Position des agents des services chinois de planification familiale vis-à-vis de la fourniture de services de santé sexuelle et génésique aux jeunes non mariés
Actitud de los agentes de planificación familiar en la prestación de servicios de salud sexual y reproductiva para la población joven soltera en China
Xiaowen TuI; Nian CuiII; Chaohua LouIII; Ersheng GaoIV, 1
IAssistant Professor, Department of Epidemiology and Social Science, Shanghai Institute of Planned Parenthood Research, Shanghai, China
IIProfessor, Sichuan Family Planning Research Institute, Chengdu, China
IIIProfessor, Department of Epidemiology and Social Science, Shanghai Institute of Planned Parenthood Research, Shanghai, China
IVProfessor, Department of Epidemiology and Social Science, Shanghai Institute of Planned Parenthood Research, 2140 Xie Tu Road, Shanghai 200032, China (email: firstname.lastname@example.org)
OBJECTIVE: To ascertain the perspectives of family-planning service providers in eight sites in China on the provision of sexual and reproductive health services to unmarried young people.
METHODS: Data were drawn from a survey of 1927 family-planning workers and 16 focus group discussions conducted in eight sites in China in 1998-99.
FINDINGS: Family-planning workers recognized the need to protect the sexual health of unmarried young people and were unambiguous about the need for government agencies to provide information and education on sexual and reproductive health to unmarried young people; however, perceptions about the appropriate age for and content of such education remained conservative. While about 70% of family-planning workers were willing to provide contraceptives to unmarried young people, and about 60% approved government provision of contraceptive services to unmarried young people, only one quarter agreed that the services could be extended to senior high schools.
CONCLUSION: Family-planning workers in China are ambivalent about the provision of sexual and reproductive health services to unmarried young people, which potentially poses a significant obstacle to the adoption of safe sex behaviours by young people, as well as to the provision of sexual and reproductive health information and services to young unmarried people in China. Training programmes for family-planning workers are urgently needed to address this issue.
Keywords: Family planning services; Sex education; Safe sex; Contraception; Reproductive medicine; Marital status; Government agencies; Community health aides; Attitude of health personnel; Cultural characteristics; Adult; China (source: MeSH, NLM).
OBJECTIF: Connaître la position des agents des services de planification familiale vis-à-vis de la fourniture de services de santé sexuelle et génésique aux jeunes adultes non mariés dans huit sites répartis sur l'ensemble de la Chine.
MÉTHODES: Les données ont été tirées d'une enquête sur 1927 agents des services de planification familiale et des débats de 16 groupes de discussion dans huit sites répartis sur l'ensemble de la Chine en 1998-1999.
RÉSULTATS: Les agents des services de planification familiale reconnaissaient la nécessité de protéger la santé sexuelle des jeunes adultes non mariés et adhéraient totalement au principe de la fourniture par les services officiels d'une information et d'une éducation en matière de santé sexuelle et génésique à destination de ces jeunes. Cependant, leur position quant à l'âge approprié pour une telle information et à son contenu restait très réservée. Alors qu'environ 70 % d'entre eux étaient prêts à fournir des contraceptifs aux jeunes non mariés et 60 % approuvaient la fourniture par l'Etat de services de contraception pour cette catégorie de population, seuls un quart d'entre eux convenaient que ces services pourraient être étendus aux jeunes en fin de scolarité secondaire.
CONCLUSION: Les agents des services chinois de planification familiale ont une position ambiguë quant à la fourniture de services de santé sexuelle et génésique aux jeunes non mariés ; une telle attitude risque de constituer un grave obstacle à l'adoption par les jeunes de comportements sexuels sans risque et à la fourniture d'information et de services de santé sexuelle et génésique à cette catégorie de population. Il est par conséquent urgent de mettre en place des programmes de formation spécifiques à l'intention des agents des services de planification familiale.
