Abstract
Sexual behavior is the dominant mode of HIV transmission in China, and young female migrants are among the populations at highest risk. This article examines how HIV-related risk behaviors among female migrants might vary according to workplace settings. Participants were young female migrants recruited from three workplace settings—factories, restaurants and entertainment venues. In a cross-sectional survey, we assessed 457 participants' sociodemographic characteristics, HIV/AIDS-related knowledge, condom use knowledge, sexual behaviors, condom use behavior and reproductive health factors. Participants working in entertainment venues were significantly more likely than those working in factories and restaurants to report sexual behavior, unprotected sex, multiple pregnancy terminations and sexually transmitted infections (STI). However, participants working in factories and restaurants reported significantly lower levels of HIV/AIDS knowledge, condom use knowledge, condom use self-efficacy and history of HIV/AIDS counseling and testing. Independent correlates of unprotected sex included employment in an entertainment venue, abortion history and sexual self-efficacy. Independent correlates of STI or genitourinary tract infection included employment in an entertainment venue, abortion history, recent migration and recent unprotected sex. These findings indicate a need for sexual and reproductive health interventions prioritizing young female migrants, and call for programs that can be incorporated into different workplace settings.
Keywords: China, women, migrants, sexual risk behaviors
INTRODUCTION
The HIV/AIDS epidemic in China has shifted from an epidemic characterized by injection drug use and contaminated plasma donation to one associated primarily with sexual transmission (Ministry of Health, 2006; State Council AIDS Working Committee Office, 2007; Ministry of Health, 2010; Ministry of Health, 2011). By the end of 2011, 46.5% of the estimated 780 000 people living with HIV in China acquired the virus through heterosexual transmission and approximately three-quarters of these cases were not attributable to sex with a married partner (Ministry of Health, 2011). Such trends indicate the role of premarital or extramarital sexual transmission in China's HIV epidemic and suggest a need to better understand factors associated with heterosexual risk factors for HIV transmission.
In parallel with the evolution of the nation's HIV epidemic, public health interventions to prevent HIV transmission in China have transformed substantially over the past decade. China's official national response to the HIV epidemic began in 2003, commencing with the comprehensive ‘Four Free and One Care’ HIV prevention strategies which including free access to HIV testing and counseling, free medications to prevent mother-to-child transmission, free access to antiretroviral drugs for people living with AIDS living in rural settings or lacking health insurance, free schooling for AIDS orphans and care and assistance to households affected by HIV (Wu et al., 2007a, 2007b). National policies have also included expansion of HIV testing to reduce secondary transmission, effective treatment to reduce mortality and public campaigns for HIV education and HIV-related stigma reduction (Sun et al., 2010). Notably, intervention strategies have placed greater focus on high-risk and marginalized groups including migrant workers, female sex workers and men who have sex with men (Ministry of Health, 2011).
Migration has been a major factor in advancing the global HIV/AIDS epidemic and is a key contributor to China's growing epidemic (State Council AIDS Working Committee Office, 2007). In the context of China's HIV epidemic, high-risk migrant populations generally include internal migrants who relocate within China, usually from rural to urban settings, in search of economic opportunities. During the past three decades, China has experienced a dramatic increase in internal migration, from 6.75 million migrants in 1982 to an estimated 221 million migrants in 2010, of which 36% were females between 18 and 49 years old (Liu et al., 2011a, 2011b; National Population and Family Planning Commission of P.R. China, 2011). Migrant populations have been identified as one of China's growing HIV risk groups. Of the 5635 HIV/AIDS cases reported in Beijing in 2008, the majority (75%) were internal migrants, compared with city residents (21%) and foreigners (4%) (Kaiser Health News, 2008). Migrants frequently return to their villages seasonally or during the Chinese Spring Festival, and this pattern of migration can facilitate the transmission of infectious diseases such as HIV from urban to rural settings.
