Lack of health risk awareness in low-income Chinese youth migrants: assessment and associated factors
Environ Health Prev Med
Lack of health risk awareness in low-income Chinese youth migrants: assessment and associated factors
Yuhui Shi 0 1
Ying Ji 0 1
Jing Sun 0 1
Yanling Wang 0 1
Xinying Sun 0 1
Chaoyang Li 0 1
Dongxu Wang 0 1
Chun Chang 0 1
Health 0 1
0 J. Sun School of Public Health, Griffith University , Meadowbrook Q4131 , Australia
1 Y. Shi Y. Ji Y. Wang X. Sun C. Li D. Wang C. Chang (&) Department of Social Medicine and Health Education, Health Science Center, Peking University , Beijing 100191 , China
Objective To analyze and assess health risk awareness of youth migrants in China and the factors that influence it, and to provide evidence for making health promotion interventions and decreasing health risks among Chinese youth migrants. Method This was a cross-sectional survey conducted in 2009 among rural-to-urban migrants aged 15-24 years in Tianjin and Xi'an, China. A total of 1,838 youth migrants were enrolled by the stratified cluster sampling method. An anonymous questionnaire was self-administered to investigate health risk awareness. The t test and v2 test were used to analyze differences between different groups. Logistic regression analysis was used to test the influence of various sociodemographic, living condition, and occupational factors. Results The smoking rate of men (66.8%) was higher than that of women (6.8%; P 0.05), the rate of sexual intercourse in men was higher than in women (56.8 vs 27.7%; P 0.05), and 75.7% of participants had written into medical care systems with 40.4% of them having undergone a physical examination during the last year. Only 438 of the participants (26% of 1,647) were considered to have a satisfactory level of health risk awareness [273 (32.4% of 958) from Tianjin and 165 (28.8% of 689) from Xi'an]. No significant difference was found between the youth migrant populations of the two cities. The percentage of youth migrants with a satisfactory level of health risk awareness who thought they had a good health status was higher than that with an unsatisfactory health risk awareness who thought they had a good health status (P 0.05). Logistic regression analysis showed that gender, age, education, reading the newspaper, and occupation significantly influenced on health risk awareness. Conclusion Youth migrants in China have a low health risk awareness. Combined and targeted health education interventions should be promoted to increase their health risk awareness.
education; Youth; Migrant; Health risk; Health promotion
Although there are many possible definitions of a ‘‘health
risk’’, according to the World Health Organization (WHO)
global health risks report 2009 [
], it can be broadly
defined as ‘‘a factor that raises the probability of adverse
health outcomes’’. The five leading risk factors, namely,
unsafe sex, alcohol use, unsafe water and sanitation, high
blood pressure, and being underweight as a child, are
responsible for one-quarter of all deaths in the world and
for one-fifth of all disability adjusted life years. Reducing
exposure to these risk factors would increase global life
expectancy by nearly 5 years [
]. Each risk has its own
causes, and many have their roots in a complex chain of
events over time, including socioeconomic factors,
environmental and community conditions, and individual
behavior. The causal chain offers many entry points for
]; in addition there are many ways that
populations can be targeted. The two major approaches to
reducing risk are targeting (1) high-risk people and (2) risk
in the entire population [
]. One of important points is the
health risk awareness of the target population. A high level
of health risk awareness is very useful to increase the
perceptual vigilance on diseases, improve utilization and
demands of health services, and decrease health risk [
Low-income populations are most affected by risks
associated with poverty, such as undernutrition, unsafe sex,
unsafe water, poor sanitation and hygiene, and indoor
smoke from solid fuels [
]. One subgroup frequently
identified as being vulnerable to acquiring behaviors that
are considered to be health risks is that of rural-to-urban
migrants. The transition of China to a global economic
player has led to greater disparities between rural and urban
economies, a situation which resulted in 147.35 million
rural-to-urban migrations in China in November 2005 [
and 261.39 million migrations in 2011 [
]. According to
the an investigation report on Chinese migrant workers [
most rural-to-urban migrants are relatively young, with an
average age of 28.6 years. After they graduate from
primary or middle school, many young migrants travel to
eastern China or large cities to work in the manufacturing
sector or as laborers in the construction industry, or as
Young migrants face disproportionate health risks
because of their poor working and living conditions,
suffering from disproportionately high rates of infectious
diseases, occupational diseases, reproductive health
problems, and mental diseases [
]. Therefore, there is a
clear need to increase the health risk awareness of young
migrant workers. To this end, a comprehensive assessment
of this target population, including their utilization of
existing health services and information on all aspects of
health [occupational health, reproductive health, human
immunodeficiency virus (HIV)/tuberculosis (TB), among
others] would provide valuable information.
