Unmarried Female Youth Population Reproductive Health Services Need To Study

Research Background:Health services need depends largely on health situation of certain population. It is the objective service needs including medical treatment, prevention, care, rehabilitation based on the gap between actual situation of health and the ideal health status determined not only by personal perception but also by health professionals.These two are sometimes consistent and sometimes inconsistent.With the social and economic development, sexual maturity of young people generally appears earlier while they tend to delay their marriage. United Nations AIDS (UNAIDS) data show that10%of young women aged between15and24had sex before15-year-old. Surveys in Asia where data can be collected show that there is a trend of early sexual debut in most Asian countries. In China, young people, nearly1/6of the total population,are increasingly subject to undesirable effectsof unwanted sexual behavior, sexually transmitted diseases, unwanted pregnancy, and abortion. Due to contradiction between early sexual maturity and physical and psychological immaturity, deficiency of knowledge about sexuality, reproductive health, and prevention and treatment of diseases, unmarried young women encounter unmarried pregnancy, increased incidence of induced abortion, reproductive tract infections, unwanted sex, etc. Unwanted sex could result in induced abortion and/or reproductive tract infections. Hence, the three reproductive health events are closed related with each other. Therefore, we should pay further attention to all of them. International Population and Development Conference (?)1994was the first to put forward that there were obvious differences between sexual and reproductive health demands of youth and adults. Those differences are one of the areas with priority should be emphasized. World Health Organization (WHO) suggests that reproductive health of unmarried young people can be affected negatively by three significant factors. Those three factors include induced abortion, sexual transmitted diseases, and unwanted sex. World Adolescents Action Program accentuates that special needs of unmarried young people should be satisfied in fields such as responsible family planning practice, domestic life, sexuality and reproductive health, sexual transmitted diseases, HIV infection, and AIDS prevention. In the International Population and Development seminar at the end of2010, Zhao Baige, deputy director of China Population and Family Planning Committee, said that there were five challenges of Chinese population development, and one of them was’unmet demands in reproductive health services, especially for vulnerable population such as unmarried, adolescents, and migrant population’.Objectives:To explore current condition of reproductive health and unmet reproductive health services demands among unmarried young women comprehensively, and to present scientific evidence for interventions, health education, and services aiming to prevent undesirable reproductive health events including unwanted sex, induced abortion, and reproductive tract infections for this group of people.Specific targets:1. To evaluate reproductive health knowledge and attitudes of unmarried young women, including knowledge and attitudes about contraception, unintended pregnancy and induced abortion, sexual health including unwanted sex and sexual dysfunction, reproductive tract infections and gynecopathy.2. To explore difference of reproductive health knowledge and attitudes among unmarried young women with different backgrounds.3. To understand reproductive health practices of unmarried young women.3.1To understand their premarital sex and contraception.3.2To understand their unintended pregnancy and history of induced abortion.3.3To understand their history of unwanted sex and sexual dysfunction.3.4To understand their history of reproductive tract infections and gynecopathy.4. To explore difference of reproductive health practices among unmarried young women with different backgrounds.Methods:This study adopted the mix method of integrating qualitative and quantitative researches. The quantitative research is a health facility-based descriptive epidemiological research, including routine premarital physical examination (gynecological examination, laboratory examination, accessory examination, and counseling and nuestionnaire survev. According to the snecific criteria, cluster samnling based on health facility was adopted to choose2premarital physical examination clinics in Huangdao and JiMo district, Qingdao city, Shandong province. We surveyed all the eligible (between20-39years old; unmarried; with willing to participate in this study) unmarried young women who sought premarital physical examination service in the selected clinics, i.e.1575unmarried young women were included in this survey. Statistical analysis methods in the quantitative study included:descriptive analysis, single factor analysis (chi-square test, single factor Logistic analysis), Fisher exact probabilities, nonparametric test, collinearity diagnostics, multiple Logistic regression analysis. Descriptive analysis was used to describe current situation of reproductive health knowledge, attitudes, and practices. Chi-squre test, single factor Logistic analysis, Fisher exact probabilities, and nonparametric test were used to understand different situations of reproductive health knowledge, attitudes, and practices among unmarried young women with different backgrounds. The qualitative research includes