The Rural-to-Urban Migrants' Awareness of Their

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					      The Rural-to-Urban Migrants’ Awareness of Their Reproductive

                                 Health Rights in Yunnan, China

                     Kaining Zhang a∗, Lichun Tiana, DENG Ruia, LIAO Ruib

a
    Institute of Health and Development Research, Kunming Medical College (IHDS,KMC), China
b
    Kunming Medical College, China


ABSTRACT

Context: the current reproductive health services for the rural-to-urban migrants
(RUMs) need to be urgently improved in Yunnan and China. During the initial phase
of improving access to and quality of reproductive health services for migrants in
Yunnan, a path-breaking step was taken to understand awareness of clients’ rights
amongst the RUMs in an urban Yunnan for exploring the extent of awareness of
reproductive health rights (RHRs) amongst the RUMs, and examining its associated
factors and possible determinants.
Methods: in the year 2006, 519 migrants who had lived in Xishan County, an urban
area of Kunming City, Yunan Province, for more than three months, aged 18~49, were
interviewed by semi-structured questionnaire.
Results: the majority of the RUMs (56.6%) lacked awareness of the RHRs.
Significant difference were recognized in the awareness of the RHRs among the
subgroups of the RUMs by sex, age, martial status, education, monthly income,
occupation, and exposure to media (P < 0.05), generally speaking, the higher
socio-economical and educational level, the higher awareness of the RHRs. The
regression analysis revealed that the variables significantly affected the RUMs’
awareness of RHRs includes education, occupation, and friends’ support, and
knowledge of reproductive health related preventive practices.
Conclusions: advocacy and educational campaign targeting migrants to arouse
awareness of the RHRs should be conducted immediately. Further study is needed to
better figure out the interesting connection between awareness of the RHRs and
knowledge of reproductive health related preventive practices.

KEYWORDS: Migrants/ Awareness/ Reproductive health/ Rights/ China

Introduction
    With the modernization of the whole country and rapid economic development in
urban areas, rural-to-urban migration has begun to have an impact on modern China.
∗
    Corresponding author. Tel.: 871-5311542     Fax: 86 871 5311542 E-mail: KnZhang49@hotmail.com.
       Address: P. O. Box 43, Kunming Medical College, 191 Renmin West Road, Kunming, 650031, P. R. China



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The rural-to-urban migrants, who account for over 10 percent of the population of
China in reproductive age, inevitably play a vital role in contributing dramatically to
the economic transition across China and the development of both urban and rural
areas. In recent decades, the inequalities between migrants and non-migrants has been
a key issue in China, in terms of availability, accessibility, and utilization of public
services, and has drawn a great deal of attention across the whole of China. Now a
clear commitment of the government is to provide RUMs with better public services.
    The reality of the current situation is that reproductive health services for RUMs
need to be improved immediately in China and Yunnan, as well as that there is a need
for a human rights framework in reproductive health services to be introduced, which
was recognized in the international society. International Planned Parenthood
Federation (IPPF) developed useful concepts and tools for the quality improvement
process in reproductive health services. It is emphasized that the clients’ rights and
providers’ needs as core issues should be taken into account in order to carry out
quality improvement in reproductive health services delivery programmes in a
participatory and sustainable way (IPPF, 1994). However, due to the fact that clients’
right in reproductive health services is an innovative and complicated issue in China,
certainly a series of investigations will be needed. As a path-breaking step, it is
necessary to gain a preliminary understanding of the awareness of reproductive health
rights (RHRs) of RUMs. Meanwhile, selected factors such as socio-demographic
factors, friend-support networks, and knowledge of reproductive health related
preventive practices, should be investigated, in order to identify the most vulnerable
subgroups, the subgroups with lowest awareness of RHRs for providing effective
information to intervention programs for improving access to quality of reproductive
health services for the RUMs.
     Based on the framework of sexual and reproductive health clients’ rights,
developed by the IPPF, as well as considering the context of reproductive health
services in Yunnan Province, the reproductive health rights in this research was
defined as six main items: right to information, right to access, right to privacy, right
to confidentiality, and right to be respected.

