Reproduction & Contraception (2003)14 (4):227~236 Study on Perception of Potential Condom Use among Unmarried Migrants Yan SHEN 1, Chao-hua LOU 1, Er-sheng GAO 1, Ye-lin XU 2, Ling ZHANG 2 1. Shanghai Institute of Planned Parenthood Research, Shanghai 200032, China 2. Changning Population and Family Planning Commission, Shanghai 200050, China Objective To understand the perception of potential condom use and its influencing factors so as to promote condom use among unmarried migrants Method A survey, using self-administered structured anonymous questionnaire, was conducted among 1 092 unmarried migrants aged 15~24 years old in urban area of Shanghai. Results The unmarried migrants had some knowledge of condom. However, their knowledge level and their attitude towards condom use were not so optimistic. Subjects knowledge of contraceptives and STD/AIDS had a positive influence on their attitude toward condom use. Subjects with positive attitude to condom use were more likely to use condom in sexual activity (OR=1.61). Conclusion Unmarried migrants have lower rate of condom use if they have insufficient knowledge of condom. Therefore, it is essential to strengthen the sexual health education among unmarried sex-active migrants in order to encourage contraceptive use, especially condom use. Key words: condom; migrants; unmarried youth With the steady progress of reform and opening-up, the migrant population in China is on the rise and that in some large cities have already become a tremendous flow. Data from the fifth population census in 2000 showed that the total number of migrant population in China is 121.07 million, which constitutes nearly 10% of the total population. And it has reached 3.87 million in Shanghai, which account for 23.6% of the resident population [1]. Migrant population makes great contributions to economic development of the city, but also brings about certain problems. Studies show that population mobilization is one of the reasons for high STD prevalence rate [2,3]. The extending of quantity and scope of migrant population is an important factor promoting the spread of AIDS, and the HIV positive in migrant population is one of the most dangerous sources of HIV/AIDS infection [4~6]. Condom promotion has been attracted more and more attention due to its double functions, contraception and preventing STD/AIDS. Therefore, it is essential to understand the perception of potential Corresponding author:er-sheng Gao; Tel:+86-21-64046106; Fax:64046128; E-mail:ersheng_gao@yahoo.com.cn 227
condom use and its influencing factors among unmarried migrants to facilitate condom use among them. Subjects & Methods This was a cross-section survey conducted in Changning District, Shanghai. Seven factories and two resident communities in Xinjing Township were selected as study sites by nonrandom cluster sampling. The recruited subjects were 1 092 unmarried migrants aged between 15~24, who had lived in Shanghai for over 3 months but did not have permernant household registration. Information about the subjects background, sex and reproductive health (RH) knowledge, source of RH knowledge, sex related attitude, perception of potential condom use, sex-related behaviors, and needs for sexual and RH services were collected by the self-administered structured anonymous questionnaire in Aug, 2002. The interviewers were local family planning workers who were thoroughly trained on interviewing technique and asked to be non-judgmental to subjects. In order to guarantee the quality of survey and avoid mutual interference between the subjects, spacious, quiet and private rooms were provided to subjects for filling in questionnaire. After being coded by special personnel, eligible questionnaires were checked up in logic manually, and then database was set up with Epi-info 6.0 software. The data was doubleinputted by two persons independently. The two copies were compared with validate program. Discrepancies were corrected by checking the questionnaire. Two copies were repeatedly compared and adjusted until they were completely the same. And then the database was transferred to SAS file, checked, and modified. Data were analyzed with SAS 8.1 edition. We used Chi-square test to analyze the difference of subjects distributions by categorical variables and ANOVA test to compare the difference of continuous variables. If the column variables were ordinal variables, CMH Chi-square test was used to evaluate the statistical comparisons of proportions. And Pearson Chi-square test was used for nominal variables. Spearman correlation analysis was used to evaluate the relationship between two factors. Multivariate logistic regression was used to analyze the influencing factors on perception of potential condom use. Binomial logistic regression was used to evaluate the effect of the perception of condom on condom use adjusted for the confounding factors. In addition, all analyses were done separately for male and female subjects. Results The demographic characteristics of subjects A total of 1 092 subjects were interviewed, including 491 males and 601 females. Most subjects (44.6%) aged 19~21. The average age of male was higher than that of female 228
