维度测量了调查地区艾办及成员单位的社会资本。调查地区艾办及成员单位信任因子高水平比例最高(69.62%)，规范因子高水平比例最低(37.97%)。网络与参与因子：各部门联络员在艾防工作中经常见面的比例最低(20.25%)；规范因子：当前艾防工作尚未建立有效的奖惩制度；信任因子：表示信任艾办工作的能力的比例最高(88.61%)；共同语言因子：大部分了解其他成员单位艾防工作职责的比例最低(44.30%)；共同愿景因子：对国家和省级重大艾防政策或活动表示高度认同的比例最高(81.01%)。(3)调查地区艾办及成员单位自评艾防工作情况。绝大多数调查部门(81.01%)对本部门艾防工作能力和效果表示满意，超过半数(59.49%)的表示对本部门艾防工作经费表示不满意。(4)社会资本与调查地区艾办及成员单位自评艾防工作的关系。信任与自评艾防工作能力、防治效果和防治经费满意度均相关，相关系数分别为0.303，0.317和0.341。(5)调查地区艾办及成员单位定性访谈结果。网络与参与因子：大部分调查对象表示目前尚未建立有效的协调机制和合作交流平台；部分非政府组织重视组织间的非正式合约关系，并激活了有形的艾防资源。规范因子：目前艾防工作尚未建立有效的奖惩制度，大多数调查对象表示有必要建立，以便规范各部门艾防工作。信任因子：大部分访谈对象表示相信艾办有能力协调艾防工作，低流行区少数调查对象表示不能认可艾办的工作。共同语言：低流行区的大部分调查对象表示基本掌握了艾防工作所需的基本知识和能力，不需要培训；而中、高流行区的部分访谈对象表示还需接受培训；大部分访谈对象表示不太清楚其他部门的艾防工作职责。共同愿景：大部分访谈对象表示认可国家和省级层面的艾防工作目标，部门之间艾防工作冲突的情况较少。(6)草根组织案例分析结果。工作组和救助小组的社会资本最突出的问题是“规范”因子水平较低，主要由于没有健全的组织体系和明确的规章制度。他们最大的优势是组织成员志愿精神较高，主动参与意识较强，发挥着正式组织不可替代的作用。
宏观层面主要结果：(1)2005~2009年的世界价值观调查中，我国的组织参与水平位于53个国家的第50位；信任水平位于第12位。(2)“组织参与水平”对HIV感染率(15-49岁)和抗病毒治疗覆盖率的影响有统计学意义。结论及策略建议
本研究主要结论：(1)社会资本在不同的高危人群中对艾滋病防制效果的影响也不同，尚未发现负面影响；(2)艾滋病防制相关人员普遍缺乏培育和利用“社会资本”的意识；(3)信任因子可以提高成员单位对艾防工作经费的满意度；(4)草根组织作为社会资本的重要来源，规范水平较低成为他们参与艾滋病防制工作的障碍；(5)国家层面社会资本与艾滋病防制的关系需要更多的研究进一步证明。
本研究提出以下社会资本综合开发和利用策略：(1)微观层面：积极培育个体水平的信任型社会资本，巩固高危人群艾滋病宣传教育的效果。充分开发亲缘中的社会资本，弥补艾防资源的不足。培育和利用结构型社会资本，增强高危人群艾防工作的长期效果。(2)中观层面：以制度建设为突破口、人际沟通为纽带，培育组织间的信任型社会资本，减少艾防工作的成本。以分类指导培训为突破口，培育共同语言型的社会资本，切实提高多部门开展艾防工作能力。以法制建设为突破口，培育规范型的社会资本，保证多部门合作机制的落实。以搭建现代化的艾防工作信息平台为突破口，培育网络与参与型社会资本，创新艾防工作的手段。以壮大艾防工作中的社会组织力量为突破口，培育公民社会型的社会资本，创新艾滋病防制模式。(3)宏观层面：树立社会资本意识，在顶层设计层面保证社会资本的开发和利用。重视社会资本和其他社会因素对艾滋病防制工作的共同作用。
Background
In recent years, the theory of social capital had been widely used in the field of healthby foreign researchers. However, fewer studies of social capital and health had beenconducted in our country. Moreover, social capital theory had not been introduced intoAIDS (Acquired Immune Deficiency Syndrome)/HIV (Human ImmunodeficiencyVirus) related issues in China to our knowledge. The epidemic situation of HIV/AIDS inour country is still rigorous, and its prevention and control is an arduous task. Socialcapital, as an intangible resources, could organically combine physical capital, humancapital and other tangible resources. It could reduce the cost and enlarge theeffectiveness of HIV/AIDS prevention and control. So it may be the “Third way” toresolve the public health issues.
