Study on sexual and reproductive health behaviors of unmarried female migrants in China

doi:10.1111/j.1447-0756.2011.01753.x J. Obstet. Gynaecol. Res. Vol. 38, No. 4: 632 638, April 2012 Study on sexual and reproductive health behaviors of unmarried female migrants in China Dian He 1,2, You Zhou 1,2, Ning Ji 1,2, Shizhong Wu 3, Zhijin Wang 4, Peter Decat 5, Eileen Moyer 6, Meile Minkauskiene 7, Cheng Pang 1,2 and Yimin Cheng 1,2 1 Graduate School of Peking Union Medical College, 2 National Research Institute for Family Planning, Beijing, 3 Donghua Research Institute of Reproductive Health, Chengdu, 4 School of Public Health, Sun Yat-sen University, Guangzhou, China; 5 Department of Obstetrics and Gynaecology, International Centre for Reproductive Health (ICRH), Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; 6 Amsterdam School for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands; and 7 Kaunas University of Medicine, Kaunas, Lithuaniajog_1753 632..638 Abstract Aim: The purpose of this study was to broadly assess the level of knowledge, attitude and behaviors related to sexual and reproductive health (SRH) among unmarried female migrants in China. Material and Methods: This cross-sectional study was conducted and a self-administered questionnaire was designed for collecting information on SRH including 15 items for knowledge, 8 items for attitude and some items for contraception and abortion related behaviors. Results: A total of 1690 unmarried female migrants were interviewed. Most of the respondents had less knowledge of SRH. Only one-third of respondents was aware of emergency contraceptives and could freely talk about SRH with their friends. Over one-third of respondents were not willing to come into contact with someone with AIDS or STDs. In this study, 10.4% participants had an unwanted pregnancy and 95% of them had an abortion. Multivariate analysis showed that having a boyfriend, duration of employment in city, knowledge on SRH and freely discussing SRH with peer were associated with having premarital sex among these unmarried female migrants. Conclusion: This study revealed that the unmarried female migrant was one of the most vulnerable groups concerning SRH. In some policy reforms, appropriate and cost-effective SRH services should be provided for these migrants. Key words: attitude, China, condom use, knowledge, migrant, unplanned pregnancy. Introduction The economic boom provoked a huge demand of manpower and resulted in large-scale migration from rural areas to urban areas in China. The number of internal male and female migrants was estimated at over 200 million each year. 1 Most of these internal migrants were employed in manual labor, including construction, manufacturing and the service industries. Women migrants were more often younger than men. 2 Previous studies demonstrated poorer sexual and reproductive health (SRH) indicators existed among internal migrant women compared to urban residents. 3,4 The number of unmarried mothers is increasing in China and abortion appears commonly. 5 It is estimated that ten million abortions are induced annually in China with about one-third of all abortions being Received: March 28 2011. Accepted: August 30 2011. Reprint request to: Dr Yimin Cheng, National Research Institute for Family Planning, 12 Da Hui Si, Hai Dian District, Beijing 100081, China. Email: chengym55@gmail.com 632 2012 The Authors

Sexual and reproductive migrant health repeated abortions, and most cases were migrants in urban areas. 6 It is reported that over 70% of unwanted pregnancies were caused by unprotected sex and failure of contraceptive methods. 7 Due to these high-risk sexual behaviors, sexually transmitted diseases (STDs) and HIV are more likely to increase among migrants. 8 A study reported only 8.4% of respondents could cite symptoms of STDs and 33.9% had not heard of AIDS. 9 Rural-to-urban migration has been identified as a contributing factor to the HIV epidemic in China. 10 Poorer sexual health among internal migrants compared to non-migrant populations has also been noted in other countries. 11 However, little is known about the determinants of the SRH of unmarried migrants. In China, family planning services are provided through the national network of family planning clinics. However, its current policies for contraception are mainly targeted at married couples. Contraceptive counseling and services for young unmarried people are limited in urban areas. Previous studies showed that knowledge about SRH determinants allowed for developing targeted, effective and feasible intervention strategies. 5,12 Therefore, a study to investigate unmarried migrant women s knowledge, attitude, needs and behaviors on SRH was urgently needed. We implemented this survey in Qingdao, China. Qingdao is a large city in eastern China, which is an important economic center and port city. The sailing competition of the 2008 Beijing Olympic was held in Qingdao. At present, about 2.1 million migrants from the rural area have been in Qingdao. The objective of this study is to investigate SRH among these unmarried female migrants. Methods This cross-sectional study was conducted to assess the level of knowledge, attitudes and behaviors about SRH among unmarried female migrants. To optimize the feasibility of the project, study locations were selected based on their distance and accessibility to the study team implementing the study. From the district administrative authorities of the city, an exhaustive list of worksites (most of them were labor-intensive or technological-intensive factories) employing between 300 and 700 female migrants and located within a range of 15 km from a collaborating health facility was obtained. Then, cluster random sampling was carried out. In total, 24 worksites were listed in Qingdao and 10 were randomly selected by coin tossing. Most of the investigations were implemented by the Research Institute of Family Planning in Qingdao one of the project units and were conducted during lunch time and at weekends. We used the unwanted pregnancies prevalence rate to calculate the sample size. 13 A previous survey in China showed 12 32% of unmarried women have had an unwanted pregnancy. 