Previous literature has suggested that young female migrants face high risk for HIV due to a lack of knowledge related to sexual health, limited skills for practicing safer sex and low awareness and use of reproductive health services in their native rural settings (Tu et al., 2004; Liu et al., 2011a, 2011b; Mantell et al., 2011; He et al., 2012; Lu et al., 2012). Furthermore, compared with their male counterparts and urban citizens, female rural-to-urban migrants face greater social and cultural vulnerability and gender-related inequalities, such as unequal work opportunities, low socioeconomic status and lack of social support (Mou et al., 2013). Due to the conservative sexual culture in China, young females face social taboos related to openly talking about sex and HIV. Thus, sexual- and HIV-related education is particularly limited among rural females. Consequently, female migrants in China are frequently undereducated and underprepared for the increased opportunities to engage in sexual behavior that are available to them in urban settings (Huang et al., 2014). In the absence of skills, knowledge and services to promote sexual health, female migrants who relocate to large urban centers may experience risk for a range of health consequences, including unwanted pregnancy, unsafe termination of pregnancy and sexually transmitted infections (STIs) (Zhang et al., 2007; Yi et al., 2010; He et al., 2012). Some research has contrasted the more permissive norms related to premarital sex in large urban contexts versus norms in rural settings, which might also contribute to health risk behaviors among rural-to-urban migrants (Yang et al., 2007).
Previous studies have shown that the majority of rural-to-urban female migrants find employment in factories, service industries (e.g. restaurants) and ‘entertainment establishments’ (Ge, 2007; Lin et al., 2007; Chen et al., 2011). In factory and restaurant venues, female migrants typically work as manual laborers or servers. Both venues tend to have rigid work schedules and management regulations which greatly restrict their contact with locals. For example, factory workers frequently are required to live in a dormitory located close to work and socialize exclusively with other factory workers. In contrast, entertainment establishments include commercial venues where patrons, mostly male, pay female employees for accompaniment in social activities including karaoke, dancing, gambling and massage (Yang et al., 2005). Employment in an entertainment venue might be considered desirable due to the relatively higher wages including tips, as well as due to the opportunities to socialize with local men. However, entertainment venues might confer behavioral risks for female employees due to the more intimate nature of services provided, including a likelihood for employees to use alcohol at the work setting and to be propositioned by patrons for sex. Owing to the different type of work in these various employment settings, risk for HIV and other STIs among female migrants might vary according to their workplace (Yang et al., 2005; Chen et al., 2011). Previous studies of female migrants have focused on young women identified as sex workers (Hesketh et al., 2005; Chen et al., 2010; Huang et al., 2011), but fewer studies have paid attention to young female migrants who work in other settings that might confer different levels of risk for behaviors and reproductive health.
This article examines HIV/STI-related sexual risk and reproductive behaviors among young female migrants recruited from three different work settings—factories, restaurants and entertainment venues. The study was conducted in Hefei, the capital city of Anhui Province. This city provides a compelling context for studying migrants due to its rapid development in a relatively less-developed provincial setting. As the city has developed during the past decade, there have been increasing numbers of new restaurants, factories and entertainment venues which provide a large job market for young female migrants. The aims of this article are to (i) describe demographic characteristics and sexual health risk according to workplace and (ii) examine independent correlates of HIV/STI-related risk among young female migrants. The findings of this article could help in developing workplace-sensitive HIV prevention strategies for young female migrants in China.
METHODS
Study sites and participants
From 2007 to 2008, we conducted a cross-sectional survey of young rural-to-urban migrant women recruited from factory, restaurant and entertainment venues in Hefei, Anhui Province, China. For the purposes of this study, rural-to-urban migrants were defined as individuals who moved from rural settings in order to life and work in Hefei, and who lacked an official household registration in Hefei. To facilitate recruitment activities in the targeted settings, which required the permission of owners/managers of targeted venues, we partnered with the local Centers for Disease Control and Prevention (CDC). In China, the CDC is responsible for all HIV/AIDS-related activities, including prevention, treatment and surveillance. Collaborating officials from the CDC helped to explain the purpose of the research to venue owners/managers and assisted in obtaining permission to recruit from within their venue. In total, one large factory, six restaurants and six entertainment venues located in Hefei agreed to serve as recruitment sites.
