Factors associated with utilization of reproductive healthcare services among migrant women workers in Chong Qing, China Shu Su, Fan Zhang, Qin Liu, Yang Wang, Jing Wen, Xiaojun Tang, Lei Zhang PII: DOI: Reference:
S0020-7292(14)00254-9 doi: 10.1016/j.ijgo.2014.04.005 IJG 7988
To appear in:
International Journal of Gynecology and Obstetrics
Received date: Revised date: Accepted date:
11 December 2013 9 April 2014 21 May 2014
Please cite this article as: Su Shu, Zhang Fan, Liu Qin, Wang Yang, Wen Jing, Tang Xiaojun, Zhang Lei, Factors associated with utilization of reproductive healthcare services among migrant women workers in Chong Qing, China, International Journal of Gynecology and Obstetrics (2014), doi: 10.1016/j.ijgo.2014.04.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT CLINICAL ARTICLE Factors associated with utilization of reproductive healthcare services among
SC R
IP
T
migrant women workers in Chong Qing, China
Shu Su a, Fan Zhang a, Qin Liu a, Yang Wang a, Jing Wen a, Xiaojun Tang a,*, Lei
School of Public Health and Management, Chong Qing Medical University, Chong
MA
a
NU
Zhang b
Qing, China
The Kirby Institute, University of New South Wales, Sydney, Australia
TE
D
b
CE P
* Corresponding author: Xiaojun Tang Chong Qing Medical University, Chong Qing Yi Xue Yuan Road 1, Yu Zhong District,
AC
Chong Qing, Postcode:400016, China. Tel.: +86 023 68485228; fax: +86 023 68485228.
E-mail address: [email protected]
Keywords: China; Low-resource country; Migrant female workers; Reproductive health
Synopsis: An interview-based study exploring the utilization of reproductive health care in western China found that migrant women workers are vulnerable owing to lack
ACCEPTED MANUSCRIPT
AC
CE P
TE
D
MA
NU
SC R
IP
T
of reproductive health care.
ACCEPTED MANUSCRIPT ABSTRACT Objective: To investigate the use of reproductive healthcare services among migrant
T
women workers in Chong Qing, China, and provide suggestions to improve the
IP
utilization of these services by young women.
SC R
Methods: In a qualitative interview-based study between March, 2013 and June, 2013, personal in-depth interviews were conducted among young women workers, factory
NU
doctors, healthcare service providers, and policy-makers in Chong Qing, China. Results: Women workers seldom visited hospitals and did so only when their pain
MA
became unbearable. The workers’ use of reproductive healthcare services was
D
particularly influenced by the high cost of hospitalization and long waiting periods.
TE
Factory doctors could only solve minor problems. Public healthcare providers stated that migrant women had a higher morbidity rate from reproductive tract infections as
CE P
compared with local women. The policy-makers considered that the health system was beneficial to women’s reproductive health; however, few workers had good
AC
comprehension of government policies. Conclusion: Migrant women workers are vulnerable owing to lack of reproductive health care. The government and both social and health enterprise should consider the convenience of these women and the affordability of treatments when formulating reproductive healthcare policies. Effective measures should be taken to improve the use of these services by migrant women workers.
ACCEPTED MANUSCRIPT 1. Introduction Governments have focused on the issue of women’s reproductive health care, but
IP
T
health services still do not meet the needs of certain populations of women, even in
SC R
high-resource countries such as the USA [1]. Being the most populous country in the world, China also faces several challenges in terms of providing sufficient healthcare
NU
for women.
MA
Reproductive health has been defined by WHO as having a responsible, satisfying, and safe sex life, along with the capability to reproduce and the freedom to decide if,
D
when, and how often to do so [2]. Traditionally, women in China have a lower position
TE
in the family than men, and this position is the reason why women have ignored their
CE P
reproductive health and felt shame at contracting a reproductive disease [3,4].
equitab
AC
The Chinese government has implemented new health reforms, which aim to provide
le reproductive healthcare to men and women in local hospitals [5]. However, the floating population of migrant workers that cannot be connected to one hospital is a weak link in the realization of these aims. Migration is inevitable during the development of the country, and thus, floating workers—particularly young female employees—should receive the complete benefits of reproductive healthcare despite their location.
ACCEPTED MANUSCRIPT Chong Qing is a major city in southwest China and one of the four municipalities directly controlled by the Chinese government (the other three are Beijing, Shanghai,
IP
T
and Tianjin). Chong Qing is also the only municipality in inland China [6]. The
SC R
numerous employment opportunities available in Chong Qin have attracted many migrant workers.