Objectives
To Understand the micro-level (individual level, the paper focused on most-at-riskpopulation, MARP), the meso-level (organizational level) and the macro-level (nationallevel) social capital status; to analyze the impacts of social capital on the HIV/AIDSprevention and control from the above three perspectives; to explore the strategies fordeveloping and utilizing social capital in the field of HIV/AIDS prevention and controlin China.
Methods
Micro-level: from September2010to December, study participants identified by meansof convenient sampling method were interviewed by face to face using self-developedquestionnaire in Anhui Province. We input the quantitative data using Epi Data3.0and carried out univariate and multivariate binary non-conditional logistic regressionanalysis using SPSS13.0. We carried out confirmatory factor analysis using AMOS20.0.Meso-level: A total of six provinces were included in the study, two of them beingselected from each of the high, middle, and low prevalence of AIDS epidemic area, i.e.Guangxi Zhuang Autonomous Region, Yunnan province, Shanxi province, Hunanprovicne, Jilin province and Anhui province. From April2012to November, weconducted a questionnaire survey and in-depth interviews with key informants of theprovincial HIV/AIDS Committee Office (PAHCO) and its member organizaions. Wecarried out case study of “Jianghuai Tongxin Working Group”(Working Group) and“Xiao County Sunweizi Community Care Assistance Team”(Assistance Team). Wetranscribed recording data into text data by the Word97software. We carried outexploratory factor analysis and correlation analysis by SPSS13.0.Macro level: We conducted the multivariate linear regression analysis for the statisticdata from the World Values Survey, the World Bank, UNAIDS and the World HealthOrganization official website using SPSS13.0.
Results
Micro-level results:(1)583FSWs (female sex workers),508subjects participatingMMT (methadone maintenance treatment) and369MSM (Men who have sex with Men)were included in this study. The first two MARP were done by another two graduates ofour team. Therefore, this thesis focused only on the findings of the MSM population.(2)The general characteristics of the MSM in our study. More than half (52.85%) ofrespondents aged25years old and below. The majority (69.92%) were not married;Nearly half (46.34%) of the monthly income were in1001to2000. The vast majoritywere from the local (72.90%).(3) Social capital status of study participants of MSM.The four core factors of social capital were respectively membership and involvement,social support, trust and friends network. The proportion of social support factor andtrust factor with high level score were68.56%and50.68%, respectively. Membership and involvement factor: more than half of the respondents did not participate in anyorganization (52.03%), and did not participate in organized activities (55.56%).16.53%of respondents often participate in community activities. Social support factor: whenencountered difficulties,17.61%of respondents can always get economic help less thanthat can always get moral support (31.98%). Trust factor: the proportion of respondentswho trust completely their parents\relatives\friends was the highest (42.28%). Theproportion of respondents who trust completely most people was the lowest (10.57%).Friends network factor: nearly half (48.51%) of the respondents have≥5close friends.72.09%of respondents have close friends with1~2occupational categories.27.10%ofrespondents have≥3kinds of relationship with close friends.(4) The effects ofHIV/AIDS prevention and control for respondents.89.16%of respondents correctlyanswered≥6AIDS-related questions.74.25%of the respondents (46.6%) knew that“Item2: HIV could not be transmitted by mosquito bites”.39.84%of respondents hadcasual partners in the last months.50.95%of respondents used condoms in the lastsexual behavior.(5) The association of social capital and HIV/AIDS prevention andcontrol. Complete trust (OR=8.47, P=0.044) and general trust (OR=5.54, P=0.015) intheir parents\relatives\friends were associated with higher AIDS-related knowledgelevel. Complete trust in CDC staff associated with higher AIDS-related knowledge level(OR=8.48, P=0.039).≥2membership, often participating organization (OR=3.27,P=0.002) and community activity (OR=3.27, P<0.001), and member of MSM voluntaryorganization (OR=3.10, P<0.001) were associated with higher probability of condomuse in the last sexual behavior. More occupational category and relationship type ofclose friends were associated with higher probability of condom use in the last sexualbehavior. Not always completely get the moral support were associated with higherlikely to have casual partners (OR=1.96, P=0.008).(6) The overall descriptives ofeffects of social capital on the HIV/AIDS related issues among MARP. The impact ofthe items of social capital on AIDS prevention and control varied due to different risk-groups.
