On the basis of controlling for multiple variables, our analyses suggested that age, residence, profession, “awareness of PMS”, “knowledge of PMS” and “attitudes towards PMS” are all significantly associated with participation in PMS. Profession and education may serve as a proxy for awareness and knowledge variables and once control is made for these, education may in fact have a negative association with the decision to participate. The variables of “gender”, “ethnicity”, “education”, “monthly income” were not significantly associated with participation, consistent with some previous literature .
Older individuals appear to have higher rates of participation in premarital screening. This may be due to the fact that, as the age increases, people attach increased importance to health. An increasing sense of responsibility with age may also influence participation . Increased concern about birth defects may also be partially responsible.
In the analyses, “residence” was significantly associated with the decision to participate.
Residents of Wuhan and Suizhou were more likely to participate than those living in Zaoyang or elsewhere. As discussed further below, the Suizhou government, in particular, places considerable importance on PMS by implementing a comprehensive examination before marriage and emphasizing free premarital screening. It gives some guidance and advice to couples before marriage and promotes PMS knowledge. The regional results suggest that local policy can exert considerable influence on PMS participation rates.
Scientists and teachers were found to be more likely to participate than those in other professions. The cultural literacy and professional characteristics of the scientists and teachers, may give them a more comprehensive and clearer understanding of PMS. Profession may in fact be serving as a proxy for knowledge and awareness of PMS and indeed our analyses which included knowledge/awareness factors in the model resulted in non-significant associations between profession and participation. Conceived of another way, knowledge and awareness may mediate the effects of profession on participation. Similar but perhaps more striking results were found for education. Education may be serve as a proxy for knowledge and awareness of PMS. Once control was made for knowledge and awareness of PMS, the education variable in fact had a negative association with participation.
After controlling the demographic factors, the awareness, knowledge and attitude variables remained significantly associated with participation. Those aware of PMS and of the free voluntary mode in the screening, those with more knowledge of PMS and those who thought PMS necessary were all more likely to participate. However, controlling for all other factors, the variable “attitude to the preventive effects of PMS" was negatively associated with participation. One possible explanation is that those who are most aware are also concerned about testing positive for various conditions. Another explanation is that those who feel positively about the preventive effects may feel they do not personally need this benefit and may have little knowledge of genetic inheritance and ignore the seriousness of hereditary disorders [25, 33, 34]. In fact, Chen Jinsheng, who also found a similar phenomenon in his study, pointed out that there is sometimes a high degree of “one's acts belie one’s words” between the attitudes towards PMS of Chinese people and whether one participates or not .
China is still in an early stage of economic development. People's living standard of living is on average still low by western standards. In some regions, medical and health care services are limited. Serious genetic diseases, infectious diseases and mental illnesses continue to be important factors that influence the people's living standards. The sharp decline of PMS rate resulted from abolishing the compulsory premarital screening policy. Some Chinese scholars have argued that the compulsory policy should be restored or a new mode of participation and screening should be considered [36, 37]. Given current policy, appropriate measures should be taken to improve the people's knowledge and awareness of and attitudes towards PMS so as to increase participation rates. The results concerning the high rates in Suizhou example strongly suggests that the local government and local strategies can have a significant impact on the local residents’ attitudes to PMS. The government there established a PMS team to manage and develop strategies to promote PMS. Such strategies include providing PMS knowledge by mass media, a special fund for PMS, a counseling hotline, and providing PMS completely free of charge. Their approach suggests that governments can effectively care for and support PMS programs and provide appropriate guidance. The results of our study strongly confirm that residents’ awareness, knowledge and attitudes play an important role in the decision to participate. Resources should be utilized to intensify promotional material on the purpose and significance of PMS in a broad sustained manner. Mass media can be used in providing information about premarital screening so that residents will have a more positive attitude towards prevention. Other research indicates that educational programs can considerably improve people's knowledge of PMS . Improving educational programs and including PMS in various curricula in both high school and university contexts may be important in increasing knowledge and awareness. Educational programs for PMS have proven to be effective in other settings .
Our study is subject to some limitations. First, the investigation sites were chosen in only three cities in Hubei province. This limits somewhat the generalizability of our findings. Second, subjective information was solicited on the questionnaires, and responses may not be fully accurate. Third, the convenience sample of the study participants obtained by surveying those who were registering for marriage at civil affairs bureaus on particular days may not be fully representative of the responses in the three cities if there are substantial seasonal or geographical variations in the patterns of those registering that are strongly correlated with the questionnaire responses. Finally, although our study gave insight into a number of important factors that influence participation and also confirmed some previous findings, while also controlling for all other variables simultaneously, the explanatory power of the model was only 17.1%. There is still a considerable portion of the variation that is not explained by the factors in this study. The decision to participate in PMS is complex and multi-faceted. Future research could attempt to explore other factors that may be associated with the decision to participate.