in-depth interviews and focused group discussion.15unmarried young women were included in the qualitative research according to the principle of information saturation. The process of interviews was taped with a record pen. We transcribed and coded the data, listed the sorting form, and composed the report.Results:Our study lasted for5months from August2011to December2011. We planned to investigate1680unmarried young women. The respondents included unmarried young women seeking for premarital physical examination services in selected clinics in two districts of Qingdao city, Shandong province. Actually we handed out1680questionnaires,1680were returned, and1575were eligible. The respondent rate was100%and the eligible questionnaire rate was93.8%.1. Reproductive health knowledge and attitudes:The questionnaire in our study used20questions to understand unmarried young women’s knowledge and attitudes about contraception, induced abortion and pregnancy, sexual health, and reproductive tract infections. Weights of each question are all the same and each question counts for1score. Respondents get1score by a correct response and0by a wrong response or by choosing ’haven’ t heard of or’don’t know’. Then, the scores were converted into100-scale. So, the full score was25for each aspect. In statistical analysis,33.0%of respondents scored40～60(in100-scale), which should be ranked as middle knowledge level.35.7%of respondents scored under40, which should be considered as low knowledge level, while31.3%of them scored higher than60. After comparison of knowledge and attitude scores of four aspects, we found out that average score of sexual health was the lowest with only9.8(in25-scale) whereas the average score of knowledge related with pregnancy and induced abortion was the highest with15.1(in25-scale). There were more than10%of respondents who scored0by answering sexual health and reproductive tract infection, which means that they knew nothing about those questions.Talking about traditional contraception, respondents always ’do not know anything about rhythm contraception’, or ’know nothing about withdrawal’. Many respondents cannot tell the differences from emergency contraceptive and oral contraceptive, considering that’they are almost the same. They should be taken before (sexual behavior) because they are both the oral contraceptives’. Experiences and stories of acquaintances can exert impact on unmarried young women’s opinions about commonly used contraception. For example,’(IUD) is not so effective because my friend got pregnant even though she used IUD’. The majority of respondents can realized that induced abortion’can result in infertility’, and they tended to regard that topics about sexual health, like unwanted sex,’should be seemed as private affairs of couples which cannot be confessed to other people’2. Difference of reproductive health knowledge and attitude among unmarried young women with different backgrounds:Comparing scores of reproductive health knowledge and attitude among unmarried young women with different backgrounds, we found out that factors such as age (OR=1.465,2.089,1.693), educational background (OR=3.040,4.461), occupation (OR=2.177), monthly income (OR=1.335), and residence (OR=1.472) were correlated with their knowledge scores (P<0.05). Those respondents with older age, superior educational background, intellectual work, higher monthly income, and nonlocal residence are more likely to acquire higher knowledge scores.For those significant factors in single factor analysis, the author conducted binary logistic regression analysis to explore influencing factors of reproductive health knowledge and attitude scores. The results showed that sites, monthly income, and educational background were the influencing factors. Compared with unmarried youngwomen in Huangdao, those in Jimo were less likely to acquire high knowledge scores (OR=0.652). Compared with respondents with monthly income less than2000yuan, those with monthly income higher than2000yuan but lower than5000yuan (OR=1.586). and higher than5000yuan (OR=3.696) are more likely to obtain high knowledge scores. Compared with unmarried young women with inferior educational background, those received high school education (OR=2.702) and college education (OR=3.255) are more likely to get high knowledge scores.3. Reproductive health practices of unmarried young women:3.1Premarital sexual behavior and contraception of unmarried youngwomen:1313respondents (83.4%) had premarital sexual behavior. The earliest sexual debut was11-year-old, and the average age of sexual debut was22.7.26.4%of first sexual behaviors were unprotected sex.11.1%of first sexual behaviors used traditional contraceptives such as rhythm or withdrawal, while the rest62.5%adopted modern contraception such as condoms, oral contraceptives, emergency contraceptives, and IUD in first sexual debut.6.3%of sexual debut were unwanted sex. Defining risky sexual debut as unwanted sexual debut, absence of contraception or using traditional contraception in sexual debut, and having sex earlier than20-year-old, we proved that occupation and age should be considered as influencing factors of risky sexual debut (P<0.05). Compared with unemployed respondents or unmarried young females engaging in labor-oriented work, those with intellectual work are less likely to have risky sexual debut (OR=0.742). Compared with respondents aged between20～23years old, those aged24～25,26～28, older than29years old are less likely to have risky sexual debut ar(?) ORs were0.695,0.677, and0.597respectively.