Data and Methods

   The study is implemented in Xishan County, an urban district of Kunming City,
Yunnan province. The population of this county is split evenly between migrants and
non-migrants. Two regions of Xishan County, Fuhai and Majie townships are
randomly selected as pilot study sites. The average population of each town is
approximately 80,000, including migrants and non-migrants, though the migrant
population probably exceeds the non-migrant population.

Data Collection

   Data were collected on April, 2006, using semi-structured questionnaire. The
subjects included rural-to-urban migrants who had lived in Xishan County, an urban

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area of Kunming City, Yunan Province, for more than three months, aged 18~49.
Stratified sampling and multistage random sampling techniques were combined to
select study sites and study population. 519 migrants as survey participants were
sampled in each of the sampled villages by using random numbers. Before field
examination began, the questionnaire went through a pretest, and the information
sheet and informed consent form examined as well. Data collection had been
conducted in the form of a household survey.
     The questionnaire used in this study has been approved by the WHO, Geneva
before acted on it. It consisted of six main parts. To examine RUMs’ awareness of
RHRs and to avoid leading the respondents by directly asking questions regarding
whether or not respondents were aware of an issue, a large amount of literature was
reviewed and compared methodologies applied in pervious research. Hence, in the
part of right awareness, respondents are tested using six scenarios based on
hypothetical situations which reflect real-life experiences regarding the circumstances
that RH-clients are often confronted with at reproductive health services delivery
points. Each scenario tells a story designed to focus on one specific aspect of
RH-clients’ rights, so as to assess awareness of specific rights, including rights to
information, access, choice, privacy, confidentiality, and respect. Respondents are
given a wide range of possible answers. Respondents will be asked to judge whether
or not they agree with the subjects’ action in the scenario, or to give advice on how to
handle certain situations depending on several given answers. They will also be asked
what they think about certain responses of a subject in a given scenario.

Data Processing and Analysis

     549 persons were actually interviewed. The number of effective callback
questionnaires was 519 (effective responding ratio: 93%). the demographic analysis
results showed that no significant difference was found in socio-demographic
backgrounds, such as age, ethnicity, educational level, and monthly income, between
effective responding population and the population withdrawing from the interview.
Data collected through the survey was managed using EPI-INFO, a full-featured data
entry package, to establish a database for subsequent analysis. Double entry was
emphasized in order to prevent input errors. Data analysis was carried out mainly
using the software of SPSS 11.5. This analysis included description and analysis of
association/correlation among variables in order to demonstrate a better understanding
of the research topic.
     Score technique was applied in this research to describe general awareness. Those
who selected the negative answers or responded as “not sure” were scored 0; those
who selected the positive answers, but were not able to provide an explanation or to
mention “right” or “RH-clients’ right” were scored 1; and 2 was scored to those who
selected a positive answer, and also provided a reason with a direct mention of “right”,
or “RH-clients’ right.” The full mark of all six themes would be 12. After calculating
respondents’ scores, the respondents were divided into three categories by using the
fiftieth percentile (3 marks) of all respondents’ total score and the mean value of the

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full mark (6 marks). Therefore the three categories are: 6 mark and above, grouped in
a high level category; 3~6 mark in a moderate level category; and less than 3 marks
grouped in a low level category.

Results and Discussion

Sample Characteristics

      In the overall sample, most respondents were married female who were in their
reproductive age, ranging from 24~ 37 years old (Table 1). The majority of them were
Han. Almost half of them had attained junior high school, though 9.6 percent were
illiterate; only 2.7 percent had attained college or higher. In an urban area, Xishan
District, most of them (59.6 percent) were employed as manual laborers in the
construction field, services industry, and domestic helper etc., followed by
Self-employment laborers (18.8 percent). Moreover, one-sixth (16.6 percent) were
housewives. The majority earned a monthly income below 800yuan (RMB) in 2006.
The majority of respondents had accessed to some form of mass media, especially
television, internet, or radio.