Meso-level findings:(1)79key informants from the PAHCO and its memberorganizations were included in the survey and89participated in-depth interview.(2)Social capital status of PAHCO and its member organizations: in this study, wemeasured organizational social capital from five factors of the network and participation,norms, trust, common language and shared vision. The proportion of high level trustwas the highest (69.62%) among the five factors. The high level of norms was thelowest (37.97%). The factor of network and participation: the proportion of respondentswho meet regularly the co-coordinators of the other member organizations for the workof HIV/AIDS prevention and control was the lowest (20.25%). The factor of norms:effective system of rewards and penalties has not been established; The factor of trust:the proportion of respondents trusting the ability of PAHCO was the highest (88.61%).The factor of common language: the proportion of respondents who mostly knew theresponsibility of the other member organizations was the lowest (44.30%). The factor ofshared vision: the proportion of respondents who recognized the national and provincialpolicy or activities was the higest (81.01%).(3) Self-assessment HIV/AIDS preventionand control work of PAHCO and its member organizations. The vast majority of surveydepartments (81.01%) expressed satisfaction with their capacity and effectiveness ofHIV/AIDS prevention and control. More than half (59.49%) of the survey departmentswere dissatisfied with their funds of HIV/AIDS prevention and control.(4) The impactsof social capital on the self-assessment of HIV/AIDS prevention and control. Trustcorrelated with self-rate satisfaction of the ability, effect and funds of HIV/AIDSprevention and control (r=0.303,0.317and0.341).(5) The outcome of qualitativeinterviews. Network and participation: Most of the respondents said that effectivecoordination mechanism and cooperation platform had not been established.Communication with coordinators of the other member organizations was insufficient.Part of the non-government organizations focused on the informal contractual relationship and activated tangible resources. Norms factor: an effective reward andpunish system had not yet been established and most respondents expressed the need toestablish the system to regulate member organization work. Trust factor: most of theinterviewees expressed the belief that the PAHCO had the ability to coordinateHIV/AIDS prevention and control. Fewer respondents from low AIDS epidemic did notrecognize PAHCO work. Common language: most of the respondents from the lowHIV/AIDS epidemic area reported they basically mastered the general knowledge, hadthe ability of HIV/AIDS prevention and control and did not need training. While part ofthe respondents from the middle and high HIV/AIDS epidemic area expressed that theyneed further training. Most of the respondents said that they did not know theresponsibility of the other member organization in the HIV/AIDS prevention andcontrol. Shared vision: most of the respondents said they recognized the objectives ofHIV/AIDS prevention and control at the national and provincial level. Less conflictexisted in the member organizations.(6) The results of case analysis of grass-rootsorganizations. For Working Group and Assistance Team, the low level “norms” is themost prominent problem of their social capital, mainly because there is no soundorganizational system and clear regulations. The biggest advantage is that members ofthe organization have the higher volunteerism and strong active sense of participation.Grass-roots organizations operate flexibly, efficiently and low-cost and playirreplaceable role of formal organizations.
Macro-level findings:(1) The World Values Survey (2005to2009) indicated the levelof organization participation in China located in50of53countries and trust level in12.
(2)"The level of organization participation" was significantly associated with HIVprevalence (15-49years), and anti-viral treatment coverage.
