【作者】 钱序；

【导师】 姜庆五； 夏国美； 赵耐青； Paul Garner；

【作者基本信息】 复旦大学 ， 流行病与卫生统计学， 2008， 博士

【摘要】 研究背景妇女的生殖健康是90年代初以来国际社会普遍接受的新的健康概念,并由于联合国人口与发展大会和第四次世界妇女大会及其后续行动而获得广泛的重视。对于生殖健康,中国长期以来一直比较关注已婚人群或常住人口的计划生育工作。近年来随着经济社会的发展和全球化、城镇化趋势,未婚人群和流动人口的生殖健康问题变得日益突出。1995-2002年中国青少年性与生殖健康相关研究的系统综述提示,对于既作为未婚人群又作为流动人口一部分的中国城市蓝领阶层的外来未婚女工,其性与生殖健康问题和行为的相关研究不多、现状不清、影响因素不明、保健服务边缘化、健康政策缺乏。据此,本研究试图基于健康行为的生态学理论研究城市外来未婚女工生殖健康相关行为的多维影响因素,并基于行为改变的社会认知理论开展安全性行为的干预探索。本研究涉及的“外来人口”概念主要从计划生育和生殖健康的角度提出,特指流入人口,不考虑在流入地居住时间的长短。研究目的在针对外来未婚女工的人群流行病学现况调查的基础上,以健康与社会的双重视角,描述上海和广东两地外来未婚女工中存在的生殖健康问题;分析产生这些问题的生态学相关因素;探讨改善外来未婚女工生殖健康行为的干预方案和潜在效果;并提出适合于改善这一人群生殖健康状况的政策建议。研究内容1.了解外来未婚女工人群的特征,并与同类男性人群的特征作比较分析。外来未婚女工的特征因素主要包括一般人口学特征、个人习惯、个人认知水平和技能、生殖健康相关行为特点、对不健康行为的态度、主要生殖健康问题、服务需求和服务利用情况。2.分析社会经济环境(个人收入和社会地位、社会支持网络、教育、就业和工作条件、社区环境等)、物质环境(生活和工作环境中的物理和生物因素)、成长环境、家庭与同伴关系、卫生服务等因素,从个人、家庭、组织、以及社会环境四个方面研究外来未婚女工性与生殖健康行为的生态学相关因素。3.建立外来未婚女工性行为和避孕行为的生态学相关因素的统计模型。4.设计并评价基于工作场所的人群综合干预方案及其实施的可行性评价。5.提出适合于改善目标人群生殖健康状况的干预策略和政策建议。研究方法1.外来未婚女工生殖健康现状及行为的生态学因素研究:采用流行性病现况调查设计和匿名自填问卷调查,非随机等比例分层整群抽样,共调查上海和广东两个生殖健康示范区的制造业、餐饮业和商业服务业的外来未婚女工1293人,其中上海601人、广东692人。采用Logistic回归分析外来未婚女工生婚前性行为和避孕行为的生态学相关因素并拟合模型。采用Framework approach的五步法分析外来未婚流动人口生殖健康行为影响因素的定性研究资料。2.干预试点采用准试验设计,即设有对照组的干预前后研究设计。主要目标在于评价综合干预措施的可行性和可接受性,同时,探索性的评价干预措施对研究对象与避孕相关的个人行为能力和目标行为的可能变化。在通过焦点组访谈了解研究地点外来未婚女工的需求和通过知情人访谈了解干预实施的可能途径之后,针对基线调查揭示的有关影响因素,运用社会认知理论的有关概念,制定了一套基于工作场所的促进外来未婚女工使用避孕措施的综合干预方案,并选择基线调查所在的上海某私营企业实施半年的干预。主要结果1.外来未婚女工性与生殖健康相关行为和行为能力的问题外来未婚女工的首次性行为平均年龄为20岁,首次性行为避孕率不到20%(同类男性为22.5%)。未避孕的主要原因是不知道如何避孕。性行为发生率女工为25.5%(同类男性为36.1%)。发生性行为时是否避孕的决定多数由双方共同决定(占64%),近6个月内外来未婚女工有性行为者使用过避孕方法的占55%,使用过紧急避孕的占31.4%,三次以上使用紧急避孕的占12.6%。外来未婚女工对生殖生理知识的知晓率绝大多数在50%以下,除易受孕期和怀孕表现外,女性的知晓率均不如男性,这种信息的不对等可能在某种程度上造成女性在性生活中处于被动地位。81.1%的女工不知道月经周期内哪个阶段最容易怀孕,71.2%的女工不知道偶尔无保护的性行为会导致怀孕。女工中能正确说出三种及以上避孕药具及其正确使用方法的只有4.5%,听说过紧急避孕药且知道其正确使用方法的只有11.2%。知道避孕套可以预防性病的女工仅占28.2%,准确了解艾滋病三种传播途径的不足10%。还有不少人有错误的知识,如3.9%的女性错误的认为人工流产是一种避孕方法。2.外来未婚女工有未满足的性与生殖健康的需要和保健服务需求近半数的未婚外来女工有月经紊乱和痛经,自报两周生殖道感染可疑症状者女性较多,主要是阴道分泌物异常(＞10%)和下腹痛(＞20%)。有70-85%的调查对象认为有必要对未婚青年进行生殖健康教育和服务,需求意愿最强烈的是正确的知识,其次是健康体检、医学咨询和常见男科和妇科疾病的诊疗服务。最希望接受的教育和服务方式是发放阅读材料,讲座、热线电话、面对面咨询、以及为未婚青年开设门诊也受到不少人(＞40%)的欢迎,而生殖保健专家是他们最信任的教育实施者。3.