However, to date, there is little in the way of integrated
research and comprehensive evaluation of young migrants’
self-reported health risk awareness. In addition, existing
studies on health care demands and utilization among
migrants which rely on prevalence rates and non-visit rates
are characterized by limitations. In 2009, in the framework
of a China–United Nations Joint Program on protecting and
promoting the rights of China’s vulnerable youth migrants
(aged 15–24 years), the WHO, United Nations Population
Fund (UNFPA), and the Chinese Ministry of Health
launched a project aimed at developing a health promotion
model for youth migrants at various pilot sites (mainly in
Tianjin and Xi’an). The ultimate goal of the project was to
increase the health knowledge and risk awareness of youth
migrants and to improve their access and utilization of
The study reported here, which is a baseline survey on
health risk awareness among youth migrants in Tianjin and
Xi’an, was conducted by Peking University with full
support of the UNFPA. In our study, we first established an
index of health risk awareness, which was derived from
responses to questions associated to health-related
knowledge, aspects of personal hygiene practice, and knowledge
of HIV/acquired immunodeficiency syndrome (AIDS) and
related behavioral aspects, awareness and knowledge of
occupational hazards, and health service utilization. The
contents of the questions were associated to the five leading
risk factors. A composite score was used as the index score
to assess whether a participant has a good health risk
awareness or not, with a score of 21 (70% correct answers)
indicating an individual with good health risk awareness.
We then used this index of health risk awareness in an
attempt to evaluate health risk awareness among youth
migrants in Tianjin and Xi’an and analyze the factors
influencing this awareness.
Sampling and data collection
From June to December 2009, we conducted a
cross-sectional survey among rural-to-urban migrants in two cities:
Tianjin, Northern China, which is governed as a
directcontrolled municipality, and Xi’an, the capital city of
Shaanxi Province, northwest China. Our study was in
accordance with the ethical standards of the committee
responsible for human experimentation of Peking
University and with the Helsinki Declaration. In order to
understand the overall health risk awareness level of youth
migrants, participants were enrolled based on local
predominating occupational clusters. The migrant populations
of Tianjin and Xi’an are of different economic types.
Because many economic and technical development zones
were located in Tianjin city, a large number of migrants
move to Tianjin and work in hotels and restaurants or in the
manufacturing and construction sectors. Xi’an is famous for
its long history and landscape, so that many migrants work
in hotels and restaurants or are self-employed. We used the
following equation to calculate sample size in each
occupational cluster: n ¼ la2pð1 pÞ d2 where la was given a
value of 1.96, d a value of 0.05, and p a value of 30% [
Considering a loss rate of 10%, we enlarged the sample size
to 355 individuals in each occupational cluster. After
obtaining permission from gatekeepers, employers, and
workplace managers, trained interviewers approached
eligible migrants. An eligible subject was defined as an
individual who (1) had a rural residence, (2) worked in the city
without having a permanent residence, and (3) was between
18 and 25 years of age. After providing informed consent,
participants were asked to complete an anonymous
selfadministered questionnaire in a separate room at their
workplace or a nearby place convenient to them. The
questionnaire, which had been pilot tested and revised prior
to the main study, took approximately 30 min to complete.
Assistance, in the form of a question reader, was provided to
a small number of respondents with limited literacy.
Questionnaires were checked for completeness on-site, and
a small gift was provided to respondents. A total of 2,129
participants were asked to complete the questionnaire, and
1,838 completed questionnaires were ultimately obtained,
yielding a response rate of 86.3%.
The survey collected the following information: (1) social
and migratory demographic characteristics, (2)
healthrelated knowledge, behaviors and awareness, including a
knowledge of infectious diseases, non-communicable
chronic diseases, HIV/AIDS, reproduction, and
occupational health hazards, and (3) utilization of health services.
The respondents were asked to suppled information on
social and migratory demographic aspects, including age,
gender, ethnicity (Han, Hui, Man, Mongolian, or others),
birthplace, marital status (single, married, or divorced),
educational level (primary, middle, high school, or
postsecondary education), and occupation. They were also
asked to provide information on their living and working
conditions, including the type of dwelling, utilities in the
dwelling, years as a migrant worker, daily working hours,
monthly income and expenses, recreational activities, and
media consumption (television, Internet, and newspapers).