NU
The aim of the present study was to understand the use of reproductive healthcare
MA
services among migrant women workers in Chong Qing, China, and to provide suggestions to improve the utilization of reproductive healthcare services by young
TE
D
women.
CE P
2. Materials and methods
Jiulongpo District was chosen for the study because it is one of nine main urban
AC
areas with many large high-technology institutions, where more than 60% of the migrant workers in Chong Qing work. Surveys were carried out between March, 2013 and June, 2013 at two major Chong Qing-based factories—a manufacturer of motorcycles and a high-technology industry—each with almost 90% floating employees from all regions of China.
Among young female floating employees in the two factories, reproductive health status, attitude toward reproductive health, and utilization rate of reproductive healthcare services were assessed to improve the nature of these services in China.
ACCEPTED MANUSCRIPT The study aimed to cover workers from as many different provinces as possible to
IP
T
ensure that the surveyed sample was highly representative of the population.
SC R
Women in the two factories were categorized into age groups: 18–24 years, 25–30 years, 31–36 years, and older than 36 years. Most workers (76.1%) were aged 18–24 years, and eight married and eight unmarried women from this age group were
NU
chosen for interview by computer-generated random selection. Seven key “insiders”
MA
were also interviewed: two directors of the factories, two obstetrician/gynecologists from public institutions, one doctor from a factory clinic, the president of a maternal
TE
CE P
included in the study.
D
and child care service center, and one policy-maker. In total, 23 participants were
Outlines of each of the interview types were created before the formal survey was
AC
conducted, and the interviews were perfected throughout the research process. The research team was trained on how to conduct qualitative discussions by a group of experts, who also provided on-the-spot guidance.
In-depth individual interviews were conducted with the 16 female workers, who were then organized into groups to create a focus group discussion. Interviews were also conducted with the seven key insiders. The results of the interviews were documented for further analysis. Recording and writing were done simultaneously in order to ensure the comprehensiveness and reliability of the data. We adopted dual
ACCEPTED MANUSCRIPT coding for the analysis process in order to reduce bias.
IP
T
The content of each of the interviews was transferred to a single record, which was
SC R
repeatedly checked for consistency with the original version after rerecording. Key statements and opinions were highlighted to establish the framework of the results
NU
with regard to the aims of the research and survey outlines.
MA
The qualitative analysis software MAXQDA 2010 (Verbi, Berlin, Germany) was used to manage and code the text. The data were then compiled and analyzed in
TE
D
accordance with the classifications.
CE P
3. Results
Seven of the 16 workers were from eastern Chinese provinces (e.g. Fu Jian and
AC
Shan Dong). Nine workers were from western Chinese provinces (e.g. Si Chuan, Gui Zhou, Yun Nan, and Gan Su). The average age of all participants was 21.6 years. The average age of the married participants was 20.5 years. Three of the women had children.
All of the participants lived in dormitories, which were arranged by the factory, with 10 women per room. The study participants were from 12 rooms. Eleven women had completed junior high school, four had completed senior high school, and one had graduated from junior college. The average income of the workers was approximately
ACCEPTED MANUSCRIPT 1800 RMB (US $295) per month.
IP
T
In terms of past use of health services, one participant had visited a doctor for a
SC R
reproductive health concern on two occasions, three had visited a hospital once for a similar matter, and the rest claimed to have never gone to a hospital for gynecologic issues. Four women further admitted that they would not visit the hospital unless their
NU
pain became unbearable and that they chose to ignore minor problems or to visit
MA
cheap and private or illegal clinics instead. The participants did not consider public hospitals as an option, given the high costs of hospitalization and the long waiting
D
periods owing to the high numbers of patients in such hospitals. Instead of public
CE P
TE
hospitals, these workers chose nearby clinics for treatment.
Five of the 16 women mentioned that the councils of their local communities
AC
occasionally distributed free condoms to promote sexual health, but the women chose not to take these condoms. The women also lacked general awareness about their sexual health.
The healthcare service providers in the factories stated that their on-site dispensaries stocked only limited medicines. Thus, regardless of the reproductive problems of women employees, healthcare service providers merely prescribed oral medicines or body wash for every complaint. The most common concerns among the employees were irregular menstruation and vaginitis. For more serious concerns, the healthcare
ACCEPTED MANUSCRIPT providers said that they recommended visiting a specialized hospital, but they did not
IP
T
know whether their advice was followed.