Conclusions and policy implications
The main conclusions:(1) The impact of social capital on the effect of HIV/AIDSprevention and control differed in different MARP and we did not yet find the negative impact.(2) HIV/AIDS prevention and control personnel were generally lack ofawareness of cultivation and use of "social capital".(3) The trust factor can improve thesatisfaction of the funds for HIV/AIDS prevention and control of member organizations.(4) Grassroots organizations are an important source of social capital. However, lowlevel norms became the barriers for them to be involved in HIV/AIDS prevention andcontrol.(5) More studies are needed to determine the association of social capital andHIV/AIDS prevention and control at the national level.
This study proposed the following strategies for developing and utilizing social capital:(1) The micro level: To actively cultivate the individual-level trust-based social capitaland consolidate the effect of the education for MARP. To develop fully relatives-basedsocial capital and make up for the limited resources of HIV/AIDS prevention andcontrol. To consciously cultivate and utilize structured social capital and enhance thelong-term effects for HIV/AIDS prevention and control for AMRP.(2) The meso level:To cultivate the inter-organizational trust-based social capital and reduce the cost ofHIV/AIDS prevention and control from the breakthrough of system construction andinterpersonal communication. To cultivate common-language-based social capital andenhance the ability of HIV/AIDS prevention and control of multisectors from thebreakthrough of classification guidance and training. To build the norms-based socialcapital and ensure the implementation of multi-sectoral cooperation mechanism fromthe breakthrough of building the legal system. To develop the network and participationbased social capital and innovate the means of HIV/AIDS prevention and control fromthe breakthrough of construction of modern information platform. To cultivatecitizen-based social capital and innovate the model of HIV/AIDS prevention and controlfrom the breakthrough of enforcement of social organization.(3) The macro level: Toestablish awareness of social capital and include the development of social capital in thetop-level design. To value the combined effect of social capital and other social factorsin HIV/AIDS prevention and control.
近些年，社会资本理论已被国外学者广泛应用于健康问题的研究。然而，我国开展社会资本与健康问题的研究较少，与艾滋病相关问题的研究尚未见报道。我国艾滋病流行形势依然严峻，防治任务十分艰巨。社会资本作为一种无形的资源，可以有机的整合艾滋病防制(艾防)工作中的物质资本和人力资本等有形的资源，降低艾防工作成本，放大艾防工作功效，成为探寻解决公共卫生问题的“第三条道路”。
目的
了解微观层面(个体水平，本论文关注高危人群)、中观层面(组织水平)和宏观层面(国家水平)的社会资本现况；分析三个层面的社会资本与艾滋病防制的关系；探讨我国艾滋病防制领域社会资本综合开发和利用的策略。方法
微观层面：2010年9月~12月，采用方便抽样的方法，使用课题组设计的问卷，在安徽省通过面对面现场问卷调查的方法收集资料。定量资料采用Epi Data3.0软件进行数据录入；使用SPSS13.0开展描述性统计分析、单因素和多因素二分类非条件logistic回归分析；使用AMOS20.0进行验证性因子分析。