TABLE 1: Distribution of respondents’ demographic characteristics by gender
                                  Male                      Female           Total
     Characteristics
                                (n=112 )                   (n=407 )         (n=519)
                          n          %               n        %         N       %
Age
15~19                     7          6.3             28       6.9       35      6.7
20~24                     22         19.6            69       17.0      91      17.5
25~29                     29         25.9            85       20.9      114     22.0
30~34                     25         22.3            108      26.5      133     25.6
35~39                     19         17.0            74       18.2      93      17.9
40~44                     8          7.1             35       8.6       43      8.3
45~49                     2          1.8             8        2.0       10      1.9
Total                     112        100.0           407      100.0     519     100.0
Marital Status
Married                   68         60.7            345      84.8      413     79.6
Unmarried                 44         39.3            62       15.2      106     20.4
Total                     112        100.0           407      100.0     519     100.0
Ethnicity
Ethnic minorities         21         18.8            56       13.8      77      14.8
Han                       91         81.3            351      86.2      442     85.2
Total                     112        100.0           407      100.0     519     100.0
Educational Attainment
Illiterate                4          3.6             46       11.3      50      9.6
Elementary school         19         17.0            147      36.1      166     32.0
Junior high school        54         48.2            160      39.3      214     41.2


                                                                                       4
Senior high school           30        26.8              45     11.1         75      14.5
College and above            5         4.5               9      2.2          14      2.7
Total                        112       100.0             407    100.0        519     100.0
Current Occupation
Unemployed                   2         1.8               26     6.5          28      5.4
Housewife                    0         0.0               67     16.6         67      13.0
Blue-collar work             86        76.8              221    54.8         307     59.6
White-collar work            7         6.3               9      2.2          16      3.1
Self-employed laborers*      17        15.2              80     19.9         97      18.8
Total                        112       100.0             403    100.0        515     100.0
Monthly income (yuan)
Less than 500                18        17.5              115    37.2         133     32.3
500~ 799                     30        29.1              85     27.5         115     27.9
800~ 999                     23        22.3              60     19.4         83      20.1
1000 and above               32        31.1              49     15.9         81      19.7
Total                        103       100.0             309    100.0        412     100.0
Exposure to Mass-media
No                           20        17.9              162    39.8         182     35.1
Yes                          92        82.1              245    60.2         337     64.9
Total                        112       100.0             407    100.0        519     100.0
Note: * self-employment laborers refer to people who run a private small-scale business by
themselves, such as vendors, rice-noodle sellers, food-shop owners, and tailor-shop owners.


Awareness of Reproductive Health rights in General

     Generally speaking, the awareness of the RHRs among RUMs in Xishan County,
an urban area of Kunming city is extremely low. The survey revealed that, of 519
respondents, more than half (56.6 percent) had a low awareness of the RHRs, ranging
from 0~2. Surprisingly, among those respondents as high as 15 percent (75
respondents) was 0 (data not shown). However, 38.0 percent of the respondents fell in
the moderate level category with scores varying from 3 to 5. Only 5.8 percent of the
respondents attained scores of 6 or higher (Table 2).

TABLE 2: RUMs’ general awareness of reproductive health rights (RHRs)
Score of General Awareness of RHRs
           ( Range:0~ 12)                        Number                 Percentage


Low         (0~ 3.0)                               294                     56.6
Moderate ( 3.0~5.0 )                               195                     37.6
High     ( 6.0 and above )                         30                      5.8
Total                                              519                    100.0
(Max= 8)




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     In the case of infringement of the RHRs, most of RUMs tended to ‘let it be’,
rather than taking active action to defend their rights. Most migrants had not heard of
RHRs, even RH; nobody could clearly explain what RHR is, or what RH is. This
probably, at least in part, is because government advocacy and educational campaign
regarding client’s RHRs has not covered this marginalized population yet in Xishan
County. Even in other areas of China, until now, no much attention to RHRs were
paid by the government, as very few literature and researches were found to look at
RHRs in China.