Mots clés: Contrôle naissances; Education sexuelle; Sexe sans risque; Contraception; Médecine reproduction; Situation matrimoniale; Service ministériel; Auxiliaire santé publique; Attitude du personnel soignant; Moeurs; Adulte; Chine (source: MeSH, INSERM).
OBJETIVO: Determinar las actitudes de los proveedores de servicios de planificación familiar en ocho lugares de China en lo relativo a la prestación de servicios de salud sexual y reproductiva a los hombres y mujeres jóvenes solteros.
MÉTODOS: Se utilizaron datos reunidos a partir de una encuesta realizada entre 1927 agentes de planificación familiar y 16 grupos de discusión organizados en ocho lugares en China en 1998-1999.
RESULTADOS: Los agentes de planificación familiar reconocían la necesidad de proteger la salud sexual de la población joven soltera, y no vacilaban en admitir también que los organismos públicos debían proporcionar información y educación en materia de salud sexual y reproductiva a esa población; sin embargo, su percepción sobre la edad idónea para tal educación y el contenido de la misma seguía siendo conservadora. Mientras que aproximadmente un 70% de los agentes de planificación familiar estaban dispuestos a proporcionar anticonceptivos a los jóvenes solteros, y un 60% aprobaba la idea de que la administración pública les ofreciera servicios anticonceptivos, sólo una cuarta parte estaba de acuerdo en que esos servicios se extendieran a las escuelas secundarias de segundo ciclo.
CONCLUSIÓN: Los agentes de planificación familiar de China muestran una actitud ambivalente ante la prestación de servicios de salud sexual y reproductiva a los jóvenes solteros, lo cual puede llegar a suponer un obstáculo importante para la adopción de prácticas sexuales más seguras por los jóvenes, así como para el suministro de información y servicios de salud sexual y reproductiva para la población joven soltera en China. Es necesario implementar urgentemente programas de capacitación para los agentes de planificación familiar a fin de resolver este problema.
Palabras clave: Servicios de planificación familiar; Educación sexual; Sexo seguro; Anticoncepción; Medicina reproductiva; Estado civil; Agencias gubernamentales; Auxiliares de salud comunitaria; Actitud del personal de salud; Características culturales; Adulto; China (fuente: DeCS, BIREME).
Under the influences of mass media, rapid modernization, economic expansion, and exposure to new ideas, sexual attitudes and norms have been changing rapidly among adolescents and young people in more and more developing countries, including China. Emerging evidence from rural and urban areas shows increasing premarital sexual activity among adolescents and young people in China (1, 5-8). Despite this, contraceptive practice is limited and irregular (1). Unprotected sexual activity puts young people at risk of unwanted pregnancy, unsafe abortion, and sexually transmitted infections (1, 6).
In China, family-planning services are provided in two ways: through the health system, which includes hospitals, maternal and child health centres, and drug stores, and through the family-planning system, which consists of family planning service units available from the community level to the province level. The staff of family-planning service units fall into two categories: contraceptive providers, who are in charge of providing contraceptives to the local family-planning service units at the primary community level and managing and supervising contraceptives, and community-based distributors, who are in charge of distributing contraceptives, as well as providing general counselling for clients in their service areas. As in most other developing countries, however, such services are mainly for married couples of reproductive age. The sexual and reproductive health needs of young people remain poorly understood and met, with little access to appropriate and acceptable sexual and reproductive health services.
In many places, studies have also shown that adolescents and unmarried young people are unable to access or are restricted from receiving these services, which leaves a gap in the service system (9, 10). Even in some developed countries, such as the United States and the United Kingdom, adolescents often face barriers to accessing sexual and reproductive health services (11, 12).