中观层面：在艾滋病高、中、低流行地区各选取2个省，分别是广西壮族自治区、云南省、山西省、湖南省、吉林省和安徽省。2012年4月至11月，对6省的省级艾滋病防治委员会办公室(艾办)和成员单位的关键知情人进行问卷调查和深入访谈。在安徽省选择江淮同心工作组(工作组)和萧县孙圩子社区关怀救助小组(救助小组)两个草根组织开展案例分析。录音资料由调查员使用Word97软件转录成文本资料。使用SPSS13.0开展探索性因子分析和相关分析。
宏观层面：使用世界价值观调查、世界银行组织、联合国艾滋病规划署和世界卫生组织官方网站的既往统计资料，应用SPSS13.0开展多元线性回归分析。
结果
微观层面主要结果：(1)实际调查到女性性工作者583人、美沙酮维持治疗人员508人和男性同性性行为者(Men who Have Sex with Men，MSM)369人。前两类人群已由另两名硕士研究生完成。本论文只重点介绍MSM人群的调查结果。(2)调查的MSM人群的基本特征。超过半数(52.85%)的调查对象年龄在25岁及以下，大多数(69.92%)没有结过婚，接近半数(46.34%)的月收入在1001~2000元，绝大多数来自本地(72.90%)。(3)调查的MSM人群的社会资本现况。社会资本4个核心构成要素分别为组织参与、社会支持、信任和朋友网络。其中社会支持和信任因子高水平的比例较高，分别为68.56%和50.68%。组织参与因子情况：超过半数的调查对象没有参加任何组织(52.03%)以及没有参加过组织开展的活动(55.56%)，经常参加“社区”活动的较少占16.53%；社会支持因子：遇到困难总能得到经济上帮助的比例(17.61%)要低于总能获得精神上支持的比例(31.98%)；信任因子：调查对象表示完全信任父母\亲戚\朋友的比例最高(42.28%)，完全信任身边大多数人的比例最低(10.57%)；朋友网络因子：接近半数(48.51%)的调查对象密切交往的朋友数为≥5，密切交往的朋友职业种类以1~2种为主(72.09%)，密切交往的朋友关系种类≥3的较少(27.10%)。(4)调查的MSM人群的艾滋病防制效果。艾滋病基本知识总体知晓率为89.16%，条目2：“蚊虫叮咬会传播艾滋病吗？”的知晓率最低(74.25%)；最近六个月有偶然性伴的147人(39.84%)；最近一次性行为使用安全套的有188人(50.95%)。(5)社会资本与调查的MSM人群的艾滋病防制效果的关系。完全信任和基本信任自己父母\亲戚\朋友的调查对象知晓艾滋病基本知识的可能性分别是完全不信任的8.47倍(P=0.044)和5.54倍(P=0.015)。完全信任疾控中心工作人员的调查对象知晓艾滋病基本知识的可能性是完全不信任的8.48倍(P=0.039)。参加组织数量≥2个的调查对象最近一次性行为使用安全套的可能性是从未参加的3.27倍(P=0.002)，经常参加组织活动和“社区”活动的调查对象最近一次性行为使用安全套的可能性是从不参加的3.12倍(P<0.001)和3.27倍(P<0.001)；参加MSM志愿者组织的最近一次性行为使用安全套的可能性是不参加的3.10倍。密切交往的朋友职业种类和关系种类越多最近一次性行为安全套使用的可能性就越大。遇到困难不能完全得到精神支持的调查对象拥有偶然性伴的可能性是总能得到支持的1.96倍(P=0.008)。(6)社会资本对三类高危人群艾滋病防制影响的总体情况。社会资本测量条目对艾滋病防制效果的影响因高危人群而异。
中观层面主要结果：(1)问卷调查了6省艾办及成员单位关键知情人79人，深入访谈关键知情人89人。(2)调查地区艾办及成员单位社会资本现况。本研究从网络与参与、规范、信任、共同语言和共同愿景5个维度测量了调查地区艾办及成员单位的社会资本。调查地区艾办及成员单位信任因子高水平比例最高(69.62%)，规范因子高水平比例最低(37.97%)。网络与参与因子：各部门联络员在艾防工作中经常见面的比例最低(20.25%)；规范因子：当前艾防工作尚未建立有效的奖惩制度；信任因子：表示信任艾办工作的能力的比例最高(88.61%)；共同语言因子：大部分了解其他成员单位艾防工作职责的比例最低(44.30%)；共同愿景因子：对国家和省级重大艾防政策或活动表示高度认同的比例最高(81.01%)。(3)调查地区艾办及成员单位自评艾防工作情况。绝大多数调查部门(81.01%)对本部门艾防工作能力和效果表示满意，超过半数(59.49%)的表示对本部门艾防工作经费表示不满意。(4)社会资本与调查地区艾办及成员单位自评艾防工作的关系。信任与自评艾防工作能力、防治效果和防治经费满意度均相关，相关系数分别为0.303，0.317和0.341。(5)调查地区艾办及成员单位定性访谈结果。网络与参与因子：大部分调查对象表示目前尚未建立有效的协调机制和合作交流平台；部分非政府组织重视组织间的非正式合约关系，并激活了有形的艾防资源。规范因子：目前艾防工作尚未建立有效的奖惩制度，大多数调查对象表示有必要建立，以便规范各部门艾防工作。信任因子：大部分访谈对象表示相信艾办有能力协调艾防工作，低流行区少数调查对象表示不能认可艾办的工作。共同语言：低流行区的大部分调查对象表示基本掌握了艾防工作所需的基本知识和能力，不需要培训；而中、高流行区的部分访谈对象表示还需接受培训；大部分访谈对象表示不太清楚其他部门的艾防工作职责。共同愿景：大部分访谈对象表示认可国家和省级层面的艾防工作目标，部门之间艾防工作冲突的情况较少。(6)草根组织案例分析结果。工作组和救助小组的社会资本最突出的问题是“规范”因子水平较低，主要由于没有健全的组织体系和明确的规章制度。他们最大的优势是组织成员志愿精神较高，主动参与意识较强，发挥着正式组织不可替代的作用。
宏观层面主要结果：(1)2005~2009年的世界价值观调查中，我国的组织参与水平位于53个国家的第50位；信任水平位于第12位。(2)“组织参与水平”对HIV感染率(15-49岁)和抗病毒治疗覆盖率的影响有统计学意义。结论及策略建议
本研究主要结论：(1)社会资本在不同的高危人群中对艾滋病防制效果的影响也不同，尚未发现负面影响；(2)艾滋病防制相关人员普遍缺乏培育和利用“社会资本”的意识；(3)信任因子可以提高成员单位对艾防工作经费的满意度；(4)草根组织作为社会资本的重要来源，规范水平较低成为他们参与艾滋病防制工作的障碍；(5)国家层面社会资本与艾滋病防制的关系需要更多的研究进一步证明。