城市外来未婚女工的生殖健康行为受个人、家庭、组织和社会环境的影响外来未婚女工婚前性行为的影响因素涉及个人层面、亲密关系者层面、工作环境和同伴、以及社会文化层面的生态学因素。可能的倾向因素有性与生殖健康知识,对婚前性行为、未婚先孕和性行为是否需要避孕的态度;可能的促成因素有单独居住类型、商业服务业特定的工作环境、避孕服务的可得性、不同的流出地和流入地环境;可能的强化因素为有固定男朋友、与父母和同伴交流的程度和受工作单位教育者的影响等。其中,在个人层面是年龄较大、城镇户口、受教育程度较低、月收入较高、单独居住类型、避孕知识得分较高、对婚前性行为持赞同或无所谓态度、对未婚先孕和性行为时采用避孕方法持无所谓态度与婚前性行为有关。在亲密关系者层面,与父母交流过性与生殖健康问题者婚前性行为较少;而有固定男友者婚前性行为较多。在工作环境和同伴层面,相对制造业而言,在餐饮业和商业服务业工作的外来未婚女工婚前性行为较多。此外,经常与同事之间交流生殖健康知识和话题和偶尔接受单位有关性与生殖健康教育与婚前性行为有关。在社会文化层面,身处不同的流入地环境可能影响婚前性行为的发生。从分行业婚前性行为的多因素分析结果来看,在个人层面,影响制造餐饮业外来未婚女工婚前性行为的有关因素是城镇户口、单独居住类型、有较高避孕相关知识得分、对婚前性行为持赞同和无所谓态度、认为婚前性行为没必要用避孕措施;而影响商业服务业外来未婚女工婚前性行为的有关因素则增加了较大年龄、较低的受教育水平、较高的收入、对未婚先孕持无所谓态度,并发现唯一的保护因素是较高的生殖生理知识得分,生殖生理知识得分较高者婚前性行为较少。在亲密关系者层面,有固定男友是所有职业外来未婚女工发生婚前性行为的危险因素,但在制造餐饮业,与父母交流过性与生殖健康方面的问题的外来未婚女工婚前性行为较少,而在商业服务业的外来未婚女工中,有严格的家教者的婚前性行为较少。在工作环境和同伴层面,避孕服务的可得性是影响制造和餐饮业外来未婚女工婚前性行为的相关因素;而在商业服务业外来未婚女工中,经常与同事交流性与生殖健康相关知识和话题及在单位偶尔接受性与生殖健康相关内容教育的人婚前性行为较多。在社会文化层面,影响制造和餐饮业外来未婚女工婚前性行为因素是不同的流入地;而影响商业服务业外来未婚女工婚前性行为的因素则与流入地和流出地都有关。从不同行业分析出的不同的行为相关因素来看,在个人倾向因素作用的基础上,环境因素对婚前性行为的发生有促成和强化的作用。影响避孕行为的倾向因素有避孕套预防性病的知识、有说服男方使用避孕套否则不发生性行为的自我效能和首次性行为时使用了避孕方法的经历;促成因素为避孕服务的可得性;同伴的影响是可能的强化因素。在所有研究因素中,个体较高的学历、有严格的家庭管教、具较高的生殖生理知识水平和与父母交流过性与生殖健康问题作为保护因子可能会减少婚前性行为的发生。避孕套预防性病知识、说服男方使用避孕套否则不发生性行为、首次性行为采用避孕措施和可得的避孕服务可能会保护良好的避孕行为。4.基于社会认知理论的工作场所外来未婚女工生殖健康行为干预是可接受的,但实施有难度工作场所外来未婚女工生殖健康的行为干预在获得单位领导认可的前期下还是可以开展的,但在私营企业中进行的难度较大,主要困难有(1)外来未婚女工本身的流动和单位根据经济效益的随时裁员政策;(2)工作场所的支持条件包括厂医的人力和能力,实施健康教育的可行性,外来未婚女工隐私权的保护等;(3)适合于外来未婚女工生殖健康需要的干预内容和适宜技术的选择;(4)外来未婚女工参与干预活动的兴趣和时间。干预研究表明,以社会认知理论为基础的综合干预方案是可接受的,并预示了潜在的效果,但其真实效果还需在更大样本的研究中获得证实。政策建议1.作为城市弱势人群的外来未婚女工的性行为和避孕行为的影响因素是非常复杂的,除了需要考虑个人、人际、工作环境和社会文化方面等因素外,情感因素在行为决策中的作用也应该在今后的研究中加以考虑。2.针对本研究所揭示的安全性行为的保护因素,让年轻人接受更长时间的学校教育、倡导家庭教育的重要性和持续提供生殖保健教育将有助于外来未婚女工减少婚前性行为。而持续的双重保护知识宣教、拒绝不安全性行为自我效能的培养和为外来未婚女工提供持续可得的避孕服务将有利于外来未婚女工更多地在性行为时采用避孕和双重保护措施。计划生育和生殖健康服务系统和服务工作者应树立起以服务对象为中心的服务理念,充分利用与未婚流动人口接触的每一次机会来提供针对不同行业特点的分类干预。3.计划生育部门和卫生部门是育龄人群生殖保健服务的主要提供者,未婚流动人口也应尽快纳入计划生育系统管理,通过社区、单位和服务机构多部门的合作机制,为未婚流动人口提供方便、可及、可接受的综合服务。4.社会管理应努力改变长期以户籍人口为对象的现象,把辖区内的所有居民都作为管理和服务的对象,包括未婚流动人口。流动人口中未婚青年的生殖健康服务除了政府要在政策和法律上予以保证,更需要家庭的教育和引导、社会各界在理念、舆论、经费、技术等方面的大力支持,尤其应大力发展与青春健康相关的非政府组织,以求得他们在教育与服务项目实施过程的大力协助。更多还原

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