Eligibility criteria included being female, 16–24 years old, unmarried, rural migrants to Hefei and employed in one of the targeted settings. Prior to recruitment, informational leaflets about our survey were distributed in each recruitment site. Of 502 individuals who were expressed initial interest in the study and were screened for eligibility, 483 participants were deemed eligible and provided informed consent to participate in the study. Before interviewing, we also inquired whether participants experienced any coercion by their managers or coworkers to participate in the study; no participants reported coercion. Twenty-six participants elected to terminate the study early, yielding 457 valid surveys for analysis (175 factory workers, 138 restaurant workers and 144 entertainment workers). The confidential face-to-face survey interviews were conducted by trained female research assistants of similar age to the participants; we elected to not ask participants to self-administer the survey due to possible limitations in literacy. All interviewers were trained to avoid asking leading questions or give any hints or guidance as to how participants should answer any of the survey questions. Interviews took place in a private room in the workplace setting during employees' breaks or before or after work shifts. Interviews lasted 30–40 min. Participants were compensated with a small gift worth 40 Chinese Yuan (∼6 U.S. dollars) after they completed the questionnaires. The study was approved by the Institutional Review Board of the investigators' institutions.
Measures
Sociodemographic characteristics were assessed including age, education, monthly income, family status (e.g. having an intact two-parent family, single-parent family or step-parent family), type of work setting and time since migration to Hefei. Behavioral health variables measured included sexual behaviors with men (number of lifetime male sexual partners, age of sexual debut and whether first sex was voluntary) and condom use (including condom use during initial sex and at last sex episode, and frequency of condom use during the past 2 months).
Four social-cognitive HIV/AIDS variables were measured, using instruments previously validated in China by Chen et al. (Chen et al., 2010). HIV/AIDS-related knowledge was measured using an 18-item measure (sample item, ‘Do you think you can be infected with HIV by hugging or shaking hands with HIV-positive people?’). Condom use knowledge was measured using a 10-item measure (sample item, ‘It is OK to put on a condom just right before the ejaculation’). Self-efficacy to use condoms was assessed using a 5-item measure (sample item, ‘Are you confident you can use condoms each time you have sexual intercourse?’). Self-efficacy to control one's sexual behavior choices was assessed using a 5-item measure (sample item, ‘Are you confident you can refuse to have sex?’).
Reproductive health items included whether participants ever terminated a pregnancy, total number of pregnancy terminations and whether they had any STI or genital tract infection in their lifetime and in the past year. Participants were also asked whether they ever received any HIV risk reduction counseling and whether they had ever undergone HIV testing.
Data analysis
EpiData 3.0 software was used to input the original data and SPSS 10.01 was used to analyze the data. Descriptive analyses, χ2, Fisher's exact tests and analysis of variance were used to compare descriptive characteristics according to work settings (factory, restaurant, entertainment venue). Univariate and multivariable regressions were conducted to examine the correlates of two dependent variables: (i) unprotected sexual behavior in the last 2 months and (ii) any STI or genital tract infection in the last year. Following Hosmer and Lemeshow (Hosmer and Lemeshow, 2000), independent variables were included in multiple logistic regression models if they were associated with the dependent variable in univariate logistic regression or based on a priori interest (such as sociodemographic variables). Multivariable regressions used the stepwise backwards method to identify the most parsimonious model. Due to low cell counts, we combined factory and restaurants members into one group in the univariate and multivariable logistic regressions.
RESULTS
Participant characteristics
Sociodemographic characteristics are presented in Table 1. The average age was 20 years (SD = 2.0), with an age range of 16–24. Nearly three-quarters (73%) had a junior high school education or less, and 62% had earned less than 1000 Yuan (roughly 150 USD) monthly. Over half (54%) had been working in Hefei for more than 2 years. Most participants (84%) had intact families at home with both parents married and living together.