-4%of respondents were already cohabitating with their male partners. Approximately70%of respondents chose condoms in the last6months, and23.5%and21.2%adopted rhythm and withdrawal, which were the second commonly used contraceptives. Emergency contraceptive and oral contraceptive were used by15.6%and4.3%of respondents in the last6months respectively.25.9%of unmarried young females had at least one unprotected sexual behavior in the last6months. As for the avenue of contraception acquisition, drug stores and supermarkets (58.5%) were the most commonly used avenue. The results of quantitative research have been further validated by qualitative study outcome. For example,’nowadays, young people tend to have sex early’, and they tend to choose contraception carelessly because they’knew nothing (about contraception)’.3.2Unintended pregnancyand history of induced abortion of unmarried young women:478(36.4%) unmarried young women had history of premarital pregnancy and213of them were pregnant when the research was conducting. Among those with history of premarital pregnancy,60.2%of them had history of unintended pregnancy and53.2%were caused by contraception failure whereas46.8%were caused by unprotected sex.269respondents (17.1%) had history of induced abortion. The earliest age of first induced abortion was14-year-old, and19.4%of them had first induced abortion at or before20-year-old.66women in our study had repeated induced abortion, accounting for24.5%of all respondents with induced abortion history. Among them,2respondents had5induced abortions.149(55.4%) respondents chose medical abortion, and146(54.3%) chose surgical abortion. The majority of (74.3%) unmarried young women who had induced abortion chose hospitals,17.6%chose family planning service centers,5.7%chose private clinics, and2.3%chose to conduct abortion at home by themselves. According to the qualitative research, interviewees chose legal medical institution like ’Renmin hospital’to seek for induced abortion services, but what should be noticed is that complications like’pelvic infection’and’cervical erosion’did occur.3.3Unwanted sexand sexual dysfunction of unmarried young women:In the last6months,301unmarried young women (23.1%) had history of unwanted sex, and66.1%of them reflected that they occasionally encountered unwanted sex whereas5.3%of them reported that they always suffered from unwanted sex.37.9%of respondents with history of unwanted sex reported absence of contraception in their latest unwanted sex, while40.5%adopted condoms.The three most common sexual dysfunction sym(?)were inability to become aroused, lack of orgasm, and inhibited sexual desire, and the percentages of respondents reporting such symptoms were over20%. The interviews of those respondents with female sexual dysfunction symptoms such as’insufficient vaginal lubrication’indicated that they can’communicate with male partner to solve these problems’.In our study, encountering sexual health disorder was defined as having at least one or more female sexual dysfunction symptoms and/or having history of unwanted sex. Under this circumstance, the influencing factors of encountering sexual health disorder by unmarried young women included coerced sexual debut (OR=3.054), reproductive health knowledge and attitude score (OR=0.526), and educational background (OR=2.051).3.4History of reproductive tract infections and gynaopathyof unmarried young women:34.1%of respondents had at least one gynecological symptom. Among them, the disorders of vaginal secretion were the most commonly reported symptom, followed by problems of menstruation. Nearly30%of respondents with gynecological symptoms did nothing to cope with the disorders, while over half of the sample sought for professional treatment in medical institutions. Besides, close to10%of them chose to buy medicines according to their own judgment, and2.8%went to illegal private clinics.17.0%of respondents have been diagnosed at least one gynaopathy. The two most common gynaopathies were abnormal menstruation or amenorrhoea (8.7%) and adnexitis (7.3%).266(16.9%) surveyed women have been diagnosed at least one reproductive tract infection. Among our respondents,9.1%have suffered from trichomonas vaginitis and/or mycotic vaginitis. In addition,9.7%have been diagnosed bacterial vaginosis. Among all the respondents with history of reproductive tract infection,41.9%had repeated reproductive tract infections. The percentage of early diagnosis of first reproductive tract infection (before20-year-old) was9.3%, which was higher than that of respondents without history of repeated reproductive tract infection (2.0%).77.5%and13.7%of reported reproductive tract infections were diagnosed in medical institutions and family planning service centers respectively, while6.8%and2.0%were diagnosed by illegal private clinics and dispensaries of workplaces respectively. More than90%of diagnosed reproductive tract infections by family planning service centers, medical institutions, and even illegal private clinics based on results of laboratory examinations whereas only60%of diagnosed reproductive tract infections by dispensaries of workplaces based on results of laboratory examinations. The majority (68.2%) of respondents with history of reproductive tract infections diagnosed by medical institutions have been cured without relapse. However, the rate of relapse of respondents with history of reproductive tract infections diagnosed by illegal private clinics was as high as61.5%. The highest rate of relapse of reproductive tract infections was those