14 We assumed that the unwanted pregnancies prevalence rate was 25% in the last 6 months. Considering a 10% loss with 95% confidence and 90% power, we needed to recruit 1320 young unmarried female participants for the investigation. So each worksite needed to contain at least 132 respondents. Data were collected by using semi-structured questionnaires. A questionnaire was designed by the study steering group including Chinese and European investigators; it was based on the illustrative questionnaire for interview-surveys with young people conceived by John Cleland for the World Health Organization. The questionnaire was developed in English, translated into Chinese and subsequently translated back into English by a different person. Both English versions were compared and inconsistencies were addressed in the Chinese version. The questionnaire was piloted among a convenient sample of 137 female migrant workers. The questionnaire consisted of three sections: (i) socio-demographic characteristics; (ii) knowledge and attitudes related to SRH; (iii) contraception- and abortion-related behaviors. In the study, the registered number of workers was chosen randomly from each selected sites, and the investigators tested eligible unmarried female migrants one by one. At this time selected subjects were encouraged to participate in the project. Information about the study and the consent form were provided on the front of the questionnaire, and participation in the study was voluntary. Efforts were made to ensure anonymity and privacy while filling out the questionnaires. Trained interviewers assisted respondents in understanding questions, if necessary. All completed questionnaires were reviewed by research staff for completeness and consistency. Experts and staff from the National Institute of Family Planning supervised and monitored the data collection. The study was approved by the ethical committee of the National Research Institute of Family Planning, China. The quantitative database was set up using Epidata2.1 (EpiData Association, Odense, Denmark). After checking and coding the questionnaires, data were 2012 The Authors 633

D. He et al. entered by two research staff separately and crosschecked again to assure the accuracy of data. The fixed database was analyzed by SPSS11.0 (SPSS, Chicago, IL, USA). Descriptive statistics were used to describe respondents demographic characteristics, knowledge, attitude and SRH-related behaviors. We recoded some continuous variables into categorical variables considering these distributions. Chi-squared tests were used to detect heterogeneity. Crude and adjusted odds ratios with 95% confidence intervals (CIs) were calculated to assess predictors for having premarital sex. Logistic regression was used to adjust for related factors, with a P-value of >0.05 as a criterion for removal of a variable from the model; P-values reported were two-tailed and an alpha level of 0.05 was used to establish statistical significance. Results Table 1 Demographical characteristics of the participants (n = 1690) Characteristics n % Age (years) <20 587 34.7 20 22 457 27.1 22 24 314 18.6 24 332 19.6 Education (years) 6 73 4.3 6 9 900 53.3 9 12 553 32.7 College or above 141 8.3 Not disclosed 23 1.4 In a relationship Yes 608 36.0 No 1067 63.1 No respondents 15 0.9 Has health insurance Yes 531 31.4 No 1130 66.9 No respondents 29 1.7 Employment duration in Qingdao (years) <1 542 32.1 1 3 678 40.1 >3 470 27.8 Matched American education level. A total of 1690 female subjects were recruited in this study. The mean age of these respondents was 21.7 2.8 and 61.7% of respondents were less than 22 years old (Table 1). About 70% of workers had lived in Qingdao for less than 3 years. Most of them didn t have health insurance and only one-third of participants reported having a boyfriend. The education level of the respondents were mostly junior high school and 90.3% were senior high school or below ( 12 years). Knowledge and attitude of respondents related to SRH We examined the females knowledge in the questionnaire using 15 questions related to contraception, induced abortion and STDs/AIDS; and these questions determine a knowledge score for each participant. Correct answers were credited with a score of one and incorrect answers or I don t know with a score of zero. We weighted these sentences and converted everyone s total score into a percentile system. Each question was given the same weight and the maximum score obtainable was 100 (based on a correct answer to all 15 questions). 