Table 1:
Sociodemographic characteristics—overall sample and workplace differences
| Variables | N (%) | Working in factory (N = 175), n (%) | Working in restaurant (N = 138), n (%) | Working in entertainment venue (N = 144), n (%) | χ2 | p-value, Fisher's exact |
|---|---|---|---|---|---|---|
| Age group (years) | 55.29 | <0.001 | ||||
| 16–19 | 207 (45.3) | 114 (65.1) | 58 (42.0) | 35 (24.3) | ||
| 20–24 | 250 (54.7) | 61 (34.9) | 80 (58.0) | 109 (75.7) | ||
| Education level | 71.91 | <0.001 | ||||
| Junior high school or less | 333 (72.9) | 164 (93.7) | 85 (61.6) | 84 (58.3) | ||
| High school or higher | 124 (27.1) | 11 (6.3) | 53 (38.4) | 60 (41.7) | ||
| Single-parent or step-parent family | 52.41 | <0.001 | ||||
| Yes | 72 (15.8) | 11 (6.3) | 11 (8.0) | 50 (34.7) | ||
| No | 385 (84.2) | 164 (93.7) | 127 (92.0) | 94 (65.3) | ||
| Monthly income (RMB) | 274.14 | <0.001 | ||||
| ≤1000 | 284 (62.1) | 139 (79.4) | 125 (90.6) | 20 (13.9) | ||
| 1001–1500 | 86 (18.8) | 35 (20.0) | 8 (5.8) | 43 (29.9) | ||
| >1500 | 87 (19.1) | 1 (0.6) | 5 (3.6) | 81 (56.2) | ||
| Migrant work time (year) | 23.09 | <0.001 | ||||
| <2 | 209 (45.7) | 57 (32.6) | 67 (48.6) | 85 (59.0) | ||
| ≥2 | 248 (54.3) | 118 (67.4) | 71 (51.4) | 59 (41.0) |
Significant workplace differences were observed for sociodemographic characteristics (see Table 1). Participants working in entertainment venues were more likely than those working in factories and restaurants to be between 20 and 24 years old (76%), from a single-parent or step-parent family (35%), have a monthly income greater than 1500 Yuan (56%) and have worked in Hefei for <2 years (59%). Participants working in factories were more likely than those working in restaurants or entertainment venues to be between 16 and 19 years old (65%) and to have completed junior high school or less (94%). Participants working in restaurants were more likely than those working factories or entertainment venues to have a monthly income of <1000 Yuan (91%).
Sexual behaviors and condom use
Prevalence of HIV-related risk behaviors and comparisons by workplace are presented in Table 2. Approximately one-third (35%) of the sample had ever had sex with a man. History of sex with a man was significantly higher among participants working in entertainment venues (87%) compared with factory workers (5%) and restaurant workers (20%). Among participants who ever had sex, most (83%) were 18 years or older at their first sexual experience and 79% experienced sexual debut voluntarily; no group differences were observed for these two variables. Among all sexually active participants, 32% used a condom during their first sex episode, 57% reported always using condoms during the past 2 months and 72% used a condom during their most recent sex episode. Participants working in entertainment venues were more likely than factory workers and restaurants workers to have used a condom during their first sex episode (38 vs. 11% and 11%, respectively), used condoms consistently during the past 2 months (64 vs. 22% and 33%, respectively) and used a condom during their most recent sex episode (80 vs. 33% and 48%, respectively). Participants working in entertainment venues reported more lifetime sex partners (M = 11.71) compared with factory workers and restaurant workers (M = 1.67 and 1.44, respectively).