diagnosed by dispensaries of workplaces (higher than90%).3.5History of other reproductive health problems of unmarried young women:The incidences of abnormal breast size, vulvar skin malnutrition, abnormal vaginal secretion (in color, property, or smell), cervical erosion, abnormal uterus size, poor mobility of uterus, and accessory tenderness were0.2%,0.2%,2.3%,4.5%,0.2%,0.2%, and0.3%respectively.Among those405respondents who went through vaginal secretion laboratory examinations, the prevalence rates of trichomonas vaginitis and mycotic vaginitis were0.7%and1.5%respectively. The rate of positive result in test of Amine was0.5%. Additionally,1.5%of respondents had vaginal cleaning degree Ⅲ.34respondents had positiveHBsAg, accounting for2.3%of the total sample.18respondents (2.2%) had abnormal ATL.166(11.1%) unmarried young women had haemoglobin lower than normal range. In RPR test,8of respondents had positive result, accounting for0.5%. HIV test did not detect any positive result.9.5%of respondents had history of vagina operation.29.2%of surveyed women in our study reported that they failed to clean vulva every day, and36.8%of them cannot ask their male partners to clean before sexual intercourse.According to the focused group discussion, the interviewees recognized that the most commonly occurredgynaopathy and reproductive tract infection was dysmenorrheal, saying that’(the most commonly occurredgynaopathy and reproductive tract infection) might be dysmenorrheal, which means belly ache during menstruation. I think that everyone of us suffered from it. I can recall that all five or six roommates in our dormitory experienced dysmenorrheal. Someone of us had apparent symptom at the first day (of menstruation) or half a day, but sometimes pain occurred to some of us so severely that we may roll on the bed and cannot stand up and even throw up’.’I haven’t heard about any friend of mine suffered from other gynaopathies. I think they will not tell other people if they suffered such diseases.’Other interviewees reflected that they had history of other menstruation disorders or abnormal vaginal secretion:’I had irregular menstruation cycle. Sometimes I had menstruation once a month, but sometimes once per three months. By the way, I also had concerns about my vaginal secretion’.Interviewees who had been diagnosed more than one gynaopathies said:’I suffered pelvic inflammationat first, and it was treated in Renmin Hospital. But relapse did occur later. And then I suffered cervical erosion... I cannot remember the degree. I sought for treatment in Renmin Hospital again. And after that, instead of counseling at hospital, I chose to buy medicine by myself (laughing), because I thought I knew the cause and therapy of my symptoms. It turned out that I can treat myself. Now I insist on cleaning every day.’Sometimes, attitudes of health staff and poor access and high feeof medical care in China appeared to be one of the major barriers of treatment seeking by unmarried young women:’It’s so difficult to seek for medical care nowadays. Despite the unaffordable fees, I cannot stand for all the troubles caused by booking an expert. For instance, I have to get up so early. Otherwise, those doctors other than experts cannot make wise diagnosis under most circumstances. Besides, they (health staff) are too busy to talk detailed information with us. I have to spend longer time in waiting than in counseling. It’s not worthy.’4.History of other reproductive health problems of unmarried young women:In our study, case group consisted of respondents with at least one kind of reproductive health problem including unwanted sex, induced abortion, and reproductive tract infections, while control group consisted of respondents without those reproductive health problems mentioned above. Results of single factor analysis showed that sites, age, monthly income, occupation, educational backgrounds, statue of cohabitation, age of sexual debut, and history of vaginal operation were correlated with risk of encountering reproductive health problems. Multiple logistic regression analysis validated that site, monthly income, age of sexual debut, and history of vaginal operation were influencing factors of reproductive health problems of unmarried young women whereas factors like age, occupation, educational backgrounds, and statue of cohabitation were excluded. Unmarried young women in Jimo were less likely to suffer from reproductive health problems compared with their counterparts in Huangdao (OR=0.357). In comparison with respondents with monthly income less than2000yuan per month, those with higher than2000yuan but lower than5000yuan per month (OR=1.873) and those with higher than5000yuan per month (OR=3.077) were more likely to encounter reproductive health problems. Those respondents had sexual debut older than20-year-old (OR=0.476) were less likely to suffer from reproductive health problems. History of vaginal operation could increase the risk of occurrence of reproductive health problems (OR=3.283).Conclusions:1. The reproductive health knowledge level of unmarried young women was not high. Most of studied respondents had moderate or even poor mastery of reproductive health knowledge. The mastery of knowledge about sexual health issues and prevention of reproductive tract infections was the poorest. According to qualitative research, the interviewees’ perception regarding common contraception tended to be affected by experiences of their acquaintance. They retained worries and discrimination about premarital pregnancy and confused about concepts