SC R
The public healthcare providers stated that 50%–60% of the female patients who went to the healthcare center for treatment were not local, and these women had a higher morbidity rate from reproductive tract infections as compared with local women.
NU
Healthcare providers believed that this finding was probably due to bad living habits
MA
and poor health in their rural hometowns. However, only half of the women opted for
D
further consultations with doctors and strictly followed medical advice.
TE
All of the women knew that condoms, oral contraceptives, and security rings could
CE P
help to avoid pregnancy. Three participants often used contraception during their sexual activity, whereas four had never used any form of contraception. The
AC
remaining participants used contraception for 20%–30% of their sexual activity. As a result, frequent unplanned pregnancies still occurred. The women were not entirely aware of how abortion might damage their health, and 87.5% (n=14) of them did not know the “safe” days of the month. Apart from lacking awareness about pregnancy prevention methods, many of these workers failed to take any precautionary measures during sex, mainly because of a lack of cooperation from their husbands and boyfriends.
Among the women, 13 were not aware of the kinds of behavior that might harm their
ACCEPTED MANUSCRIPT reproductive health. For example, thee workers did not know the right time to have an abortion procedure or how to decide between a drug abortion and an artificial abortion.
IP
T
Furthermore, the workers considered abortion as a simple and low-cost procedure,
SC R
and therefore did not pay much attention to unplanned pregnancies. Immediately after an abortion, the women continued doing intense jobs without getting adequate rest because they considered an abortion to be a private matter that should not be
MA
NU
discussed with others.
The participants knew even less about venereal disease than about other
D
reproductive problems, but did not seek guidance and information because they
TE
regarded venereal disease to be an extremely sensitive subject. One of the prevalent
CE P
misconceptions among the women was that HIV can spread from sharing meals or talking. Notably, nearly all of the women lacked knowledge of how to prevent venereal
AC
diseases.
Participants in the married group had got married younger compared with local women and at younger ages than those permissible by Chinese law. In China, the legal ages for marriage for men and women are 22 and 20 years, respectively; marriage before these ages is considered illegal [7]. The study found that unplanned pregnancies at these ages had caused critical damage to the reproductive health of the study participants.
ACCEPTED MANUSCRIPT The policy-maker who was interviewed claimed that an excellent system for the management of female reproductive health exists. National policies have been
IP
T
established to address reproductive issues, such as abortion, parturition, and
SC R
marriage, among others. However, nearly all of the surveyed women lacked knowledge of these policies. For instance, 87.5% (n=14) of the participants were not aware that they were eligible for free physical examinations to address their
NU
reproductive problems, maternity leave, abortion leave, and alternative work
MA
arrangements during pregnancy.
D
4. Discussion
TE
Owing to limited funding, only 23 individuals were surveyed during the in-depth
CE P
interviews. Although the sample population was small, it represented the women migrant workers. All of the migrant workers lived in 10-person dormitories, had a
AC
close relationship with each other, and shared a similar opinion regarding the subject matter. The study participants revealed their roommates’ opinions and experiences during the interview. Thus, one interviewee shared the opinion of her roommates. Moreover, the women interviewed were from the main provinces from which workers in Chong Qing usually originate—namely, Si Chuan, Gui Zhou, Yun Nan, Shan Dong, and Qing Hai [8]. According to data on migrant women workers in Chong Qing, 70% of migrant women workers are aged between 18 and 24 years [9], which is consistent with the present study sample. Nevertheless, further research should be conducted on a large sample size to make convincing recommendations.
ACCEPTED MANUSCRIPT
Overall, the participants were apathetic about their reproductive health and did not
IP
T
seek help from healthcare providers because they lacked basic knowledge about
SC R
reproductive health. Moreover, the women believed that they were very young, and therefore immune from serious consequences. Sensible suggestions were provided but were largely ignored by these workers. The women would conceal their
NU
reproductive illnesses for fear of criticism from doctors and discrimination by their
MA
superior or colleagues because of the belief that the patient’s disease would infect other workers [10,11]. The women were embarrassed about discussing these matters
D
with doctors and would only visit the healthcare centers for issues such as venereal
TE
diseases and unplanned pregnancies. They chose to purchase medicines from the
CE P
drugstore and personally handle their health issues. However, such actions only
AC
worsen their health conditions.
Factory management and policy-makers did not consider the establishment of relevant health policies for the female employees in the factories. Moreover, factory management and policy-makers did not clarify their reproductive health policies on maternity, marriage, and abortion leave, or work arrangements during pregnancy. Reproductive health education was not offered to female employees.