Table 2:
Sexual behaviors—overall sample and workplace differences
| Variables | N (%) | Working in factory (N = 175), n (%) | Working in restaurant (N = 138), n (%) | Working in entertainment venue (N = 144), n (%) | χ2/F | p-value Fisher's exact |
|---|---|---|---|---|---|---|
| Ever have sex with male | 270.77 | <0.001 | ||||
| Yes | 161 (35.2) | 9 (5.1) | 27 (19.6) | 125 (86.8) | ||
| No | 296 (64.8) | 166 (94.9) | 111 (80.4) | 19 (13.2) | ||
| Age of sexual debuta | 0.75 | 0.725 | ||||
| <18 | 27 (16.8) | 1 (11.1) | 3 (11.1) | 23 (18.4) | ||
| ≥18 | 134 (83.2) | 8 (88.9) | 24 (88.9) | 102 (81.6) | ||
| Voluntary first sexa | 4.34 | 0.117 | ||||
| Yes | 127 (78.9) | 5 (55.6) | 24 (88.9) | 98 (78.4) | ||
| No | 34 (21.1) | 4 (44.4) | 3 (11.1) | 27 (21.6) | ||
| Condom use during the first sexa | 9.67 | 0.006 | ||||
| Yes | 52 (32.3) | 1 (11.1) | 3 (11.1) | 48 (38.4) | ||
| No | 109 (67.7) | 8 (88.9) | 24 (88.9) | 77 (61.6) | ||
| Condom use with male partners in the past 2 monthsa | 36.52 | <0.01 | ||||
| Always | 91 (56.5) | 2 (22.2) | 9 (33.3) | 80 (64.0) | ||
| Sometimes | 52 (32.3) | 0 (0.00) | 12 (44.4) | 40 (32.0) | ||
| Never | 18 (11.2) | 7 (77.8) | 6 (22.3) | 5 (4.0) | ||
| Condom use in the last sex with mena | 16.99 | <0.01 | ||||
| Yes | 116 (72.0) | 3 (33.3) | 13 (48.1) | 100 (80.0) | ||
| No | 45 (28.0) | 6 (66.7) | 14 (51.9) | 25 (20.0) | ||
| The number of male sexual partners in lifetime (M± s)a | 1.67 ± 0.50 | 1.44 ± 0.80 | 11.71 ± 25.17 | 2.94 | 0.057 |
aIncludes those who reported ever having sex with male.
Reproductive health, HIV counseling and testing and HIV/AIDS-related cognitive factors
Table 3 presents prevalence and group differences in reproductive health factors, HIV counseling and testing and measures of HIV/AIDS-related knowledge and self-efficacy. Overall, 16% of participants ever had a termination of pregnancy, 5% had more than one termination, 19% ever had an STI or genital tract infection and 11% had an STI or genital tract infection during the past year. Only 6% had ever received HIV/AIDS risk reduction counseling, and 6% had received an HIV test. Participants working in entertainment venues were more likely than factory and restaurant workers to have ever experienced termination of a pregnancy (43 vs. 2% and 5%, respectively), two or more terminations (15 vs. 0% and 1%, respectively), an STI or genital tract infection during the past year (32 vs. 1% and 4%, respectively), HIV/AIDS risk reduction counseling (17 vs. 1% and 1%, respectively) and an HIV test (16 vs. 2% and 1%, respectively).
Table 3:
Reproductive health factors and HIV/AIDS-related knowledge—overall sample and workplace differences
| Variables | N (%) | Working in the factories (N = 175), n (%) | Working in the restaurants (N = 138), n (%) | Working in the entertainment venue (N = 144), n (%) | χ2/F | p-value Fisher's exact |
|---|---|---|---|---|---|---|
| Ever had to terminate pregnancy | 108.96 | <0.001 | ||||
| Yes | 73 (16.0) | 4 (2.3) | 7 (5.1) | 62 (43.1) | ||