(21.3±2.13 vs. 19.9±1.92). Most of the subjects (88.1%) have their registered residence in rural area. Many people came from nearby provinces such as Jiangsu, Anhui, Jiangxi, Shandong, and Zhejiang. They mainly worked in factories, construction companies, and service industries. The education of most subjects (96.3%) was above junior high school. Nearly 70% of the subjects income were below 700 RMB per month and 18% of them were engaged (Table 1). The association between perception of potential condom use and RH knowledge The perception of potential condom use Totally, the unmarried migrants had some knowledge about condom, especially the males. There were respectively 63.5% of male and 19.8% of female who had seen a condom. About one third of subjects thought that it was easy to buy condom, the percentage of male (49.3%) was higher than that of female (20.1%). Respectively 38.5% of male and 9.7% of female thought that it was easy to use condom and the difference between the two groups was statistically significant. Only one third of the subjects knew that a condom could be used once and the percentage of male was higher than female (Table 2). The percentage of male migrants who agreed that carrying a condom by himself is one kind of self-protection behaviors, who were against that carrying a condom means you want to have sex with somebody, and who were against that using condom during sex intercourse means that you didn t trust your partner was higher than that of female. These data showed that male were easier to accept condoms than female. Also the results from Table 2 showed that about one third of the subjects opposed the idea that carrying a condom is one kind of self-protection behaviors. In addition, nearly half of the subjects were not sure of their perception of potential condom use or lacked of condom knowledge. The score of perception about potential condom use In order to describe in a clear and concise manner, score was used to illustrate the content of subjects potential condom use perception. Various points were given to the former 7 questions in Table 2, originated from the questionnaire to evaluate perception of potential condom use. One was awarded to those whose answer was tended to accept condom/ use condom / use condom correctly and zero for others. For example, one was given to those who agreed that carrying a condom is one kind of self-protection behaviors and zero to those who disagreed or unknown. The cumulative value for all 7 questions were defined as the score of perception of potential condom use and a higher score meant a more positive perception of condom and more possible to accept/use condom. Table 3 was the scores of potential condom use perception. The result showed that potential condom use of male was more positive than female. The less male (21.0%) and more female (50.2%) had scored zero, which meant their knowledge of condom were poor and their attitude toward condom use were negative. The proportions of male and female 229
Table 1 Distribution of respondent s demographic characteristics (%) Characteristics Age(year) # 15~18 Male(n =491) 16.5 Female(n =601) 32.8 Total(n =1 092) 25.4 19~21 36.9 50.9 44.6 22~24 46.6 16.3 30.0 Household registration* Urban 14.7 9.7 11.9 Rural area 85.3 90.3 88.1 Birth place* Anhui 27.7 62.9 47.1 Jiangsu 20.6 10.5 15.0 Zhejiang 8.1 1.2 4.3 Sichuan 8.2 3.0 5.3 Henan 6.5 6.2 6.3 Shangdong 7.5 7.8 7.7 Jiangxi 12.0 1.6 6.3 Others 9.4 6.8 8.0 Education level # Primary school 4.3 3.3 3.7 Junior high school 66.4 84.0 76.1 Senior high school 24.4 11.7 17.4 College or above 4.9 1.0 2.8 Occupation* Builders 31.6 0.2 14.3 Service workers 24.0 15.6 19.4 Self-employed laborers/owners of the private sector Factory workers 30.6 78.2 56.8 Managers 4.7 2.5 3.5 Others 1.8 0.8 1.3 Nature of unit* State-owned enterprise 39.1 2.4 18.8 Joint venture enterprise 1.9 78.5 44.1 Private enterprise 59.0 19.1 37.1 Monthly income(yuan) # <500 