| BackgroundWomen's reproductive health (RH) has been highly recognized by the international society since 1990s and become more popular after International Conference for Population and Development and the World Fourth Conference on Women. Family planning (FP) is a long term strategic policy in China but the policy mainly targets the married couple instead of unmarried population. Along with the social economic development and the trends of globalization and urbanization, the reproductive health issues among unmarried migrants are getting on the agenda. A review of literature and projects of sexual and reproductive health of adolescents and youths in China recognized a special population, which are unmarried female migrants. There are only a few researches on their RH status, behavior issues and associated factors. They are not covered by current FP services and there is no specific policy for this population. The purpose of this study is to explore the ecological factors associated with reproductive health behaviors among unmarried female migrants from rural or less developed areas to developed urban cities. An intervention designed according to social cognitive theory will be piloted in one factory in China.The term of "Migrants" in this paper is defined as a population from rural and less developed areas to developed urban cities, no matter how long they will stay in the urban cities.Study goalThe study is try to survey the current RH status of unmarried migrant females; to find the RH related health needs and demands; to understand the ecological factors associated with sexual and contraceptive behaviors among study population; to pilot an intervention based on social cognitive theory and finally to make the policy recommendations. Study contents1. To describe the features of unmarried female migrants and to compare them with the features of unmarried male migrants in order to find the possible vulnerabilities in the female. The features included demographics, personal habits, RH behaviors and related knowledge, attitudes and self efficacies, RH needs and demands for the services.2. To analyze possible ecological factors associated with RH behaviors, which may including social economic factors (personal income, social network, education, employee, working and living environment), work environment and peer relationships, growing environment and family relationships, health care and services facotors.3. To set up ecological models for sexual behavior and contraceptive behavior among unmarried female migrants.4. To pilot an intervention designed according to social cognitive theory and to evaluate its applicability and acceptability as well as potential effects.5. To make policy and service recommendations for the improvement of RH status in target population.Study methodologies1. Cross sectional anonymous self filling survey method and non randomized stratified cluster sampling techniques were used in the study on ecological factors associated with RH behaviors among unmarried female migrants. 1293 unmarried female migrants from manufacturing, restaurants and commercial & service enterprises were surveyed. 601 of them are from Shanghai RH demonstrating district and 692 of them are from Guangdong RH demonstrating district. Logistic regression was used to analyze ecological factors associated with sexual behavior and contraceptive behavior for the purpose of confounding control. Framework approach was used to analyze the qualitative data related to RH behavior among unmarried female migrants.2. Quasi-experimental design was used in the intervention pilot. In consultation with clients, we developed a workplace based intervention to promote contraception use in unmarried female migrants in a privately owned factory. We then implemented this in one factory, using a controlled before-and-after design. The intervention included lectures, demonstrations, bespoke information leaflets, and supports to the factory doctors in providing contraceptive services.Main findings1. The issues related to RH behaviors and their abilities of unmarried female migrantsThe age of the first sex is 20 year-old averagely, and 20% of the first sex use contraceptive measure. Most of unmarried female migrants don't know how to use contraceptive measures while they have first sex. The female sexual behavior rate is 25.5% (36.1% in male). In recent 6 months, 55% of the female used contraception when they have sex. 31.4% of them used emergency contraception. 12.6% of the females who have sex in recent 6 months used emergency contraception more than 3 times.The unmarried female migrants don't have enough knowledge for good reproductive health. The correct answer rate of reproductive physiology is below 50% mostly. The correct answer rate of males is higher than that of females except of easy conceiving period and manifestation of pregnancy. Such inequality of information will make females more vulnerable during the sex intercourse to the some extent. 81.1% of the females don't know what menstrual phase is the easiest pregnant period and 71.2% of them don't know whether or not occasional unprotected sexual behavior will cause pregnancy. Only 4.5% females surveyed can tell three or more contraception methods and their correct use and only 11.2% females surveyed hear of emergency contraceptives and know their correct use. 28.2% of the females know condoms can prevent STD. Though a number of people know AIDS, under 10% of them know accurate transmission routes of AIDS. Besides, there are parts of people have false recognition, for example, 3.9% females think induce abortion is a method of contraception.2. Unmet needs and demands of RH in unmarried female migrantsNearly half of unmarried female migrants suffered from menstrual disorder and dysmenorrhea. They also reported suspected symptoms of reproductive tract infection, which are abnormality of vagina discharge (>10%) and lower abdominal pain(>20%) mainly.70-85% of the females think it is necessary to have reproductive health education and service. The most intensive demand is correct