15 The study showed that the median score for knowledge of respondents was 40.0 points. For 75% of them the score for knowledge was less than 60.0 points. Although they were able to answer some statements correctly, many misconceptions still exist among these respondents. Less than one-third of respondents are aware that sex was the main mode of HIV transmission and lots of respondents thought that people could suffer HIV through mosquito bites. The results also show that about half of respondents can correctly recognize that induced abortion is not a contraceptive method. But only one-third of respondents are aware of emergency contraceptives (Table 2). The distribution of respondents attitude of each statement is shown in Table 3. Over half of them agree that free condoms should be provided to unmarried women. Although 42.8% participants discuss SRH with a doctor freely, fewer respondents do it with their friends. About one-third of respondents reported that they are not willing to come into contact with someone with STDs and even believed that he/she should be separated from the worksite. Contraception-related behaviors The distribution of respondents behavior related to contraception is indicated in Table 4. About one-tenth of unmarried female migrants (193 respondents) reported having sexual intercourse in the last 6 months. About 10% of sexually active workers had an unwanted pregnancy and 95% of them had an abortion. We used the binary logistic regression to analysis related factors that were associated with having premarital sex (Table 5). Age, education, relationship 634 2012 The Authors

Sexual and reproductive migrant health Table 2 Respondents knowledge of SRH (n = 1690) Statements Correctly % answered (n) Emergency contraceptives can be used as a main contraceptive method 647 38.3 Induced abortion can be used as a main contraceptive method 984 58.2 Rhythm method is an effective method to prevent pregnancy for young people 629 37.2 Withdrawal method is an effective method to prevent pregnancy for young people 615 36.4 Emergency contraceptives were available after a condom breaking during sexual intercourse 560 33.1 A woman may become pregnant if she skips oral pills during menstruation 387 22.9 Induced abortion may increase the risk of infertility in the future 826 48.9 People can protect themselves from getting HIV by having just one sex partner 336 19.9 People can protect themselves from getting HIV by always using a condom during sex 815 48.2 People can protect themselves from getting HIV by having no sex at all 479 28.3 People can get HIV from a mosquito bite 544 32.2 People can get HIV from sharing food with a person who has AIDS 958 56.7 It is possible that a healthy-looking person has HIV 1035 61.2 It is possible that a woman of child-bearing age can become pregnant or acquire HIV after having 742 43.9 unprotected sex once Vaginal irrigation after sexual intercourse can prevent STDs 415 24.6 Table 3 Attitudes of participants related to sexual and reproductive health (n = 1690) Attitudes related to SRH Agree (%) Disagree (%) Not disclosed (%) Free condoms should be available to unmarried women 879 (52.0) 806 (47.7) 5 (0.3) You feel free to discuss SRH with your friends 549 (32.5) 1134 (67.1) 7 (0.4) You feel free to discuss SRH with a doctor 724 (42.8) 957 (56.6) 9 (0.5) Rape can t happen between a couple 405 (24.0) 422 (25.0) 863 (51.1) You avoid contact with someone with STDs 460 (27.2) 1214 (71.8) 16 (0.9) You want to be separated from someone with STDs at the worksite 236 (14.0) 1435 (84.9) 19 (1.1) You avoid contact with someone with AIDS 598 (35.4) 1065 (63.0) 27 (1.6) You want to be separated from someone with AIDS at the worksite 381 (22.5) 1273 (75.3) 36 (2.1) Table 4 Contraception behavior among sexually active workers in the last 6 months (n = 193) Behaviors n % Had more than one sexual partner 15/193 7.8 Had unwanted sex at least once 60/193 31.1 Never use contraception 19/170 11.2 Always use contraception during sex 75/151 49.7 Use a condom repeatedly 3/151 2.0 Had an unwanted pregnancy 20/193 10.4 Used contraception but had an 9/20 45.0 unwanted pregnancy Had an abortion 19/20 95.0 23 no response. There were 151 participants who had used contraceptive. Only 20 participants had an unwanted pregnancy. status, duration of employment in city, knowledge on SRH and freely discussing SRH with peers affected having premarital sex among these female migrants. We found that those in a relationship are more likely to have premarital sex than those who didn t (adjusted odds ratio [AOR] = 30.73, 95% CI = 17.11 55.18, P < 0.001). Duration of employment in city was significantly associated with having premarital sex (AOR = 2.13, 95% CI = 1.43 3.13, P < 0.001). Respondents with lower knowledge scores on SRH are more likely to have premarital sex (AOR = 3.77, 95% CI = 2.48 5.75, P < 0.001). Although there is no significant differences on freely discussing SRH with peers, we believe that those willing to discuss SRH with peers are more likely to have premarital sex than who didn t (AOR = 1.38, P = 0.093). Discussion Without basic risk perception and self-protection skills, these youths might become high-risk for unsafe sexual behaviors. 16 These migrants left their parents homes and moved to cities for work. The majority of respondents were young and had a low level of school education. A study among female college students in Iran 2012 The Authors 635