本研究提出以下社会资本综合开发和利用策略：(1)微观层面：积极培育个体水平的信任型社会资本，巩固高危人群艾滋病宣传教育的效果。充分开发亲缘中的社会资本，弥补艾防资源的不足。培育和利用结构型社会资本，增强高危人群艾防工作的长期效果。(2)中观层面：以制度建设为突破口、人际沟通为纽带，培育组织间的信任型社会资本，减少艾防工作的成本。以分类指导培训为突破口，培育共同语言型的社会资本，切实提高多部门开展艾防工作能力。以法制建设为突破口，培育规范型的社会资本，保证多部门合作机制的落实。以搭建现代化的艾防工作信息平台为突破口，培育网络与参与型社会资本，创新艾防工作的手段。以壮大艾防工作中的社会组织力量为突破口，培育公民社会型的社会资本，创新艾滋病防制模式。(3)宏观层面：树立社会资本意识，在顶层设计层面保证社会资本的开发和利用。重视社会资本和其他社会因素对艾滋病防制工作的共同作用。
Background
In recent years, the theory of social capital had been widely used in the field of healthby foreign researchers. However, fewer studies of social capital and health had beenconducted in our country. Moreover, social capital theory had not been introduced intoAIDS (Acquired Immune Deficiency Syndrome)/HIV (Human ImmunodeficiencyVirus) related issues in China to our knowledge. The epidemic situation of HIV/AIDS inour country is still rigorous, and its prevention and control is an arduous task. Socialcapital, as an intangible resources, could organically combine physical capital, humancapital and other tangible resources. It could reduce the cost and enlarge theeffectiveness of HIV/AIDS prevention and control. So it may be the “Third way” toresolve the public health issues.
Objectives
To Understand the micro-level (individual level, the paper focused on most-at-riskpopulation, MARP), the meso-level (organizational level) and the macro-level (nationallevel) social capital status; to analyze the impacts of social capital on the HIV/AIDSprevention and control from the above three perspectives; to explore the strategies fordeveloping and utilizing social capital in the field of HIV/AIDS prevention and controlin China.
Methods
Micro-level: from September2010to December, study participants identified by meansof convenient sampling method were interviewed by face to face using self-developedquestionnaire in Anhui Province. We input the quantitative data using Epi Data3.0and carried out univariate and multivariate binary non-conditional logistic regressionanalysis using SPSS13.0. We carried out confirmatory factor analysis using AMOS20.0.Meso-level: A total of six provinces were included in the study, two of them beingselected from each of the high, middle, and low prevalence of AIDS epidemic area, i.e.Guangxi Zhuang Autonomous Region, Yunnan province, Shanxi province, Hunanprovicne, Jilin province and Anhui province. From April2012to November, weconducted a questionnaire survey and in-depth interviews with key informants of theprovincial HIV/AIDS Committee Office (PAHCO) and its member organizaions. Wecarried out case study of “Jianghuai Tongxin Working Group”(Working Group) and“Xiao County Sunweizi Community Care Assistance Team”(Assistance Team). Wetranscribed recording data into text data by the Word97software. We carried outexploratory factor analysis and correlation analysis by SPSS13.0.Macro level: We conducted the multivariate linear regression analysis for the statisticdata from the World Values Survey, the World Bank, UNAIDS and the World HealthOrganization official website using SPSS13.0.