Factory clinics were not equipped to offer professional consultations on reproductive health, and only basic medicines and simple testing equipment were available to
ACCEPTED MANUSCRIPT employees. Public hospitals might offer a complete range of reproductive health services, but they should be more sensitive to the situations of migrant employees by
IP
T
lowering the expenses incurred and developing a green channel for migrant treatment.
SC R
In the present study, migrant workers were not encouraged to seek timely health care, and half of the population that was interviewed lacked knowledge of the healthcare
NU
rights offered by the government.
MA
Female employees should be educated about welfare policies for women, such as maternity insurance. Rules on holidays, including marriage, maternity, and abortion
D
leave, should be clearly communicated to prevent these workers from exerting
TE
themselves by doing heavy work at sensitive times. The gynecologic census and
CE P
provision of free physical examinations should be promoted among the women, and funds should be allocated to equip factory clinics with specialized medical instruments.
AC
Moreover, hospitals could establish special gynecologic tests for migrant female employees, and the factory management should pay more attention to the health of female employees.
Factories, hospitals, and communities should cooperate to offer systematic healthcare education to floating populations via informative lectures, leaflets, and compact discs. These educational tools should provide information on the prevention and harmful effects of venereal diseases, especially AIDS, along with information on contraception measures, solutions for unplanned pregnancies, the harmful effects of
ACCEPTED MANUSCRIPT abortion, and the importance of premarital physical examinations. Consequently, young women would be encouraged to protect themselves and to make informed
SC R
IP
T
choices about their own sexual behavior.
We recommend establishing communities in the factory or living areas to help female employees address their reproductive health needs by prevention and treatment.
NU
When distributing free condoms to floating female populations, the family planning
MA
office should educate these women on the relevance of condom use in preventing
D
pregnancy and the spread of sexually transmitted infections such as HIV.
TE
Nowadays, cities develop and grow extremely fast with the help of a large floating
CE P
population of migrants who contribute to the development of that city and the country. Despite their contribution, however, these women usually live in poor conditions and
AC
lack basic knowledge of reproductive health. Healthcare services can effectively help lower the incidence of venereal diseases, unplanned pregnancies, artificial abortions, and other serious health issues among migrant workers. The workers should also develop good living habits, self-esteem, and a positive attitude toward their own reproductive health. Such development will benefit their own families and help to improve the reproductive health status of women in China.
Conflict of interest The authors have no conflicts of interest.
ACCEPTED MANUSCRIPT References [1]
Saleeby E, Brindis CD. Women, reproductive health, and health reform. JAMA
World Health Organization. Reproductive Health.
[3]
SC R
http://www.who.int/topics/reproductive_health/en/.
IP
[2]
T
2011;306(11):1256–7.
Jeffreys E. Introduction: Talking Sex and Sexuality in China. In: Jeffreys E, ed.
[4]
NU
Sex and Sexuality in China. London: Routledge; 2007:1–20.
Xiao Z, Mehrotra P, Zimmerman R. Sexual revolution in China: Implications for
Tang S, Meng Q, Chen L, Bekedam H, Evans T, Whitehead M. Tackling the
D
[5]
MA
Chinese women and society. AIDS Care 2011;23 Suppl 1:105–12.
[6]
TE
challenges to health equity in China. Lancet 2008;372(9648):1493–501. Briney A. Geography of China’s Municipalities: Learn about China’s Four
CE P
Direct-Controlled Municipalities.
http://geography.about.com/od/chinamaps/tp/china-municipalities.htm. Agarwal R. Marriage law in China revised. China Report 2002;38:407–413.
[8]
Yang Yali, Zhang Cuiju. Correlation analysis between Chong Qing population
AC
[7]
movement and economic development. Hei Long Jiang Agricultural Science 2011;5:102–105. [9]
Wu J. The impact of floating population on the socio-economic development
and the countermeasures—based on the census data of Shapingba, Chong Qing. Journal of Shijiazhuang University of Economics 2013;6:111–114. [10]
Liu H, Li M, Jin M, Jing F, Wang H, Chen K. Public awareness of three major
infectious diseases in rural Zhejiang province, China: a cross-sectional study. BMC
ACCEPTED MANUSCRIPT Infect Dis 2013;13(1):192. [11]
Yan HJ. HIV/AIDS related stigma and discrimination in people living with
IP
T
HIV/AIDS and intervention strategies in Jiangsu Province China. International Journal
AC
CE P
TE
D
MA
NU
SC R
of Infectious Diseases 2008;12:e156–e157.