| No | 384 (84.0) | 171 (97.7) | 131 (94.9) | 82 (56.9) | ||
| The total of pregnancy terminations | 109.41 | <0.001 | ||||
| 0 | 384 (84.0) | 171 (97.7) | 131 (95.0) | 82 (56.9) | ||
| 1 | 50 (10.9) | 4 (2.3) | 6 (4.3) | 40 (27.8) | ||
| ≥2 | 23 (5.1) | 0 (0.0) | 1 (0.7) | 22 (15.3) | ||
| Got STD or genital tract infection in lifetime | 138.75 | <0.001 | ||||
| Yes | 88 (19.3) | 3 (1.7) | 11 (8.0) | 74 (51.4) | ||
| No | 369 (80.7) | 172 (98.3) | 127 (92.0) | 70 (48.6) | ||
| Got STD or genital tract infection in the last year | 85.17 | <0.001 | ||||
| Yes | 52 (11.4) | 1 (0.6) | 5 (3.6) | 46 (31.9) | ||
| No | 405 (88.6) | 174 (99.4) | 133 (96.4) | 98 (68.1) | ||
| Ever had HIV/AIDS counseling | 41.92 | <0.001 | ||||
| Yes | 28 (6.1) | 1 (0.6) | 2 (1.4) | 25 (17.4) | ||
| No | 429 (93.9) | 174 (99.4) | 136 (98.6) | 119 (82.6) | ||
| Ever had HIV testing | 34.31 | <0.001 | ||||
| Yes | 27 (5.9) | 3 (1.7) | 1 (0.7) | 23 (16.0) | ||
| No | 430 (94.1) | 172 (98.3) | 137 (99.3) | 121 (84.0) | ||
| STD and HIV/AIDS knowledge (M ± s)a | 7.47 ± 4.17 | 10.52 ± 3.98 | 13.66 ± 3.07 | 105.32 | <0.001 | |
| Condom use knowledge (M ± s)b | 0.56 ± 1.24 | 2.04 ± 2.75 | 6.94 ± 2.07 | 403.46 | <0.001 | |
| Condom self-efficacy (M ± s)c | 11.43 ± 4.78 | 11.30 ± 4.01 | 13.78 ± 4.60 | 14.184 | <0.001 | |
| Sexual behavior self-efficacy (M ± s)d | 15.33 ± 4.52 | 13.93 ± 3.92 | 13.15 ± 4.64 | 10.22 | <0.001 |
aHigher scores reflect greater levels of STD and HIV/AIDS-related knowledge; range 0–18.
bHigher scores reflect greater levels of condom use knowledge; range 0–10.
cHigher scores reflect greater levels of condom self-efficacy; range 0–20.
dHigher scores reflect greater levels of sexual behavior self-efficacy; range 0–20.
Participants working in entertainment venues reported significantly higher HIV/STI knowledge compared with factory workers and restaurant workers (M = 13.7 vs. M = 7.5 and 10.5, respectively), higher knowledge about condom use (M = 6.9 vs. 0.6 and 2.0, respectively) and higher condom self-efficacy (M = 13.8 vs. 11.4 and 11.3, respectively), but reported lower sexual behavior self-efficacy (M = 13.2 vs. 15.3 and 13.9).
Independent correlates of unprotected sexual behavior
Univariate and multivariable logistic regression models examining correlates of unprotected sexual behavior during the past 2 months are summarized in Table 4. In univariate logistic regressions, unprotected sexual behavior during the past 2 months was associated with workplace, education level, pregnancy termination history, STI or genital tract infection in the last year, condom use-related knowledge and sexual behavior self-efficacy. In the multivariable logistic regression model controlling for age, education level and family type, unprotected sexual behavior during the past 2 months was associated with working in an entertainment venue [adjusted odds ratio (AOR) = 2.69, confidence interval (CI) = 1.33, 5.43], abortion history (AOR = 3.23, CI = 1.56, 6.71) and sexual behavior self-efficacy (AOR = 0.85, CI = 0.79, 0.91).