Several obstacles that inhibit the access of adolescents and unmarried young people, particularly women, to contraceptive and other sexual and reproductive health services have been identified. Prominent among obstacles to the provision of sexual and reproductive health information and services is the reluctance and ambivalence on the part of adult gatekeepers - policy-makers, programme managers, parents, and service providers (9, 13-15). In many settings, studies have reported that family-planning providers perceive their roles as serving the needs of married adults and not those of young or unmarried people (Senerowitz J, unpublished data, 2000). Several studies of providers conducted elsewhere have pointed to factors that influence providers' willingness to serve young people. One study reported that sociodemographic characteristics of family workers such as marital status, age, and level of education can have a bearing on the quality of services they provide to adolescents (16). More studies, however, point to providers' attitudes as a prominent factor that constrains adolescents from using reproductive health services (9, 14, 17-19), especially in settings where sexuality is associated closely with marriage and childbearing (9, 14, 17). To change the attitudes of providers is a major concern in these societies (9). Unfortunately, few studies in China have explored providers' perspectives and attitudes towards provision of sexual and reproductive health services to unmarried young people, and this paper aims to do so.
The paper explores the perceptions and attitudes of service providers in eight sites in China on the provision of sexual and reproductive health services to unmarried young people, and, in doing so, it assesses the extent to which the perceptions of providers do indeed reinforce those of young people.
Data sources and methods
Data are drawn from a multi-centre project between 1998 and 1999 on unmet needs and factors that impede access to sexual and reproductive health services among sexually active unmarried young adults in eight Chinese sites: Shanghai and Chongqing cities and Hebei, Henan, Jiangsu, Zhejiang, Fujian, and Sichuan Provinces. These eight sites are located in different areas of China with high population densities and are fairly representative of rapidly developing areas of China. Among the eight sites, Shanghai is the most "open" and significantly developed city in the east of China and has the broadest contacts with foreign countries in terms of economic trade and culture exchange. It also has been affected comprehensively by western culture over the years, especially since the economic reform in China in 1980s: for example, the people's traditional attitudes to premarital sexual activity, especially young people's attitudes, have weakened greatly in this city. Jiangsu and Zhejiang are developed areas also in the east of China. Fujian is a developed area in the southeast of China, which is inhabited by a large number of relatives of Chinese people who live overseas and Chinese people who have returned from overseas. Hebei and Henan are less developed areas among the eight sites located in north China. Sichuan and Chongqing are rapidly developing areas in south-west China and include a large number of minority groups. Sites from which family-planning workers were drawn were selected purposely (three urban areas and three rural areas in each site) to represent areas in which economic development levels (high, middle, and low) were representative of the local province or city (Shanghai and Chongqing administrative regions contain rural and urban areas).
The study consisted of a mix of quantitative and qualitative methods. A survey was conducted among two types of family-planning workers, namely contraceptive providers and community-based distributors. Focus group discussions were conducted with unmarried young people, as well as gatekeepers such as parents, family-planning workers, and policy-makers. This paper focuses on family-planning workers. Study participants were recruited after informed consent was obtained.
The survey was conducted among 1927 family-planning workers, including 965 contraceptive providers and 962 contraceptive distributors. In each of the eight sites, 120 providers and 120 distributors comprised, on average, about 60% of all providers and about 20% of all distributors. The sample in each of the eight sites was drawn from three urban areas and three rural areas. In each of the six urban or rural areas, 20 providers and 20 distributors, on average, were selected on a convenience basis. Trained interviewers administered face-to-face interviews. All family-planning workers who were approached agreed to be interviewed.
A total of 16 focus group discussions were held with a total of 123 family-planning workers: two discussions in each site - one with contraceptive providers and one with family planning staff (full time staff involved in administrative affairs in family planning at neighbourhood and township level or above). After carefully discussing the representatives and local situation of the eight sites with the local principal investigators, four of the eight sites (Shanghai, Fujian, Sichuan, and Chongqing) were chosen to provide samples from rural areas, while in the four remaining sites (Henan, Hebei, Jiangsu, and Zhejiang), family-planning workers were drawn from urban areas. All participants were married and were chosen with the assistance of local organizers who were familiar with the demographic characteristics of family-planning workers. When focus groups were assembled, care was taken to ensure that participants did not know each other, and local leaders, who may have inhibited free discussion, were excluded. Moderators made it clear that the intention was to discuss perceptions of and attitudes towards the provision of services for unmarried young people in general. The proceedings of focus group discussions were tape-recorded as well as noted. Procedures for conducting the focus group discussions, introductory remarks, and guidelines, as well as detailed instructions, were identical for all eight centres to ensure the quality and comparability of the data.