RHRs Awareness in General and Respondents’ Characteristics

    Bivariate analysis gave an examination of the relationship between selected
background variables and the score to the awareness of RHRs in general using cross
tabulation (Table 3).
    Around half or higher of the migrants with diverse backgrounds were at a low
level of awareness of RHRs in general. This means that as potential RH clients to
accessible reproductive health services in public health facilities, the most RUMs
faced with an infringement of RHRs in a public hospital, are more likely to have a
propensity to ignore or give up taking action. However, although all at a very low
level, significant difference were recognized in the awareness of RHRs among the
subgroups of the RUMs by sex, age, martial status, education, monthly income,
occupation, and exposure to media (P<0.05). Nevertheless, it was noted that no
significant difference was identified in the awareness of RHRs between Han and
minorities among the RUMs (P>0.05). Men, the younger, unmarried, better educated,
high-income group, or white-collar workers are more likely to exhibit a relatively
higher awareness of the RHRs than female, the older, poor educated, married ones,
low-income group, or blue-collar workers of subgroups of the RUMs. Moreover,
migrants who contacts to media frequently are more likely to exhibit a higher level of
awareness of the RHRs than the counterpart. Generally speaking, it was found that the
higher socio-economical and educational level, the higher RHRs awareness. In other
word, the most vulnerable subgroups with the lower level awareness of RHRs are
females, married migrants, the elderly, poorly educated, low-income groups, and
blue-collar workers of the RUMs.

      TABLE 3: Percentage distribution of the RUMs’ general RHRsA*** by
                      socio-demographic characteristics
      Socio-Demographic
                                       General RHRsA
            Factors                                                      X2       P
                                                               Total
                                Low      Moderate      High
                                                                (N)
   Sex**                                                               10.702   0.001
    Male                        44.6        43.8       11.6    112
    Female                      60.0        35.9       4.1     407
   Age*                                                                 8.044   0.018


                                                                                        6
    18~ 23                          49.1        42.6          8.3    108
    24~ 37                          56.2        38.1          5.7    331
    38~ 49                          68.8        28.8          2.4     80
   Marital Status**                                                         9.628   0.002
    Unmarried                       44.3        45.3          10.4   106
    Married                         59.8        35.6          4.6    413
   Education**                                                             65.000   0.000
    Illiteracy                      78.0        22.0          0.0    50
    Elementary school               71.1        28.3          0.6    166
    Junior high school              51.4        43.5          5.1    214
    Senior high school              34.7        45.3          20.0   75
    College and above               7.1         71.4          21.5   14
   Ethnicity                                                                3.217   0.073
    Han                             58.1        36.7          5.2    442
    Ethnic minorities               48.1        42.8          9.1     77
   Monthly income (yuan)**                                                 20.601   0.000
   <500                             64.7        34.6          0.7    133
   500~ 799                         56.5        37.4          6.1    115
   800~ 999                         49.4        44.6          6.0     83
   1000 and above                   37.0        49.4          13.6    81
   Occupation**                                                            24.649   0.000
   Unemployment                     50.0        42.9          7.1    28
   Housewife                        59.7        35.8          4.5    67
   Blue-collar work                 60.3        35.8          3.9    307
   Self-employment laborers         52.6        41.2          6.2    97
    White-collar work               12.5        43.7          43.8   16
   Exposure to the media**                                                  8.479   0.004
    Rarely (or never)               64.8        31.9          3.3    182
    Often                           52.2        40.7          7.1    337
  Note: the figure underlined is to indicate P-value < 0.05
      *Significant at p≤0.05; **p≤0.01
      ***RHRsA: Reproductive Health Rights Awareness


Multivariate Findings

    The selected independent variables were those associated with awareness of the
RHRs with statistic significance drawn from bivariate analysis, such as age, sex,
education, marital status, occupation, media exposure, monthly income, friends’
supports, and personal preventive reproductive health related knowledge. Moreover,
monthly income is a relatively sensitive topic to the RUMs in China. According to the
principle of informed consent, the missing cases (107 cases) of this item due to refusal
were more than one fifth of the total sample size (519). However, in order to ensure a