information, then health examination, medical consultation and diagnosis and treats service of common andrological and gynecological diseases. The most acceptable forms of education and service are distributing reading materials, lecture, hot line call, and face to face consultation; Besides, opening clinic for unmarried youths are welcomed by many people (>40%) and specialists in reproductive healthcare are their most trusted educator.3. Personal, interpersonal, organizational and society factors associated with RH behaviors of unmarried female migrantsEcological factors associated with RH behaviors of unmarried female migrants are related to personal level, intimate relationship level, working environment and peer influence, and social cultural environment. Regarding to premarital sexual behavior, the possible predisposing factors included sexual and RH knowledge, the attitudes towards premarital sexual behavior, premarital pregnancy and contraception during sex; the possible enabling factors included living conditions, commercial and service enterprise working environment, the availability of contraception, different original place they came from and the place they live now; the possible reinforcing factors included fixed boyfriend, the extent of communication with parents, and the educators from the workplace.In manufacturing and restaurants enterprises, the associated ecological factors are original urban residency, type of living conditions, contraceptive knowledge level, the attitude towards premarital pregnancy, the status of boyfriend, communicating with parents, the availability of contraceptives and the place where they live now.Different associated factors were found in commercial and service enterprises, which included older age, lower educational level, higher income, open attitudes towards premarital sex and the places they come from as well as they live now.Regarding to contraceptive behavior, the possible predisposing factors included knowledge of condom to protect from STDs, the self efficacy to negotiate with boy friend on condom use and the experience of using contracetptives at first sex; the possible enabling factors included the availability of contraception; peer influence may be a possible reinforcing factor.Higher educational level, good family education, higher RH knowledge level and communication with parents may protect the female from premarital sex. The knowledge of condom to protect from STDs, the self efficacy to negotiate with boy friend on condom use and the experience of using contracetptives at first sex and the availability of contraception may help to keep good contraceptive behaviors.4. Workplace based intervention to promote contraceptive use is acceptable by unmarried female migrants but its implementation is difficultThe prerequisite of workplace based intervention must get support from workplace leaders. The difficulties in the implementation included (1) The migrant or 'floating' population working in factories means that young people move jobs frequently. In addition, during the intervention period, management issued a new human resource policy, and many young women were made redundant. (2) Workplace RH service supportive condition such as workplace based service providers, the possibilities of health education implementation and the confidential services carried. (3) Appropriate intervention contents and techniques to be chosen. (4) The time and interests of unmarried female migrants to involve the intervention activities. The intervention designed according to social cognitive theory showed acceptable by unmarried female migrants and has the potential effects which still need to be assessed in larger and more representative population.Policy recommendation1. Unmarried female migrant as a vulnerable group of population, their RH behaviors affected by many complicated factors. In additional to the ecological factors related to personal, interpersonal, working and social environment level, emotional factor should be considered as an associated factor related to decision making of RH behavior in the future study.2. Accoding to the protect factors founded in this study, leaving the young people longer enough in school, adovacating good family educaton, and continuously providing RH educaiton may help unmarried female to prevent from premarital sex behaviour. Dissemination of knowledge on duel protection, self afficacy on refuse unprotected sex and always making the contraceptives available are good for unmarried female to keep good contraceptive behaviours. Specific intervention should be given to the female migrants based on their work environment. Health care system and RH service providers should target the possible intervention factors to provide humanity-based services. Accessible and effective services should be provided at every contact point to make sure the service can reach the target population at large.3. Family planning department and health department are main providers for the reproductive health service. Unmarried migrants should also be brought into family planning management system as soon as possible. And health service institutions should provide available services for this population. But subjects in this particular population disperse in different workplaces and communities. So inter-departments collaboration is necessary. A convenient, accessible and acceptable service package should be prepared and provided to this group of population.4. Society management should not only concern about people with registered permanent residence but also should regard all residents including unmarried migrants as management and service subjects. The reproductive health service of unmarried migrant's population should be ensured by government on policy and laws. And it also needs powerfully support of idea, consensus, financing and technology from all fields of the society. Especially NGOs related to youth health should be developed energetically to assist the implementation of education and service programs. |
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