S0020-7292(14)00254-9 doi: 10.1016/j.ijgo.2014.04.005 IJG 7988
To appear in:
International Journal of Gynecology and Obstetrics
Received date: Revised date: Accepted date:
11 December 2013 9 April 2014 21 May 2014
Please cite this article as: Su Shu, Zhang Fan, Liu Qin, Wang Yang, Wen Jing, Tang Xiaojun, Zhang Lei, Factors associated with utilization of reproductive healthcare services among migrant women workers in Chong Qing, China, International Journal of Gynecology and Obstetrics (2014), doi: 10.1016/j.ijgo.2014.04.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT CLINICAL ARTICLE Factors associated with utilization of reproductive healthcare services among
SC R
IP
T
migrant women workers in Chong Qing, China
Shu Su a, Fan Zhang a, Qin Liu a, Yang Wang a, Jing Wen a, Xiaojun Tang a,*, Lei
School of Public Health and Management, Chong Qing Medical University, Chong
MA
a
NU
Zhang b
Qing, China
The Kirby Institute, University of New South Wales, Sydney, Australia
TE
D
b
CE P
* Corresponding author: Xiaojun Tang Chong Qing Medical University, Chong Qing Yi Xue Yuan Road 1, Yu Zhong District,
AC
Chong Qing, Postcode:400016, China. Tel.: +86 023 68485228; fax: +86 023 68485228.
E-mail address: [email protected]
Keywords: China; Low-resource country; Migrant female workers; Reproductive health
Synopsis: An interview-based study exploring the utilization of reproductive health care in western China found that migrant women workers are vulnerable owing to lack
ACCEPTED MANUSCRIPT
AC
CE P
TE
D
MA
NU
SC R
IP
T
of reproductive health care.
ACCEPTED MANUSCRIPT ABSTRACT Objective: To investigate the use of reproductive healthcare services among migrant
T
women workers in Chong Qing, China, and provide suggestions to improve the
IP
utilization of these services by young women.
SC R
Methods: In a qualitative interview-based study between March, 2013 and June, 2013, personal in-depth interviews were conducted among young women workers, factory
NU
doctors, healthcare service providers, and policy-makers in Chong Qing, China. Results: Women workers seldom visited hospitals and did so only when their pain
MA
became unbearable. The workers’ use of reproductive healthcare services was
D
particularly influenced by the high cost of hospitalization and long waiting periods.
TE
Factory doctors could only solve minor problems. Public healthcare providers stated that migrant women had a higher morbidity rate from reproductive tract infections as
CE P
compared with local women. The policy-makers considered that the health system was beneficial to women’s reproductive health; however, few workers had good
AC
comprehension of government policies. Conclusion: Migrant women workers are vulnerable owing to lack of reproductive health care. The government and both social and health enterprise should consider the convenience of these women and the affordability of treatments when formulating reproductive healthcare policies. Effective measures should be taken to improve the use of these services by migrant women workers.
ACCEPTED MANUSCRIPT 1. Introduction Governments have focused on the issue of women’s reproductive health care, but
IP
T
health services still do not meet the needs of certain populations of women, even in
SC R
high-resource countries such as the USA [1]. Being the most populous country in the world, China also faces several challenges in terms of providing sufficient healthcare
NU
for women.
MA
Reproductive health has been defined by WHO as having a responsible, satisfying, and safe sex life, along with the capability to reproduce and the freedom to decide if,
D
when, and how often to do so [2]. Traditionally, women in China have a lower position
TE
in the family than men, and this position is the reason why women have ignored their
CE P
reproductive health and felt shame at contracting a reproductive disease [3,4].
equitab
AC
The Chinese government has implemented new health reforms, which aim to provide
le reproductive healthcare to men and women in local hospitals [5]. However, the floating population of migrant workers that cannot be connected to one hospital is a weak link in the realization of these aims. Migration is inevitable during the development of the country, and thus, floating workers—particularly young female employees—should receive the complete benefits of reproductive healthcare despite their location.
ACCEPTED MANUSCRIPT Chong Qing is a major city in southwest China and one of the four municipalities directly controlled by the Chinese government (the other three are Beijing, Shanghai,
IP
T
and Tianjin). Chong Qing is also the only municipality in inland China [6]. The
SC R
numerous employment opportunities available in Chong Qin have attracted many migrant workers.