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stable and valid logistic regression model establishing escaped from reducing the
number of cases and a potentially significant non-response bias to the results, those
missing cases were categorized into one group, which was able to be incorporated in a
logistic regression analysis, but which asserted no influence on results.
    Education attainment has the strongest statistically significance level at 0.000 in
this model (Table 4). Migrants with college or higher educational level were eleven
times more aware of their RHRs than illiterate, followed by senior and junior high
school attainment (odd ratio: 6.84 and 3.06, respectively). In other words, among the
RUMs with various educational backgrounds, those of having college or above
educational levels exhibited highest awareness of the RHRs, after controlling for the
effects of other all selected variables in this model. Meanwhile, there was no
significant difference in awareness of the RHRs between migrants with elementary
school education and illiterate. Migrants engaged in such white-collar works as
Hi-tech, professional or managerial occupations were four times more aware of their
RHRs than those employed as manual workers (odd ratio:4.70), such as
unskilled/skilled laborers, waiters, domestic maids etc. Regarding friends’ supports,
migrants who not only keep good relationships with hometown confidants, but also
extend confidants’ network to local residents were almost two times more aware of
RHRs than those merely maintained their hometown confidants’ network in an urban
destination (odd ratio: 1.93).




 TABLE 4: Ordinal logistic regression of selected variables affecting the RUMs’
                                awareness of the RHRs

                                      Reference
 Independent     Comparison group                      ß      OR (95%CI)           P
                                       group
 Variables


Age (year)       38~49                18~23         -0.305    0.74 (0.33~1.65)   0.460
                 24~37                              -0.116    0.89 (0.47~1.69)   0.723

Sex              Male                 Female        0.239     1.27(0.78~2.08)    0.340

Education        College or Above     Illiteracy    2.463    11.74(2.86~48.18)   0.001**
attainment       Senior high school                 1.923    6.84(2.62~17.83)    0.000**
                 Junior high school                 1.118    3.06(1.33~7.06)     0.009**
                 Elementary school                  0.455    1.58(0.68~3.66)     0.289

Marital status   Married              Unmarried     0.049    1.05(0.53~2.08)     0.888

Occupation       White-collar         Blue-collar   1.547    4.70(1.56~14.18)    0.006**
                 workers              workers
                 Self-employment                    0.355    1.43(0.87~2.35)     0.164

                                                                                         8
                   laborers
                   Housework                              0.462       1.59(0.87~2.90)   0.133

Contact with       Yes                      No            0.120       1.13(0.73~1.74)   0.589
media

Friends            No any confidants        Having        0.449       1.57(0.97~2.53)   0.067
support                                     only
                   Having only local        hometown      -0.259      0.77(0.34~1.75)   0.534
                   confidants               confidants
                   Having both                            0.657       1.93(1.14~3.27)   0.014*

RH preventive      More than average        Less than     0.462       1.59(1.05~2.41)   0.030*
knowledge          level                    average
                                            level


Monthly             1000 and above          0~499         0.557       1.75(0.92~3.30)   0.087
income (yuan)       800~ 999                              0.485       1.62(0.88~3.00)   0.122
                    500~ 799                              0.036       1.04(0.58~1.85)   0.902
                    Non-response cases                    -0.166      0.85(0.46~1.56)   0.593
                   (107)
Notes: ‘ß’ is regression coefficients; ‘OR’ is odds ratio; ‘P’ is significance
       *Significant at p≤0.05; **p≤0.01