14.8 54.0 36.4 500~ 30.2 34.9 32.8 700~ 35.2 7.6 19.4 1 000~ 19.8 3.5 10.8 Engagement of marriage* Yes 26.3 12.0 18.4 No 73.7 88.0 81.6 *: P<0.01, compared the male with the female (Pearson 2 test) #: P<0.01, compared the male with the female (CMH 2 test) scored over 3 were 47.4% and 15.0% respectively. Namely, their perceptions of potential condom use were more positive (Table 3). The correlation between perception of potential condom use, sex and RH knowledge The scores of contraception knowledge were gained from 25 questions about contraception, contraceptives use and the way to obtain contraceptives. And the scores of STD/AIDS knowledge come from 25 questions about STD/AIDS transmission route and 230 7.3 2.7 4.7
Table 2 The subjects perception of potential condom use (%) * Perception of potential condom use It is easy to buy condom Agree Male(n =491) 49.3 Female(n =601) 20.1 Total(n =1 092) 33.2 Disagree 20.2 16.6 18.2 Unknown/ Not sure 30.5 63.3 48.6 It is easy to use condom Agree 38.5 9.7 22.6 Disagree 17.5 9.7 13.2 Unknown/ Not sure 44.0 80.6 64.2 Condom use has an impact on the quality of sexual intercourse Agree 21.8 7.2 13.7 Disagree 27.5 9.5 17.6 Unknown/ Not sure 50.7 83.3 68.7 Using condom during sex intercourse means that you don t trust your partner Agree 8.8 4.8 6.6 Disagree 55.8 32.3 42.9 Unknown/ Not sure 35.4 62.9 50.5 Carrying a condom is one kind of self-protection behaviors Agree 21.4 10.2 15.2 Disagree 40.5 34.4 37.2 Unknown/ Not sure 38.1 55.4 47.6 Carrying a condom means you want to have sex with somebody Agree 18.9 15.3 16.9 Disagree 46.1 24.3 34.1 Unknown/ Not sure 35.0 60.4 49.0 A condom was not appropriate to be used repeatedly Agree 7.3 1.8 4.3 Disagree 50.1 19.6 33.3 Unknown/ Not sure 42.6 78.6 62.4 *:P<0.01, compared the male with the female (Pearson 2 test) Table 3 The score of perception of potential condom use(cmh 2 test) Score Male(n =491) Female(n =601) Total(n =1 092) n % n % n % P 0 103 21.0 302 50.2 405 37.1 <0.0001 1~2 155 31.6 209 34.8 364 33.3 3~6 233 47.4 90 15.0 323 29.6 preventive ways. The maximum score was 100. The scores of contraception knowledge and STD/AIDS knowledge were different, and the score of perception of condom were different as well. Subjects who scored higher in perception of condom also scored higher in contraception knowledge and STD/AIDS knowledge (Table 4). Spearman s rank correlation was used to analyze the relationship between the knowledge and the attitude. The result showed that Spearman s rank correlation coeffi- 231
cients between perception of condom use and contraception knowledge among male and female were 0.534 8 and 0.458 9, respectively. The coefficients between perception of condom use and STD/AIDS knowledge among male and female were 0.453 4 and 0.389 8 respectively. The positive correlations mentioned above were statistically significant (P<0.01). The coefficient between perception of condom use and STD/AIDS knowledge among male and female were 0.453 4 and 0.389 8, respectively (P<0.01). The positive correlation was found between general knowledge of contraception and STD/AIDS and perception of condom, namely, subjects who had higher score in contraception and STD/AIDS knowledge held more positive attitude towards condom use. Table 4 The average RH knowledge score by different perception of potential condom use ( x _ ) Item M ale score of potential condom use Female score of potential condom use 0 1~2 3~6 0 1~2 3~6 Contraception 20.3 38.6 55.4** 15.4 31.3 41.2** STD/AIDS 34.8 53.9 68.7** 27.4 50.8* 56.3* *: P<0.05, compared with 0 score group **: P<0.05, the difference is significant between 0 score or 1~2 score group by ANOVA test The influencing factors on perception of potential condom use Subjects perception of potential condom was influenced by demographic characteristics (such as age, sex, education level, occupation, and income), duration of stay in Shanghai, sex education received (from parents, school and unit/community), communicated sex-related question with parents/ peers, and the time spent on media. Additionally, RH knowledge also had a positive effect on the attitude (Table 3, 4). But some variables mentioned above were associated with RH knowledge, which effect on the perception of potential condom use would be reflected on the RH knowledge. The ordinal logistic regression model was fitted to see the factors influencing the score of potential condom use. The dependent variable was the rank of perception of condom, which was ordinal variable and was scaled as grade1 (score=0), grade 2 (score=1~2) and grade 