In both phases of the study, family-planning workers were asked to estimate the percentage of young people aged 18-24 years who may have experienced sexual relations and to discuss whether premarital sexual relations were "unavoidable" in prevailing circumstances and whether they perceived premarital sexual behaviour and abortion as health problems for young people. They also provided insights into the extent and kind of knowledge young people have on issues related to sex, contraception, and sexually transmitted infections and the kinds of services currently available to them. The core of the research, however, focused on family-planning workers' attitudes towards the provision of sex education, contraceptives, abortion, and counselling services to young people; appropriate age for the provision of such education; and preferences with regard to content and mode of delivery.
Data processing and analysis
Survey data were entered in EpiInfo software (version 6.04; Centers for Disease Control and Prevention, Atlanta, GA, USA) and analysed with Statistical Analysis Software (version 8.01; SAS Institute, Carey, NC, USA).
Profile of respondents
As described earlier, although providers include those who have a supervisory role at the primary level, distributors are more likely to be community-level workers supervised by those at primary and higher levels. This is reflected in the socioeconomic differences of characteristics of family-planning workers included in the survey (Table 1 and Table 2). Although some variation was seen between sites, both groups largely comprised married females (51-93% for providers and 65-100% for distributors), and in all sites, providers, in general, were better educated and younger than distributors (Table 2). For example, the overall mean age of providers was 37.6 years (ranging from 32.9 years in Fujian to 42.2 years in Shanghai) but of distributors was 39.2 years (ranging from 34.3 years in Henan to 44.1 years in Shanghai). The term "respondents" is used interchangeably with "family-planning workers".
Attitudes towards provision of information on sexuality and contraception to unmarried young people
Respondents, irrespective of group or area of residence, agreed that young people in China were poorly informed on issues related to sex, contraception, and sexually transmitted infections, and >90% argued that educational activities on sexuality were inadequate and limited.
Not surprisingly, respondents' attitudes about the provision of sexual health information to unmarried young people was overwhelmingly positive. More than 92% of providers in all sites argued for more in-depth and explicit information about sexuality and contraception for unmarried adolescents and felt that the advantages of complete information far outweigh the disadvantages. Similar proportions were found in distributors (92%), except in Hebei (70%), Henan (88%), and Zhejiang (82%). These views were reinforced in focus group discussions.
Respondents were more conservative, however, in their perceptions of appropriate content and timing of sex education. Providers' and distributors' responses to these questions in the same site were very similar, but they varied between sites. With regard to content, 81% of all respondents (ranging from 52% in Zhejiang to 89% in Jiangsu and Fujian) argued that "sex morals, psychology, and physiology" were central to sex education; in addition, 53% (ranging from 22% in Hebei to 68% in Shanghai) argued for the inclusion of information on contraception and available methods Respondents were more conservative, however, in their perceptions of appropriate content and timing of sex education. Providers' and distributors' responses to these questions in the same site were very similar, but they varied between sites. With regard to content, 81% of all respondents (ranging from 52% in Zhejiang to 89% in Jiangsu and Fujian) argued that "sex morals, psychology, and physiology" were central to sex education; in addition, 53% (ranging from 22% in Hebei to 68% in Shanghai) argued for the inclusion of information on contraception and available methods and 29% (ranging from 4% in Zhejiang to 40% in Hebei) argued for the inclusion of counselling facilities alongside the provision of sex education (Table 3). Similarly, considerable ambivalence was seen with respect to appropriate timing of sex education. Fewer than one-third of all respondents approved the provision of sex education to adolescents aged under 18 years, most (about 37%) considered 18 years (the average age for graduation from high school and the age at which young people are issued identity cards) as appropriate, and the remaining one-third argued that such education should be held back until young people reach the legal minimum age for marriage - that is, 20 years old. Compared with respondents from Hebei, Henan, Jiangsu, and Shanghai, respondents from Zhejiang, Fujian, Sichuan, and Chongqing preferred to provide sex education at a younger age (Table 4).