Table 4:
Correlates of unprotected sexual behavior (past 2 months) and STI or genital tract infection (past year)
| Variables | Unprotected sexual behavior, past 2 months |
STI or genital tract infection, past year |
||
|---|---|---|---|---|
| Univariate regression OR (95% CI) | Multivariable regression AORa (95% CI) | Univariate regression OR (95% CI) | Multivariable regression AORa (95% CI) | |
| Workplace | ||||
| Restaurant or factory | Ref | Ref | Ref | Ref |
| Entertainment venue | 5.24 (3.05–8.98) | 2.69 (1.33–5.43) | 24.02 (9.96–57.94) | 3.97 (1.76–8.96) |
| Education level | ||||
| Junior high school or less | Ref | Ref | ||
| High school or higher | 2.51 (1.49–4.25) | 2.86 (1.59–5.16) | ||
| Migrant work time (year) | – | |||
| ≥2 | Ref | Ref | ||
| <2 | 1.88 (1.05–3.39) | 1.98 (0.88–4.48) | ||
| Ever had HIV test | – | |||
| No | Ref | |||
| Yes | 4.50 (1.90–10.63) | |||
| Ever had an abortion | ||||
| No | Ref | Ref | Ref | Ref |
| Yes | 8.43 (4.75–14.96) | 3.23 (1.56–6.71) | 22.38 (11.35–44.13) | 6.78 (3.07–14.98) |
| STI or genital tract infection, past year | – | |||
| No | Ref | |||
| Yes | 6.69 (3.58–12.51) | |||
| Unprotected sexual behavior, past 2 months | – | |||
| No | Ref | Ref | ||
| Yes | 6.69 (3.58–12.51) | 2.85 (1.28–6.31) | ||
| Condom use self-efficacy (M ± s)b | 0.94 (0.89–0.99) | – | ||
| Sexual behavior self-efficacy (M ± s)b | 0.83 (0.78–0.88) | 0.85 (0.79–0.91) | 0.87 (0.82–0.93) | |
aModel adjusted for age, education level and family type.
bContinuous variables (greater value in scores for condom use sell-efficacy and sexual behavior self-efficacy reflect higher overall levels).
Independent correlates of STI or genital tract infection
Univariate and multivariable logistic regression models examining correlates of STI or genital tract infection in the last year are summarized in Table 4. The univariate logistic regressions showed that STI or genital tract infection in the last year was associated with workplace, education level, length of work as a migrant, HIV testing history, pregnancy termination history and unprotected sexual behavior during past 2 months. In the multivariable logistic regression model controlling for age, education level and family type, STI or genital tract infection in the last year was associated with working in an entertainment venue (AOR = 3.97, CI = 1.76, 8.96), recent migration (AOR = 1.98, CI = 0.88, 4.48), pregnancy termination history (AOR = 6.78, CI = 3.07, 14.98) and unprotected sexual behavior in past 2 months (AOR = 2.85, CI = 1.28, 6.31).
DISCUSSION
The current study brings attention to young female migrants in China as a vulnerable subpopulation with potentially high risk for HIV/AIDS and poor reproductive health. Due to the size and movement in China's migrant population, and in light of the critical sexual and reproductive health needs of this population, increasing access to appropriate health services to reduce behavioral risk for HIV and other STIs among female migrants is a priority (Anderson et al., 2003).
This study found important subpopulation differences within young female migrants. Overall, migrants working in entertainment venues showed elevated risk for sexual and reproductive health problems, including greater sexual risk behavior, history of pregnancy termination, any STI and genital tract infection. History of HIV counseling and HIV testing in the sample was low overall, although slightly higher (but still inadequate) among workers in entertainment venues. Female migrants who worked in entertainment venues had spent less time working in the urban setting, were less likely to have intact families and were significantly older than female migrants who worked in factories and restaurants. In contrast, migrants working in factories were the least educated, and migrants working in restaurants reported the lowest monthly incomes. Factory and restaurant workers also reported lower levels of HIV/AIDS-related knowledge and self-efficacy compared with migrants working in entertainment venues.
Group differences observed in this study are consistent with previous research from China revealing family structures and socioeconomic backgrounds of female adolescents influence their employment opportunities and tendencies to engage in sexual risk behaviors (Li et al., 2009; Yan et al., 2009). Specifically, those who come from single-parent or step-parent families experience greater financial pressure to work in entertainment venues. Indeed, the majority of females who worked in entertainment venues were more likely to earn more than 1500 Yuan monthly than females worked in factory and restaurants, indicating the possible influence of financial motivations in migrants' decisions to work in entertainment venues (Fang et al., 2007). Findings reported here are also consistent with other studies indicating that females working in entertainment venues are likely to have multiple sexual partners (Fang et al., 2007; Chen et al., 2011; Hong et al., 2011). Findings are consistent with results reported by Yang et al. (Yang et al., 2005), who found that females working in entertainment establishments in China engaged in risky sexual practices twice as frequently as females working in non-entertainment establishments.