D. He et al. Table 5 Factors associated with practicing premarital sex in the last 6 months among respondents Variables Practicing premarital sex Adjusted odds ratio P-value Yes (n = 193) No (n = 1497) (95% CI) Age 0.623 <21 years 59 (7.0%) 785 (93.0%) 1.0 21 years 134 (15.8%) 712 (84.2%) 1.10 (0.74 1.64) Education duration 0.440 <9 years 97 (10.0%) 876 (90.0%) 1.0 9 years 91 (13.1%) 603 (86.9%) 1.15 (0.80 1.67) In a relationship 0.000 No 14 (1.3%) 1053 (98.7%) 1.0 Yes 174 (28.6%) 434 (71.4%) 30.73 (17.11 55.18) Employment duration in city 0.000 <1.5 years 69 (8.2%) 772 (91.8%) 1.0 1.5 years 124 (14.6%) 725 (85.4%) 2.13 (1.43 3.13) Knowledge on SRH 0.000 median score 42 (5.3%) 748 (94.7%) 1.0 <median score 151 (16.8%) 749 (83.2%) 3.77 (2.48 5.75) Can freely discuss SRH 0.093 No 113 (10.0%) 1021 (90.0%) 1.0 Yes 79 (14.4%) 470 (85.6%) 1.38 (0.95 2.00) Median. Dependent variable is coded: practiced premarital sex = 2; didn t practice premarital sex = 1. The shortfall in some denominators is due to missing information. CI, confidence interval; SRH: sexual and reproductive health. showed that respondents were more likely to have premarital intercourse if they did not live with both parents (OR = 2.0). 17 Most of the respondents had a low level of knowledge about SRH and some misconceptions still exist among them. Only one-third of respondents are aware of emergency contraceptives compared to Shanghai s rate of 50%. 18 Recent research indicated that it was mostly young male and female migrants who lacked knowledge and awareness of effective contraception methods and believed induced abortion was one kind of contraception methods. 12 Few female migrants could freely talk about SRH with their friends, but two-thirds of rural youth were willing to communicate with their peers on SRH issues. 15 In addition, the passive role of females in society might also inhibit them to initiate conversations with their partner on sexuality and contraceptive use. In this study, more and more unmarried Chinese women considered abortion as a stopgap for unwanted pregnancies. We focused on behaviors of SRH in the last 6 months and only 11.4% (193) of unmarried female migrants reported having sexual intercourse. Considering that 608 (36%) participants reported having a boyfriend, only 31.7% (193/608) of participants with a boyfriend had premarital sex in the last 6 months. This result was similar to other studies. 8 A survey in Bangladeshi revealed that among 1048 unmarried males between 15 and 19 years of age, 12.8% reported having had sex. 19 A study among college students in Wuhan, China found that over 18% of female students reported having had sexual intercourse. 20 In comparison with a previous study, which was conducted in 1994 in Qingdao, we found that the rate of premarital sex from this time has increased sharply from 14.7 in 1994 to the current 31.7%. 9 Although the rate of unwanted pregnancy changed lightly (10.4%), the incidence rate of induced abortion after an unwanted pregnancy increased rapidly (95.0%). 14 It stated abortion after an unwanted pregnancy had been accepted commonly as a stopgap among unmarried migrants in urban areas. Multivariate analysis showed that having a boyfriend, duration of employment in the city, knowledge on SRH and freely discussing SRH with peer are associated with having premarital sex among these unmarried female migrants. Having a boyfriend and longer duration of employment in the city are positively associated with having premarital sex. 17 The migrants who live in the city longer have more liberal values, so these migrants along with unmarried migrant women with a boyfriend were likely the high-risk groups with poor SRH. Some specific intervention should be addressed for them. This study also found that the respondents who had talked about sex-related issues with peer were more 636 2012 The Authors

Sexual and reproductive migrant health likely to engage in premarital sex. A study in Bangladeshi demonstrated that having talked with friends about sex-related issues increased the peer-influenced score and increased the odds of premarital sex threefold. 19 A survey among 2394 unmarried youth in Hanoi, Vietnam indicated peer social deviance increased the likelihood of having premarital sex by at least 2.6 times. 21 A growing body of literature from around the world has shown a connection that a parent can be associated with delay of premarital sex for youth migrants. 19 21 Therefore, interventions to protect young women from STDs need to target early sex education and address peer and parents influences. 20 From this study, we found that on the one hand these female migrants lacked knowledge on SRH and selfprotection skills; on the other hand they couldn t obtain helpful counseling easily. So, there is a need for better reproductive health education, accessible medical care and social support among these women. Correct open communication on SRH issues should be enhanced to address obstacles for access to SRH services. In addition, free or low-priced condoms and comprehensive SRH services should be available for migrants, in particular for unmarried migrants, so that they may be encouraged to engage in safer sexual behavior. 22 Therefore, the next study to be undertaken in Qingdao will focus on a demonstration-intervention for the duration of 6 months. The comprehensive interventions, including providing education and information, condoms, individual counseling, lectures and videos, peer education etc. aim at exploring an effective intervention to improve SRH services among migrants. Because sampling was limited to only a city, we could not claim that our findings were representative for all female migrants in China. 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