Whatever their misgivings, >80% of family-planning workers expressed their willingness to provide information and counselling about sex and contraception to unmarried young people who sought it, except in Hebei (65%) and Henan (76%).
Attitudes toward provision of contraceptive services for unmarried young people
Findings showed similar ambivalence about provision of contraceptive and other reproductive health services to unmarried young people. Table 5 shows responses to a series of questions (footnote a) that probed attitudes to the provision of services to unmarried young people. Findings suggest, for example, that although more than two-thirds of all respondents were willing to provide contraceptives to unmarried people, they qualified such willingness with the condition that the clients were aged >18 years. At the same time, respondents were more divided about regulating the provision of services to unmarried young people. About 60% of respondents approved government provision of contraceptive services to unmarried young people, and about half agreed that services should be provided at workplaces and colleges or universities (about 51% and 55%, respectively). Only about a quarter, however, agreed that contraceptive services should be provided at senior high school level. Differences between providers and distributors were not as apparent between sites. Table 5 shows that respondents from Shanghai, Fujian, Chongqing, and Sichuan, by and large, were far more open to the provision of services to unmarried young people than respondents from other settings. In contrast, family-planning workers from Hebei, Henan, Jiangsu, and Zhejiang (particularly those from Hebei) were less likely to hold positive attitudes to the provision of services. The possible explanation for this might be that traditional Chinese values are still strong in Hebei, so that people's attitudes on sex are more conservative than in other provinces.
Regional differences were replicated in focus group discussions. Conservative attitudes were expressed in focus discussion groups for family-planning workers in urban Hebei, Henan, Jiangsu, and Zhejiang. Participants from Hebei and Henan clearly felt, for example, that provision of contraceptive services was contrary to traditional Chinese values and would mislead unmarried young people and increase the incidence of premarital sex.
Most participants from other sites, particularly those in rural Shanghai, Sichuan, and Chongqing, favoured active provision of contraceptive services to unmarried young people by family planning departments, especially for those who had a steady partner or who were cohabiting.
Participants in focus group discussions from rural areas were more likely than those in urban areas to favour the provision of contraceptives to unmarried young people who were dating or living together. They argued that the need was expressed by unmarried young people themselves, as well as their parents. Possible explanations for this finding might be that:
• the practice of couples living together between engagements and marriage is relatively accepted in rural China, so rural family-planning workers correspondingly were more tolerant towards premarital sex and the provision of contraceptives to unmarried young people
• many hospitals and drug stores are found in urban areas, so it is convenient to get contraceptives; family-planning workers in urban areas thus might be less likely to be approached by unmarried young people for contraceptive services and hence be less acutely aware of the need for services.
Focus group discussions, however, also showed that family-planning workers may not perceive unmarried young people as their target clients. They thought their task and role was "to provide contraceptive services to married couples, especially to married women, with no responsibility or obligation to provide the services to unmarried people".