There are several limitations in the current study. First, we used convenient sampling rather than random sampling of employees, which limits generalizability due to a potential for volunteer bias. Generalizability might be particularly limited because we required the permission of owners/managers to recruit and implement the study in their venues. Second, due to the sensitive nature of the study topic, participants might have underreported risk factors as a result of a social desirability bias; biological confirmation of STI status would be useful to verify self-reported sexual health data. Third, we did not collect information on other behavioral risk factors such as alcohol use and drug abuse. Previous studies revealed that the overlap between substance use as co-occurring risk factors in most-at-risk populations for HIV (Kalichman et al., 2007; Li et al., 2010). Fourth, this cross-sectional study was conducted between 2007 and 2008 in a single, moderately developed city in eastern China, which may not be comparable with other mega-metropolitan coastal cities (e.g. Beijing, Shanghai or Guangdong). Results do not permit causal inference and may not be generalized to other populations currently in China. Finally, measures included in the survey focused on individual-level factors and, thus, analyses do not permit conclusions related to specific social or structural–environmental factors related to risk outcomes.
Implications for health promotion and practitioners
The current study has implications for future HIV prevention programs addressing the needs of young female migrants in China. A systematic review of HIV prevention programs in China identified a growing body of individual-level behavioral interventions delivered in clinical settings and high-risk venues, and noted an emerging interest in workplace interventions (Hong and Li, 2009). Differences in HIV risk according to workplace settings call for the development of tailored workplace interventions. Young migrant women working in entertainment venues evinced high behavioral risk for HIV, sexual and reproductive health problems, whereas young women working in factories and restaurants had low access to HIV counseling and testing and low levels of HIV-related knowledge and self-efficacy. Thus, HIV prevention strategies for young female migrants working in entertainment venues should focus on reducing unprotected sex, increasing HIV/STI testing and reducing unintended pregnancy; prevention strategies for females working in factory and restaurant establishments should focus on enhancing HIV/AIDS-related knowledge, condom use knowledge and condom use self-efficacy.
Workplace health promotion interventions in China offer opportunities for providing health education to large numbers of employees and might be especially useful for reaching migrant populations (Hong and Li, 2009). A nascent body of research conducted in China has shown promising effects of workplace interventions on improved HIV knowledge (Li et al., 2006; Wu et al., 2007a, 2007b) and contraception education (Qian et al., 2007). Health promotion interventions delivered at venues where young female migrants work may be useful in enhancing knowledge and skills to engage in condom use, increase HIV and STI testing and practice birth control. Activities should particularly focus on increasing young female migrants' self-efficacy and strategies for avoiding risky sexual situations.
However, in order to conduct such interventions, it will be necessary to engage the trust and collaborations of managers/owners of workplace settings to obtain access and implement change in the workplace environment (Qian et al., 2007). Due to the structural–environmental processes that may contribute to sexual and reproductive risks among young female migrants in China, research is needed to understand and address factors beyond the individual level that determine HIV risk (Hong and Li, 2009). Research is particularly needed on social policies, laws and regulations for creating healthier environments to promote the sexual and reproductive health of young migrant women.
CONFLICT OF INTEREST
The content is solely the responsibility of the authors and does not necessarily represent the official views of any study sponsors.
FUNDING
This work was supported by China AIDS Program Round 3, Global Fund to Fight AIDS, Tuberculosis and Malaria (No. ZY38), the Brown University Office of International Affairs Global Health and infrastructure and resources provided by the Brown University Alcohol Research Center on HIV/AIDS (NIH/NIAAA P01AA019072) and the Lifespan/Tufts/Brown Center for AIDS Research (NIH/NIAID P30AI042853).
ACKNOWLEDGEMENTS
We thank all participants who supported this research by sharing with us the details about their behaviors and beliefs. We also thank staff of the Luyang District Centre for Disease Control and Prevention of Hefei for their help in facilitating this study.
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