3 (score=3~6). The independent variables were the factors mentioned above except the RH knowledge. Results showed that significant determinants of potential condom use were age, sex, education level, monthly income, duration of stay in Shanghai, receiving sex education at school, communicated sex-related question with peers and the time spent on the media (Table 5). Subjects who were elder, male, better educated, had higher monthly income, receiving sex education at school, communicating sex-related question with peers and spent more time on the media, were more likely to have higher score of potential condom use. The results of stratified multivariate logistic regression analysis for male and female were different. The male s perception of potential condom use was associated with age, education level, income, and the time spent on the media. Namely, subjects who were elder, 232
better educated, had higher monthly income, spent more time on the media, were more likely to have higher score of potential condom use. The female s score of potential condom use were higher among those who were better educated, service workers, received sex education offered by unit/community, and communicated sex-related question with peers. It seems that the female s attitude towards condom was also associated with the factors of age and duration of stay in Shanghai (P=0.059 6 and P=0.055 6, respectively) (Table 5). Table 5 Logistic regression analysis for the perception of potential condom use (OR, 95%CI ) Variable Male (n =486) Female (n =596) Total (n =1 082) Δ Age (year) 15~19 * 20~24 1.92(1.30~2.84) 1.37(0.99~1.91) 1.56(1.22~1.99) Sex Female * Male - - 2.90(2.20~3.83) Education level Junior high * Senior high 2.87(1.85~4.46) 2.43(1.49~3.95) 2.65(1.92~3.65) Occupation Non-service workers * Service workers 1.35(0.91~2.00) 1.55 (1.02~2.35) 1.30 (0.98~1.72) Monthly income Ordinary variable # 1.41 (1.10~1.81) 1.19 (0.93~1.52) 1.32 (1.11~1.56) Duration of stay in Shanghai 1year* >1year 1.17 (0.82~1.68) 1.38 (0.99~1.92) 1.27 (1.00~1.62) Received sex education from parents? No * Yes 0.93 (0.60~1.44) 1.34 (0.91~1.98) 1.10 (0.83~1.47) Asked parents sex-related question? No * Yes 1.22 (0.77~1.94) 1.22 (0.84~1.79) 1.23 (0.92~1.64) Received any school sex education? No * Yes 1.51 (0.99~2.31) 1.20 (0.84~1.72) 1.35 (1.03~1.77) Received sex education offered by community/unit? No * Yes 0.79 (0.55~1.14) 1.57 (1.13~2.19) 1.15 (0.90~1.47) Communicated sex-related question with peers? No * Yes 1.19 (0.82~1.74) 1.78 (1.27~2.49) 1.53 (1.19~1.96) Time spent on the media? A little * Much 1.44 (1.01~2.07) 1.24 (0.90~1.71) 1.37 (1.08~1.73) sing (5 male, 5 female) The impact of perception of condom on condom use The proportion of subjects who had sex experienced were 34.8% and 12.7% in male 233
and female, respectively. Among them 60.4% subjects or their partners had ever used a condom. Multivariate logistic regression analysis was used to reveal the effects of perception of condom on the condom use in sexual intercourse. The dependent variable was whether the subjects or their partners had used condom during sexual intercourse, one point was given if condom was used, otherwise zero point was given, and the independent variable was the rank of perception of condom. And the adjusted variables were age, sex, education level, occupation, monthly income, duration of stay in Shanghai, whether their parents had offered sex education, whether the youth had asked their parents sex-related questions and their attitude toward induced abortion. The result showed perception of condom had positive effects on condom use in sexual intercourse. Subjects who had higher score of perception toward condom were more likely to use condom (OR=1.61, 95%CI: 1.05~2.48) than those who had lower score of perception of condom (Data not shown). Discussion Research results indicated that unmarried migrants had some knowledge of condom, but their attitudes towards potential condom use was not very positive, especially that of females, half of whom scored zero in the test on perception of potential condom use. While a considerable portion of the subjects admitted to have had sexual experience, they were not aware of or had never practiced safe sexual behavior. Only 60.4% of sexually active subjects had once used condoms. Therefore, it is essential and necessary to promote condom use among unmarried migrants. It was reported that knowledge of STDs/AIDS prevention had relative larger impact on the acceptance of condom. Condom use possibility would be increased if the subject s