     In terms of reproductive health related preventative knowledge, it has a statistical
significance level at 0.030 which was a slightly weaker than that of the other two
determinants, education and occupation (Table 4). Migrants who had a higher score of
common reproductive health preventative practice knowledge were more aware of
their RHRs. However, although an association between awareness of the RHRs and
knowledge of the reproductive health-related preventative practices has been
demonstrated in both bivariate and multivariate analysis, the relationship between
them is not well understood because of difficulties in establishing a cause link in a
cross-section study. Moreover, reproductive health-related knowledge in this study
was restricted to the general preventive RH understanding /information about prenatal
and gestation care, induced abortion care and IUD operation, STDs/STI, and
HIV/AIDS rather than the specific knowledge related to RH clients’ rights, while
awareness is actually consciousness of the clients’ rights in reproductive health
services. Therefore, there is no satisfactory explanation to provide strong reasons for
an association between them.
    The results of ordinal regression analysis revealed that the variables significantly
affecting the RUMs’ awareness of the RHRs in general include the following four
factors: education attainment, current occupation, friends’ support and personal
knowledge of reproductive health related preventive practices. The migrants who had


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a higher educational level, who perform white-collar jobs, who had both hometown
and local confidents in urban destination, or who got the higher score of reproductive
health related knowledge were more likely to be aware of their RHRs.

Conclusions

    In brief, this study was conducted in an urban area of Kunming City, Yunnan
province to investigate the RUMs’ awareness of their RHRs awareness. It found that
quite few migrants were aware of their RHRs; awareness of the RHRs varied among
subgroups of the RUMs by diverse socio-demographic characteristics. Moreover,
variables significantly affected the RUMs’ awareness of RHRs includes education,
occupation, and friends’ support, and knowledge of reproductive health related
preventive practices. In addition, having new friends in destination urban area and
keeping a reasonable connection with fellows from the same resource rural area
demonstrated a positive factor to understand the RHRs for the RUMs. These results
indicate that advocacy and educational campaign is needed to raise awareness of the
RHRs for the migrants; female migrants, especially housewives, illiterates and those
with elementary educational level, and low-income unskilled workers or waiters
should be given prior consideration in awareness raising campaigns; establishing a
better social support for the migrants in their urban destinations should be considered
in current intervention activities. Moreover, further study is needed to better
understand the relationship between knowledge of reproductive health related
preventive practices and awareness of reproductive health rights.

Study Limitations

    As a bath-breaking study attempting to understand awareness of RHRs among the
RUMs in China, this study is subject to several limitations. First, as limitations in
sample size, time and budget, and unexpected operational difficulties are predictable.
In order to better understand RHRs awareness among the RUMs in China, more
in-depth investigations should be continued. For example, it would be worthy to
address the association between lengths of time the RUMs have left hometown and
awareness of the RHRs in the future study. Second, using a non-proportional sampling
approach, it is not simple to estimate the awareness for the whole migrating
population. Because one of the main objectives of this study is to examine awareness
of reproductive health rights for the disadvantaged migrating women, especially those
married already, great efforts were made to give an ear to the voices of married female
migrants. In terms of sampling design, an approach of disproportional multiple-stage
stratified and randomized sampling for household surveys, or a sampling frame of
non-self-weighting sampling was utilized. As a matter of fact, a 4:1 ratio of women to
men was identified among the interview respondents. This provided a bigger
opportunity to listen to the more vulnerable migrating married women about the
sensitive issues of their RH rights. Nevertheless, cost for the strong reason of
gender-sensitivity is that the sample of this study is “not representative for the RUMs

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population (men plus women) in general”. There should be a statistical calculation to
get the “real awareness” for the whole population (men plus women). In other words,
it is not simple to estimate the general awareness for the whole population of migrants.
To do this, proportions of married/ unmarried women and men among the migrants
are needed, to calculate the “real rates or average” awareness for the whole migrating
population, representing the RUMs in general.


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Acknowledgments



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     The authors acknowledge sponsors of ‘Xishan Project’, the Word Health
Organization (WHO) and the Ford Foundation. The authors also appreciate the input
of Dr. Philip Guest, program associate and country representative in the Population
Council's Bangkok, Thailand office, for his valuable comments and constructive
suggestions during the questionnaire design and presentation of findings. In addition,
the efforts of research assistants and interviewers in conducting the fieldwork and the
respondents for their time are highly commended.




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