Female migrants need more than information for consistent condom use in China
High rates of inconsistent condom use among female migrants in China point to need for interventions to focus on building key behavioural skills to promote condom use.
A study of migrant factory workers in Shanghai China found only 13.8% of unmarried female migrants reported consistent condom use in the past six months. Moreover, being knowledgeable about condoms was not enough to change behaviour in this group.
Internal migration is a public health challenge in China. In 2016, an estimated 281 million people migrated within the country, mostly from rural to urban locations.
Between June and December 2015, 2,543 unmarried rural-urban migrant females over 18 were recruited from several industrial factories in Shanghai and invited to take an anonymous and self-reported questionnaire. After removing incomplete questionnaires and those who did not have vaginal intercourse with a man in the last six months, a total of 903 were included in the final analysis.
Socio-demographic data and reproductive health status information were collected. The mean age of the participants was 23.4 years old, 69.4% had reached senior high school, and 61.8% had worked in Shanghai for more than one year. Nearly one-third (29.9%) of the surveyed women had an unintended pregnancy, of which 94.4% had an abortion. The authors note that these rates are higher than other previous regional findings. 13.8% of the women used a condom every time they had sex, while 32.6% reported using a condom ‘most of the time’.
The authors then scrutinised the data further using both the information-motivation-behavioural skills (IMB) model and a modified version of it which included psychological and personal inputs.
The IMB model theorises that in order for someone to engage in a given health behaviour – in this case, use a condom consistently – they need to be informed and have basic knowledge about sexual health and HIV (Information). They also need to be motivated to consistently engage in non-risky behaviours (Motivation), and they must have the behavioural skills, such as self-efficacy, to pick-up and maintain the behaviour and therefore reduce their risk of HIV and other sexually transmitted infections (STIs) (Behaviour).
To assess the information component, surveys included questions around HIV knowledge. For motivation they included questions around attitudes towards condom use (e.g. “I think condoms are an excellent means of contraception”, “Condom use ruins the sex act” and “I feel embarrassed when suggesting using a condom”).
The surveys also contained questions around intentions (e.g., “the likelihood of using a condom during sex,” and “the likelihood of talking about condom use with partners”), and social norms (e.g. “What do people that you respect think about using condoms every time if you have sex” and “What does your partner think about using condoms every time when you have sex with him”).
Behavioural skills were measured via two parameters: objective skills for promoting condom use (e.g. How often did you “make it clear that I would not have sex if condoms are not used.” and “tell a partner that we both would be safer from disease if we used a condom”). The second looked at a sense of self-efficacy for using a condom (e.g. “I am confident that I can talk about condoms with my partner,” and “I am confident that I can convince my partner to use a condom even if he doesn’t want to”).
Psychological and personality factors, including depression, self-esteem, loneliness, and condom use behaviour were also analysed in the modified IMB model.
In both iterations of the IMB model used by the authors, they found that information was not associated with behavioural skills or consistent condom use, demonstrating the complexity of behaviour change for health. The authors note that HIV knowledge is a necessary, but insufficient condition as other factors also plays an important role. Moreover, it may be an important facilitating initial behaviour change, but other factors are necessary to ensure maintenance of condom use over time.
Power dynamics between genders are an important factor, and women as migrants are compounded by intersecting vulnerabilities that may make condom negotiation difficult.
In both models, it was behavioural skills that were found to directly influence consistent condom use, and motivation was associated indirectly by affecting behavioural skills.
“Interventions targeted at enhancing self-efficacy and at promoting condom use skills may have a strong effect on consistent condom use,” explain the authors. “However, to the best of our knowledge, no published study has focused on intervention for both self-efficacy and condom use skills among unmarried rural-to-urban female migrants, which should be addressed in future studies.”
Consistent with studies elsewhere, psychological and personality factors influenced consistent condom use directly – and participants with higher levels of depression, higher levels of loneliness, and lower levels of self-esteem were less likely to use a condom consistently.
The authors conclude that their findings provide some new insights for future reproductive health promotion. “Further research promoting consistent condom use among unmarried rural-to-urban female migrants could develop preventive interventions not only on the basis of the IMB model but also on the basis of psychological and personality factors.”