of reproductive tract infections and gynaopathy. Sexual health issues have been regarded as the most embarrassed topic to be discussed by interviewees. Their channels of reproductive health information limited to television programs or internet.2. Respondents from different places, with different monthly income, having different educational backgrounds achieved different levels of knowledge scores in our study. Higher level of reproductive health knowledge score was acquired by unmarried young women in Huangdao. Economic background influenced level of reproductive health knowledge score positively. Respondents with superior educational backgrounds were more likely to gain higher level of reproductive health knowledge score.3. Reproductive health service demands exist among unmarried young women. The occurrence of premarital sex was prevalent among such population, and early sexual debut, unwanted sex, and risky sex did happen. There were a high percentage of respondents who had history of induced abortion, repeated induced abortion, and risky induced abortion. It is worthy of paying more attention to sexual health issues such as unwanted sex and female sexual dysfunction. Unmarried young women concerned about problems about vaginal secretion and menstruation. Besides, a part of respondents had abnormal menstruation, amenorrhoea, adnexitis, trichomonal vaginitis, mycotic vaginitis, and bacterial vaginitis. Though many respondents managed to seek for professional treatment in medical institutions for reproductive tract infections, the repeated infections, which appeared to be correlated with treatment seeking in illegal institutions, should be paid more(?)tion. Rate of anaemia was high according to our laboratory examination, demo(?)ting that this issue might be prevalent among this group of population. Measurements aiming at improving daily health habits of unmarried young women should be developed.4. There were differences in occurrence of reproductive health problems among respondents from different places, with different monthly income, age of sexual debut, and history of vaginal operation. Compared with respondents from Jimo and those with monthly income less than2000yuan per month, those from Huangdao and those earning more than2000yuan per month were more likely to suffer from reproductive health problems such as unwanted sex, induced abortion, and reproductive tract infections. The contradiction between relatively high level of knowledge mastery and relatively high risk of encountering reproductive health problems indicated that the current mastery of knowledge by such group of population might not profound enough to instruct their practical behaviors. Furthermore, unmarried young women with early sexual debut and history of vaginal operation were more likely to suffer from reproductive health problems.Suggestions:1. Further efforts should be made in order to improve reproductive health knowledge mastery of unmarried young women. Instructions and education as well as services should target profound knowledge so that the mastery of knowledge could exert positive impact on practical behaviors. In addition, prevention and symptoms of reproductive tract infections and gynaopathy should be stressed too. Information about unwanted sex and sexual dysfunction of young females should be propagandized further to form positive and healthy attitudes towards sexuality. In this way, helpful treatment seeking could be encouraged to confront with sexual health issues.2. Services, such as instruction and education, counseling, and lectures, etc., aiming at reproductive health knowledge and attitudes improvement should incorporate unmarried young women in rural area or regions with inferior economic development, with lower monthly income, and inferior educational backgrounds into the focused population.3. Reproductive health s(?) demands do exist among unmarried young women. Because of prevalent (?)tal sex, unwanted sex, unintended pregnancy, reproductive tract infections, gynaopathy, and sexual health issues among such group of population, the unmarried young women-oriented reproductive health service should be separated from the married women-oriented services so that satisfy those unmet service demands of the former population. The core elements of this customized service should include education and instruction of reproductive health knowledge, correction of misunderstanding and unhealthy attitudes towards sexuality, cultivation of positive daily health habits, encouragement of eugeniescounseling before pregnancy, etc. Service attitudes of health staff should be bettered. 4. Unmarried young women from places with superior economic development and monthly income should be regarded as focused group of reproductive health services. Improvement of behaviors of such group of population can hardly be achieved without long term interventions and services instead of short term instruction and education. Delay of sexual debut age and prohibition of vaginal operation by illegal clinics should be considered as targets of reproductive health services.5. Premarital physical examination appears to be one of the effective avenues to timely detect prevalent reproductive health problems among unmarried young women. It managed to help us to detect hepatitis B, anaemia, syphilis, etc. before marriage so that future severe impact on marriage and reproduction by undesirable reproductive health events could be prevented. Therefore, standardization and acceptance of premarital physical examination should attract further attention.