NU
The aim of the present study was to understand the use of reproductive healthcare
MA
services among migrant women workers in Chong Qing, China, and to provide suggestions to improve the utilization of reproductive healthcare services by young
TE
D
women.
CE P
2. Materials and methods
Jiulongpo District was chosen for the study because it is one of nine main urban
AC
areas with many large high-technology institutions, where more than 60% of the migrant workers in Chong Qing work. Surveys were carried out between March, 2013 and June, 2013 at two major Chong Qing-based factories—a manufacturer of motorcycles and a high-technology industry—each with almost 90% floating employees from all regions of China.
Among young female floating employees in the two factories, reproductive health status, attitude toward reproductive health, and utilization rate of reproductive healthcare services were assessed to improve the nature of these services in China.
ACCEPTED MANUSCRIPT The study aimed to cover workers from as many different provinces as possible to
IP
T
ensure that the surveyed sample was highly representative of the population.
SC R
Women in the two factories were categorized into age groups: 18–24 years, 25–30 years, 31–36 years, and older than 36 years. Most workers (76.1%) were aged 18–24 years, and eight married and eight unmarried women from this age group were
NU
chosen for interview by computer-generated random selection. Seven key “insiders”
MA
were also interviewed: two directors of the factories, two obstetrician/gynecologists from public institutions, one doctor from a factory clinic, the president of a maternal
TE
CE P
included in the study.
D
and child care service center, and one policy-maker. In total, 23 participants were
Outlines of each of the interview types were created before the formal survey was
AC
conducted, and the interviews were perfected throughout the research process. The research team was trained on how to conduct qualitative discussions by a group of experts, who also provided on-the-spot guidance.
In-depth individual interviews were conducted with the 16 female workers, who were then organized into groups to create a focus group discussion. Interviews were also conducted with the seven key insiders. The results of the interviews were documented for further analysis. Recording and writing were done simultaneously in order to ensure the comprehensiveness and reliability of the data. We adopted dual
ACCEPTED MANUSCRIPT coding for the analysis process in order to reduce bias.
IP
T
The content of each of the interviews was transferred to a single record, which was
SC R
repeatedly checked for consistency with the original version after rerecording. Key statements and opinions were highlighted to establish the framework of the results
NU
with regard to the aims of the research and survey outlines.
MA
The qualitative analysis software MAXQDA 2010 (Verbi, Berlin, Germany) was used to manage and code the text. The data were then compiled and analyzed in
TE
D
accordance with the classifications.
CE P
3. Results
Seven of the 16 workers were from eastern Chinese provinces (e.g. Fu Jian and
AC
Shan Dong). Nine workers were from western Chinese provinces (e.g. Si Chuan, Gui Zhou, Yun Nan, and Gan Su). The average age of all participants was 21.6 years. The average age of the married participants was 20.5 years. Three of the women had children.
All of the participants lived in dormitories, which were arranged by the factory, with 10 women per room. The study participants were from 12 rooms. Eleven women had completed junior high school, four had completed senior high school, and one had graduated from junior college. The average income of the workers was approximately
ACCEPTED MANUSCRIPT 1800 RMB (US $295) per month.
IP
T
In terms of past use of health services, one participant had visited a doctor for a
SC R
reproductive health concern on two occasions, three had visited a hospital once for a similar matter, and the rest claimed to have never gone to a hospital for gynecologic issues. Four women further admitted that they would not visit the hospital unless their
NU
pain became unbearable and that they chose to ignore minor problems or to visit
MA
cheap and private or illegal clinics instead. The participants did not consider public hospitals as an option, given the high costs of hospitalization and the long waiting
D
periods owing to the high numbers of patients in such hospitals. Instead of public
CE P
TE
hospitals, these workers chose nearby clinics for treatment.
Five of the 16 women mentioned that the councils of their local communities
AC
occasionally distributed free condoms to promote sexual health, but the women chose not to take these condoms. The women also lacked general awareness about their sexual health.
The healthcare service providers in the factories stated that their on-site dispensaries stocked only limited medicines. Thus, regardless of the reproductive problems of women employees, healthcare service providers merely prescribed oral medicines or body wash for every complaint. The most common concerns among the employees were irregular menstruation and vaginitis. For more serious concerns, the healthcare
ACCEPTED MANUSCRIPT providers said that they recommended visiting a specialized hospital, but they did not
IP
T
know whether their advice was followed.
SC R
The public healthcare providers stated that 50%–60% of the female patients who went to the healthcare center for treatment were not local, and these women had a higher morbidity rate from reproductive tract infections as compared with local women.