Results
Micro-level results:(1)583FSWs (female sex workers),508subjects participatingMMT (methadone maintenance treatment) and369MSM (Men who have sex with Men)were included in this study. The first two MARP were done by another two graduates ofour team. Therefore, this thesis focused only on the findings of the MSM population.(2)The general characteristics of the MSM in our study. More than half (52.85%) ofrespondents aged25years old and below. The majority (69.92%) were not married;Nearly half (46.34%) of the monthly income were in1001to2000. The vast majoritywere from the local (72.90%).(3) Social capital status of study participants of MSM.The four core factors of social capital were respectively membership and involvement,social support, trust and friends network. The proportion of social support factor andtrust factor with high level score were68.56%and50.68%, respectively. Membership and involvement factor: more than half of the respondents did not participate in anyorganization (52.03%), and did not participate in organized activities (55.56%).16.53%of respondents often participate in community activities. Social support factor: whenencountered difficulties,17.61%of respondents can always get economic help less thanthat can always get moral support (31.98%). Trust factor: the proportion of respondentswho trust completely their parents\relatives\friends was the highest (42.28%). Theproportion of respondents who trust completely most people was the lowest (10.57%).Friends network factor: nearly half (48.51%) of the respondents have≥5close friends.72.09%of respondents have close friends with1~2occupational categories.27.10%ofrespondents have≥3kinds of relationship with close friends.(4) The effects ofHIV/AIDS prevention and control for respondents.89.16%of respondents correctlyanswered≥6AIDS-related questions.74.25%of the respondents (46.6%) knew that“Item2: HIV could not be transmitted by mosquito bites”.39.84%of respondents hadcasual partners in the last months.50.95%of respondents used condoms in the lastsexual behavior.(5) The association of social capital and HIV/AIDS prevention andcontrol. Complete trust (OR=8.47, P=0.044) and general trust (OR=5.54, P=0.015) intheir parents\relatives\friends were associated with higher AIDS-related knowledgelevel. Complete trust in CDC staff associated with higher AIDS-related knowledge level(OR=8.48, P=0.039).≥2membership, often participating organization (OR=3.27,P=0.002) and community activity (OR=3.27, P<0.001), and member of MSM voluntaryorganization (OR=3.10, P<0.001) were associated with higher probability of condomuse in the last sexual behavior. More occupational category and relationship type ofclose friends were associated with higher probability of condom use in the last sexualbehavior. Not always completely get the moral support were associated with higherlikely to have casual partners (OR=1.96, P=0.008).(6) The overall descriptives ofeffects of social capital on the HIV/AIDS related issues among MARP. The impact ofthe items of social capital on AIDS prevention and control varied due to different risk-groups.