knowledge on STDs/AIDS prevention was sufficient [7]. In this study we also noticed that the higher score subjects got on STDs/AIDS, the higher score they could get on perception of potential condom use, i.e., they got higher possibility of using condoms in future sexual activities. The result suggested that there is a direct proportional relationship between the knowledge of condom and knowledge of other contraception. The subjects knowledge about sex and RH had influence on their potential condom use, and their negative attitude to condom was closely related to their poor knowledge of sex and RH. The perception of potential condom use directly influenced condom use. The result of multivariate logistic regression analysis showed that there were strong relationships between perception of potential condom use and condom use in their sexual activities (OR=1.61). Generally speaking, considerable part of subjects had insufficient or even wrong knowledge of condom use and they were not sure whether they should have their attitude about condom. That situation of RH knowledge had negative impact on possible condom use. So it was essential to provide the right knowledge of condom use and correct wrong ideas of unmar- 234
ried migrants. The accessibility of condom also affected condom use. Only one third of the subjects thought it was easy to get condom, which reflected barriers and difficulties still existed for unmarried migrants to get condoms. The barriers and difficulties could possibly result from two sides: on one hand, the way condom was provided did not always appear to be convenient, such as no nearby drug store/condom vending machine, traffic inconveniences, improper time of service, bad service attitude and so on; on the other hand, due to their own personality, when buying/obtaining the condom, some of the unmarried migrants may feel that someone else was peeking at their privacy, or they were embarrassed or ashamed, or they could not afford the price of the condom. Therefore, emphasis should be put on improving the way condom was provided, increasing the accessibility of condoms, such as setting special counters in supermarket or putting up more condom vending machine and any other ways to enable the young clients to choose freely, decide freely and buy confidently so as to promote the accessibility of condom and improve condom use. In India and England, that condom use would affect the feeling of sex activities was one of the factors that prevent condom use [7]. In this study, 21.8% of male and 7.2% of female thought condom use had an impact over the feeling of sexual intercourse, so it was also critical to improve the quality of condom and raise public awareness of condom in order to promote condom use. Commercial sex, multiple sex partners and reproductive tract infections (RTIs)/STDs, had also been found in unmarried migrants and increased their risk to infect or transmit HIV/ RTIs and other STDs. One research in Hangzhou [8] showed that high-risk sex behaviors, including casual sex, commercial sex, and unprotected sex, resulted in the continuous increase of STDs among unmarried youth. Research findings from the study also proved that the unmarried migrants knowledge of condom was not high; especially the females were extremely lack of necessary knowledge of condom. It was, therefore, of great necessity to increase the knowledge of condom among unmarried migrants, especially those sexually active ones. Reproductive health education had been proved to be a very effective and practical way to promote condom use among migrants. Firstly, let them have condom knowledge thoroughly, such as provide them with knowledge on condom s double function in both contraception and preventing venereal disease/aids, and condom advantage, etc., so as to make them accept condom easier and choose to use it in time of need. Then show them the right way to use condom. Videotape, illustration and practice model may be used if available. In addition, the condom availability and accessibility could also affect the promotion of condom use, so they had to be improved to facilitate unmarried youth. The family planning branches of local government should consider expanding the channel from which condom was provided, especially those convenient and confident/secure ways, such as setting up 235
condom vending machines in those community and working unit where unmarried youth were densely habitated. In the meantime, the quality of condom should be improved to ensure the continuity of use. References (Receive on August 20,2003) 236