NU
Healthcare providers believed that this finding was probably due to bad living habits
MA
and poor health in their rural hometowns. However, only half of the women opted for
D
further consultations with doctors and strictly followed medical advice.
TE
All of the women knew that condoms, oral contraceptives, and security rings could
CE P
help to avoid pregnancy. Three participants often used contraception during their sexual activity, whereas four had never used any form of contraception. The
AC
remaining participants used contraception for 20%–30% of their sexual activity. As a result, frequent unplanned pregnancies still occurred. The women were not entirely aware of how abortion might damage their health, and 87.5% (n=14) of them did not know the “safe” days of the month. Apart from lacking awareness about pregnancy prevention methods, many of these workers failed to take any precautionary measures during sex, mainly because of a lack of cooperation from their husbands and boyfriends.
Among the women, 13 were not aware of the kinds of behavior that might harm their
ACCEPTED MANUSCRIPT reproductive health. For example, thee workers did not know the right time to have an abortion procedure or how to decide between a drug abortion and an artificial abortion.
IP
T
Furthermore, the workers considered abortion as a simple and low-cost procedure,
SC R
and therefore did not pay much attention to unplanned pregnancies. Immediately after an abortion, the women continued doing intense jobs without getting adequate rest because they considered an abortion to be a private matter that should not be
MA
NU
discussed with others.
The participants knew even less about venereal disease than about other
D
reproductive problems, but did not seek guidance and information because they
TE
regarded venereal disease to be an extremely sensitive subject. One of the prevalent
CE P
misconceptions among the women was that HIV can spread from sharing meals or talking. Notably, nearly all of the women lacked knowledge of how to prevent venereal
AC
diseases.
Participants in the married group had got married younger compared with local women and at younger ages than those permissible by Chinese law. In China, the legal ages for marriage for men and women are 22 and 20 years, respectively; marriage before these ages is considered illegal [7]. The study found that unplanned pregnancies at these ages had caused critical damage to the reproductive health of the study participants.
ACCEPTED MANUSCRIPT The policy-maker who was interviewed claimed that an excellent system for the management of female reproductive health exists. National policies have been
IP
T
established to address reproductive issues, such as abortion, parturition, and
SC R
marriage, among others. However, nearly all of the surveyed women lacked knowledge of these policies. For instance, 87.5% (n=14) of the participants were not aware that they were eligible for free physical examinations to address their
NU
reproductive problems, maternity leave, abortion leave, and alternative work
MA
arrangements during pregnancy.
D
4. Discussion
TE
Owing to limited funding, only 23 individuals were surveyed during the in-depth
CE P
interviews. Although the sample population was small, it represented the women migrant workers. All of the migrant workers lived in 10-person dormitories, had a
AC
close relationship with each other, and shared a similar opinion regarding the subject matter. The study participants revealed their roommates’ opinions and experiences during the interview. Thus, one interviewee shared the opinion of her roommates. Moreover, the women interviewed were from the main provinces from which workers in Chong Qing usually originate—namely, Si Chuan, Gui Zhou, Yun Nan, Shan Dong, and Qing Hai [8]. According to data on migrant women workers in Chong Qing, 70% of migrant women workers are aged between 18 and 24 years [9], which is consistent with the present study sample. Nevertheless, further research should be conducted on a large sample size to make convincing recommendations.
ACCEPTED MANUSCRIPT
Overall, the participants were apathetic about their reproductive health and did not
IP
T
seek help from healthcare providers because they lacked basic knowledge about
SC R
reproductive health. Moreover, the women believed that they were very young, and therefore immune from serious consequences. Sensible suggestions were provided but were largely ignored by these workers. The women would conceal their
NU
reproductive illnesses for fear of criticism from doctors and discrimination by their
MA
superior or colleagues because of the belief that the patient’s disease would infect other workers [10,11]. The women were embarrassed about discussing these matters
D
with doctors and would only visit the healthcare centers for issues such as venereal
TE
diseases and unplanned pregnancies. They chose to purchase medicines from the
CE P
drugstore and personally handle their health issues. However, such actions only
AC
worsen their health conditions.
Factory management and policy-makers did not consider the establishment of relevant health policies for the female employees in the factories. Moreover, factory management and policy-makers did not clarify their reproductive health policies on maternity, marriage, and abortion leave, or work arrangements during pregnancy. Reproductive health education was not offered to female employees.