Meso-level findings:(1)79key informants from the PAHCO and its memberorganizations were included in the survey and89participated in-depth interview.(2)Social capital status of PAHCO and its member organizations: in this study, wemeasured organizational social capital from five factors of the network and participation,norms, trust, common language and shared vision. The proportion of high level trustwas the highest (69.62%) among the five factors. The high level of norms was thelowest (37.97%). The factor of network and participation: the proportion of respondentswho meet regularly the co-coordinators of the other member organizations for the workof HIV/AIDS prevention and control was the lowest (20.25%). The factor of norms:effective system of rewards and penalties has not been established; The factor of trust:the proportion of respondents trusting the ability of PAHCO was the highest (88.61%).The factor of common language: the proportion of respondents who mostly knew theresponsibility of the other member organizations was the lowest (44.30%). The factor ofshared vision: the proportion of respondents who recognized the national and provincialpolicy or activities was the higest (81.01%).(3) Self-assessment HIV/AIDS preventionand control work of PAHCO and its member organizations. The vast majority of surveydepartments (81.01%) expressed satisfaction with their capacity and effectiveness ofHIV/AIDS prevention and control. More than half (59.49%) of the survey departmentswere dissatisfied with their funds of HIV/AIDS prevention and control.(4) The impactsof social capital on the self-assessment of HIV/AIDS prevention and control. Trustcorrelated with self-rate satisfaction of the ability, effect and funds of HIV/AIDSprevention and control (r=0.303,0.317and0.341).(5) The outcome of qualitativeinterviews. Network and participation: Most of the respondents said that effectivecoordination mechanism and cooperation platform had not been established.Communication with coordinators of the other member organizations was insufficient.Part of the non-government organizations focused on the informal contractual relationship and activated tangible resources. Norms factor: an effective reward andpunish system had not yet been established and most respondents expressed the need toestablish the system to regulate member organization work. Trust factor: most of theinterviewees expressed the belief that the PAHCO had the ability to coordinateHIV/AIDS prevention and control. Fewer respondents from low AIDS epidemic did notrecognize PAHCO work. Common language: most of the respondents from the lowHIV/AIDS epidemic area reported they basically mastered the general knowledge, hadthe ability of HIV/AIDS prevention and control and did not need training. While part ofthe respondents from the middle and high HIV/AIDS epidemic area expressed that theyneed further training. Most of the respondents said that they did not know theresponsibility of the other member organization in the HIV/AIDS prevention andcontrol. Shared vision: most of the respondents said they recognized the objectives ofHIV/AIDS prevention and control at the national and provincial level. Less conflictexisted in the member organizations.(6) The results of case analysis of grass-rootsorganizations. For Working Group and Assistance Team, the low level “norms” is themost prominent problem of their social capital, mainly because there is no soundorganizational system and clear regulations. The biggest advantage is that members ofthe organization have the higher volunteerism and strong active sense of participation.Grass-roots organizations operate flexibly, efficiently and low-cost and playirreplaceable role of formal organizations.
Macro-level findings:(1) The World Values Survey (2005to2009) indicated the levelof organization participation in China located in50of53countries and trust level in12.
(2)"The level of organization participation" was significantly associated with HIVprevalence (15-49years), and anti-viral treatment coverage.
Conclusions and policy implications
The main conclusions:(1) The impact of social capital on the effect of HIV/AIDSprevention and control differed in different MARP and we did not yet find the negative impact.(2) HIV/AIDS prevention and control personnel were generally lack ofawareness of cultivation and use of "social capital".(3) The trust factor can improve thesatisfaction of the funds for HIV/AIDS prevention and control of member organizations.(4) Grassroots organizations are an important source of social capital. However, lowlevel norms became the barriers for them to be involved in HIV/AIDS prevention andcontrol.(5) More studies are needed to determine the association of social capital andHIV/AIDS prevention and control at the national level.
This study proposed the following strategies for developing and utilizing social capital:(1) The micro level: To actively cultivate the individual-level trust-based social capitaland consolidate the effect of the education for MARP. To develop fully relatives-basedsocial capital and make up for the limited resources of HIV/AIDS prevention andcontrol. To consciously cultivate and utilize structured social capital and enhance thelong-term effects for HIV/AIDS prevention and control for AMRP.(2) The meso level:To cultivate the inter-organizational trust-based social capital and reduce the cost ofHIV/AIDS prevention and control from the breakthrough of system construction andinterpersonal communication. To cultivate common-language-based social capital andenhance the ability of HIV/AIDS prevention and control of multisectors from thebreakthrough of classification guidance and training. To build the norms-based socialcapital and ensure the implementation of multi-sectoral cooperation mechanism fromthe breakthrough of building the legal system. To develop the network and participationbased social capital and innovate the means of HIV/AIDS prevention and control fromthe breakthrough of construction of modern information platform. To cultivatecitizen-based social capital and innovate the model of HIV/AIDS prevention and controlfrom the breakthrough of enforcement of social organization.(3) The macro level: Toestablish awareness of social capital and include the development of social capital in thetop-level design. To value the combined effect of social capital and other social factorsin HIV/AIDS prevention and control.
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