This paper explored the perceptions of family-planning workers on the provision of sexual and reproductive health services to unmarried young people in China. More importantly perhaps, it shows the extent to which those who have the main responsibility for the provision of services are willing to provide and committed to providing these services to unmarried young people in China. Family-planning workers in China were ambivalent about the provision of sexual and reproductive health services to unmarried young people, and their perceptions are paramount in determining perspectives of the need to provide contraceptive services to unmarried young people. Similar results have been found in many other developing countries (9, 14, 17). Underlying this ambivalence are misperceptions, continued adherence to traditional norms, and ambiguities and limitations in the current policy on the one hand and their recognition of the need to protect the sexual health of unmarried young people on the other. As young people prefer to get information about sexuality, and contraceptive services (particularly in rural areas), from family-planning workers (findings from the same study (20, 21)), their concerns, together with the ambivalence of the parents of unmarried young people (findings from the same study (4)) may pose a significant obstacle to the adoption of safe sex behaviours by young people, as well as the provision of sexual and reproductive health information and services to young unmarried people in China.
While family-planning workers were unambiguous about the need for government agencies to provide information and education on sexual and reproductive health to unmarried young people, however, perceptions about the appropriate age for and content of such education remained clearly conservative. Ambiguities equally were evident in the case of service provision. For example, while family-planning workers recognized that premarital sex has increased and, in general, approved of the provision of contraceptives to unmarried young people, no more than three-fifths advocated that the government should extend services to unmarried young people, and only one-quarter agreed that services could be extended to high schools. This was also a finding observed among parents (4). In short, although family-planning workers genuinely seemed concerned about the sexual health needs of unmarried young people and many were accustomed to responding to the service or counselling needs when they were requested, they were not entirely comfortable about providing targeted services to young people through government services or services provided at employment sites and educational institutions.
The study has brought forth the challenge of providing sexual and reproductive health information and services when the very people who are to provide these services are ambivalent. It has also shown that the concerns of unmarried young people with regard to the attitudes of providers are not entirely unfounded.
Limitations of the data must be acknowledged. Findings from the study are not intended to be representative of China generally nor could the huge ethnic and cultural diversity existing in the country have been captured in this in-depth study of eight sites. Caution must be exercised in generalizing findings, even to the province or city from which data are drawn.
Nevertheless, findings offer several suggestions for action. For example, the dilemmas faced by family-planning workers need to be recognized and addressed. Training programmes are needed that are directed to family-planning workers: important aspects of such training include an overview of the current sexual behaviour situation of unmarried young people, ways in which family-planning workers can contribute to averting adverse consequences, and clarification that unmarried young people do indeed fall within their target populations. At the same time, family-planning workers need to be trained in the techniques and skills needed to serve unmarried young people.
Despite the ambivalence expressed by family-planning workers, they are clearly concerned for the well-being of unmarried young people and agreed with the establishment of programmes that enable young people to know about and protect themselves from unwanted pregnancy, disease, and abortion. Family-planning workers seemed willing to empower the government to establish educational and service delivery programmes for unmarried young people, and it is important that government acts upon this expression of interest.
Finally, it should be noted that any expansion of family-planning services in China needs policy and organizational support. In addition, activities that raise public awareness of the need for comprehensive sexual and reproductive health education and services for unmarried young people are required urgently.
The study on which this article is based was supported by WHO, Strategic Programme Component of Social Science Research on Reproductive Health, UNDP/UNFPA/WHO/World Bank, Special Programme of Research, Development & Research Training in Human Reproduction. Views expressed in this paper are those of the authors and do not necessarily reflect those of the funding agencies. We are very grateful to Dr Iqbal Shah and Dr Shireen Jejeebhoy for technical assistance and guidance. We also appreciate greatly the contributions of the institutes that participated in the study and the principal investigators from each: X.W. Tu, Shanghai Institute of Planned Parenthood Research (the coordinating centre); J.R. Yu, Hebei Family Planning Research Institute (FPRI); S.X. Gan, Henan FPRI; J.H. Ding, Jiangsu FPRI; D.L. Sun, Zhejiang Academy of Medical Sciences FPRI; Y.L. Zhang, Fujian FPRI; N. Cui, Sichuan FPRI; and H. Li, Chongqing FPRI.
Conflicts of interest: none declared.
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Submitted: 28 February 02
Final revised version received: 30 July 03
Accepted: 31 July 03
1 Correspondence should be sent to this author.