Factory clinics were not equipped to offer professional consultations on reproductive health, and only basic medicines and simple testing equipment were available to
ACCEPTED MANUSCRIPT employees. Public hospitals might offer a complete range of reproductive health services, but they should be more sensitive to the situations of migrant employees by
IP
T
lowering the expenses incurred and developing a green channel for migrant treatment.
SC R
In the present study, migrant workers were not encouraged to seek timely health care, and half of the population that was interviewed lacked knowledge of the healthcare
NU
rights offered by the government.
MA
Female employees should be educated about welfare policies for women, such as maternity insurance. Rules on holidays, including marriage, maternity, and abortion
D
leave, should be clearly communicated to prevent these workers from exerting
TE
themselves by doing heavy work at sensitive times. The gynecologic census and
CE P
provision of free physical examinations should be promoted among the women, and funds should be allocated to equip factory clinics with specialized medical instruments.
AC
Moreover, hospitals could establish special gynecologic tests for migrant female employees, and the factory management should pay more attention to the health of female employees.
Factories, hospitals, and communities should cooperate to offer systematic healthcare education to floating populations via informative lectures, leaflets, and compact discs. These educational tools should provide information on the prevention and harmful effects of venereal diseases, especially AIDS, along with information on contraception measures, solutions for unplanned pregnancies, the harmful effects of
ACCEPTED MANUSCRIPT abortion, and the importance of premarital physical examinations. Consequently, young women would be encouraged to protect themselves and to make informed
SC R
IP
T
choices about their own sexual behavior.
We recommend establishing communities in the factory or living areas to help female employees address their reproductive health needs by prevention and treatment.
NU
When distributing free condoms to floating female populations, the family planning
MA
office should educate these women on the relevance of condom use in preventing
D
pregnancy and the spread of sexually transmitted infections such as HIV.
TE
Nowadays, cities develop and grow extremely fast with the help of a large floating
CE P
population of migrants who contribute to the development of that city and the country. Despite their contribution, however, these women usually live in poor conditions and
AC
lack basic knowledge of reproductive health. Healthcare services can effectively help lower the incidence of venereal diseases, unplanned pregnancies, artificial abortions, and other serious health issues among migrant workers. The workers should also develop good living habits, self-esteem, and a positive attitude toward their own reproductive health. Such development will benefit their own families and help to improve the reproductive health status of women in China.
Conflict of interest The authors have no conflicts of interest.
ACCEPTED MANUSCRIPT References [1]
Saleeby E, Brindis CD. Women, reproductive health, and health reform. JAMA
World Health Organization. Reproductive Health.
[3]
SC R
http://www.who.int/topics/reproductive_health/en/.
IP
[2]
T
2011;306(11):1256–7.
Jeffreys E. Introduction: Talking Sex and Sexuality in China. In: Jeffreys E, ed.
[4]
NU
Sex and Sexuality in China. London: Routledge; 2007:1–20.
Xiao Z, Mehrotra P, Zimmerman R. Sexual revolution in China: Implications for
Tang S, Meng Q, Chen L, Bekedam H, Evans T, Whitehead M. Tackling the
D
[5]
MA
Chinese women and society. AIDS Care 2011;23 Suppl 1:105–12.
[6]
TE
challenges to health equity in China. Lancet 2008;372(9648):1493–501. Briney A. Geography of China’s Municipalities: Learn about China’s Four
CE P
Direct-Controlled Municipalities.
http://geography.about.com/od/chinamaps/tp/china-municipalities.htm. Agarwal R. Marriage law in China revised. China Report 2002;38:407–413.
[8]
Yang Yali, Zhang Cuiju. Correlation analysis between Chong Qing population
AC
[7]
movement and economic development. Hei Long Jiang Agricultural Science 2011;5:102–105. [9]
Wu J. The impact of floating population on the socio-economic development
and the countermeasures—based on the census data of Shapingba, Chong Qing. Journal of Shijiazhuang University of Economics 2013;6:111–114. [10]
Liu H, Li M, Jin M, Jing F, Wang H, Chen K. Public awareness of three major
infectious diseases in rural Zhejiang province, China: a cross-sectional study. BMC
ACCEPTED MANUSCRIPT Infect Dis 2013;13(1):192. [11]
Yan HJ. HIV/AIDS related stigma and discrimination in people living with
IP
T
HIV/AIDS and intervention strategies in Jiangsu Province China. International Journal
AC
CE P
TE
D
MA
NU
SC R
of Infectious Diseases 2008;12:e156–e157.