General health-related knowledge
Participants were asked to answer nine questions directed
toward assessing their knowledge of infectious diseases,
non-communicable chronic diseases, and life style. The
measure of internal consistency reliability, Cronbach’s a,
Personal hygiene practice
Participants were asked to answer seven questions aimed at
assessing their personal hygiene practice. The internal
consistency reliability measure, Cronbach’s a, was 0.409.
Knowledge of reproduction and HIV/AIDS
Thirteen survey questions were directed toward assessing
the respondent’s knowledge of HIV/AIDS prevention,
sexual intercourse, contraception, and condom use. The
internal consistency reliability measure, Cronbach’s a, was
0.802. Only the first three questions about HIV/AIDS
prevention and contraception were used for the health risk
awareness assessment because response process would be
stopped in the case of a participant who reported having no
Awareness and knowledge of occupational hazards
Six survey questions assessed the respondents’ awareness
and knowledge of occupational health aspects and
awareness and use of occupational health services. The internal
consistency reliability measure, Cronbach’s a, was 0.430.
Health service utilization
The questionnaire included three questions to determine a
participant’s use of health services: ‘‘Did you have a
physical examination in the past year?’’, ‘‘Do you have
medical insurance?’’, and ‘‘Do you actively seek health
knowledge?’’. Cronbach’s a was 0.227.
Health risk awareness
In our study, health risk awareness was composed of
general health-related knowledge, personal hygiene
practice, knowledge of reproduction and HIV/AIDS,
knowledge and awareness of occupational hazards, and health
service utilization. The composite score of general health
knowledge was created by summing all correct or positive
answers (from a total of 28 questions), with higher scores
reflecting higher levels of health risk awareness. A personal
score of C21 was considered to indicate an individual with
a satisfactory level of health risk awareness. The health risk
awareness in the two provinces was compared based on the
frequency of individuals with a satisfactory level of health
Data were independently entered twice and validated using
Epidata software ver. 3.1 (EpiData Association, Odense,
Denmark). All statistical analyses were performed using
SPSS software ver. 13.0 (SPSS, Chicago, IL). Samples
were deleted if answers to more than half of the questions
were missing in any one part, information was missing for
key demographic variables (e.g., gender), or the answers
were illogical (e.g., a man aged 10 years old but married).
Samples with one-half or less of the questions unanswered
were treated as random missing data and remained in the
analysis; they were deleted only when the respective
statistical analysis was performed. Frequencies, percentage,
ratios, t test, v2 test, and Wilcoxon rank sum test were used
to analyze the data, and logistic regression analysis was
used to test for the influence of factors associated with a
person with a satisfactory level of health risk awareness.
The dependent variable was a satisfactory level of health
risk awareness or not, and independent variables entered
into multivariate model included city, gender, age,
education, marital status, monthly expenditure, monthly income,
watching television, reading newspapers, using the
Internet, living environment, occupation (no job,
manufacturing, hotel and restaurant, construction, and self-employed),
and occupational training. Satisfactory statistical
significance was set at P \ 0.05.
A final sample size of 1,684 was retained in our database.
A total of 1,838 migrants in Tianjin and Xi’an were
surveyed, but 154 questionnaires were deleted from the data
file due to substantial missing data in the completed
questionnaire. The validity rate of the questionnaires was
Table 1 presents the characteristics of study participants
in Tianjin and Xi’an. The mean age of participants was
21.23 ± 2.23 years. In Tianjin, a large proportion of those
surveyed were had completed middle school (47.9%) or
high school (35.8%); in Xi’an, these values were 34.5 and
44.0%, respectively (P \ 0.05). The education levels and
living conditions of the respondents were much better than
those reported previously in similar studies [
]. Most of
the respondents (79.3%) were single, and there was no
significant difference in this characteristic between Tianjin
Due to the different economies in Tianjin and Xi’an,
youth migrant workers in the two sample areas had
different occupational choices. In Tianjin, half of the
respondents worked in manufacturing factories, while most
of the others worked in hotels and restaurants, with some
working in the construction sector. In contrast, half of the
Xi’an respondents worked in hotels and restaurants, while
some were self-employed.
Living conditions were related to occupation—most of
those working in the manufacturing and construction
sectors were living in accommodation provided by their
employer, while hotel and restaurant workers and the
selfemployed were living in rented rooms or with relatives and
friends. Wherever the migrants lived, conditions were
crowded and there was poor ventilation and a lack of basic
sanitary facilities. Half of the respondents (50.1%) had left
their hometown and worked as a migrant worker during the
past 3 years.
Health-related knowledge, behavior, and awareness
Table 2 showed the results of health-related knowledge,
behaviors, and awareness among youth migrant workers.
Most youth workers knew how to prevent infectious
diseases—by being vaccinated and avoiding unsafe drinking
water. However, only 43.3% of respondents (and only
38.1% in Tianjin) gave correct answers about the
symptoms of TB. Approximately one-third of respondents
correctly answered questions about non-communicable
diseases (NCD), anemia, and hypertension. These results
show that health education in migrant workers needs
improvement and that more attention should be paid to
providing comprehensive general health-related knowledge
to this population subgroup. Most respondents had good
personal hygiene practices; they did not consume much
alcohol, washed their hands, brushed their teeth, and
regularly changed their underwear. The no-smoking overall
rate was 34.5%; smoking rates were 65.5% overall (60.3%
in Tianjin and 72.7% in Xi’an), being significantly much
higher in men (66.8%) than women (6.8%; P \ 0.05).
Among the 1,684 participants, 674 (40%) reported
having had sexual intercourse. The number of those with
sexual experience was higher among men (56.8%) than
among women (27.7%, P \ 0.05). Men also answered
more questions on reproduction and HIV/AIDS correctly
than women. For example, 77.6% of men knew about using
condoms for contraception and preventing HIV infection,
while only 56.7% of women answered the associated
questions correctly (P \ 0.05); 23.8% of men knew the
mode of transmission HIV/AIDS compared to only 20% of
women (P \ 0.05). In addition, 61.3% of men used a
condom during their last sexual encounter, while only
49.4% of women used a condom (P \ 0.05).
Knowledge of occupational health was low. Only 54.1%
of participants believed that there was some hazardous
material in or around their workplace, and just 29.5% of
subjects gave correct answers on the symptoms of chemical
poisoning. Only 36.3% of subjects identified the explosive
Although 71.2% of participants had written into medical
care systems, only 40.7% of them had taken a physical
examination in the last year. The reasons why they did not
take physical exams included a lack of time and the view
that it was unnecessary or that it was too expensive. In
addition, 75.9% of participants showed initiative in seeking
health information and health knowledge.
Health risk awareness The assessment of health risk awareness took into account general health-related knowledge, personal hygiene practice, reproduction and HIV/AIDS knowledge and behaviors,
SD Standard deviation
a There was a significant difference between Tianjin and Xi’an (P \ 0.05)
occupational hazard knowledge, and an awareness and use
of health care services. Table 3 presents the scores for the
five parts of the survey questionnaire and the final health
risk awareness in the youth migrants sampled in ours study.
A composite score was created by summing all correct or
positive answers (possible range 0–28) of the 28 items, with
higher scores reflecting higher levels of health risk
awareness. A person who scored C21 was considered to have a
satisfactory level of health risk awareness. There was no
significant difference between scores for youth migrants in
Tianjin (18.28 ± 3.87) and those in Xi’an (17.92 ± 3.83)
(P [ 0.05). However, scores for behavior and reproduction
in Xi’an were significantly higher than those in Tianjin.
Scores of health-related knowledge were higher in Xi’an,
while those of occupational hazards and health service
utilization were higher in Tianjin. Only 438 of the
participants (26% of 1,647) were considered to have a satisfactory
level of health risk awareness, of whom 273 (32.4% of 958)
were from Tianjin and 165 (28.8% of 689) were from Xi’an.
No significant difference was found in health risk awareness
between two cities.
Correlation between health risk awareness and health
Table 4 shows the correlation between health risk
awareness and health status among the youth migrants in our
study sample. No difference was found in self-reported
health status between youth workers with a satisfactory/
unsatisfactory level of health risk awareness. However, the
percentage of youth migrants with a satisfactory level of
health risk awareness who thought they had a good health
status was higher than that with an unsatisfactory health risk
awareness who thought they had a good health status. In
Xi’an (n = 708)
HID/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome
a v2-test was used to compare the percentages in the two cities
addition, the proportions of subjects reporting excellent and
bad health status were higher among the unsatisfactory
group than the satisfactory group. No difference was found
in whether the respondents had been sick in the last 2 week.
The percentage of common diseases contracted by youth
migrants with a satisfactory level of health risk awareness
during then last year was higher than that among those with
an unsatisfactory level of knowledge (P \ 0.05).
Logistic regression analysis of influencing factors
Table 5 depicts the results of the multivariate logistic
regression analyses. Satisfactory health risk awareness or
not was used as the dependent dichotomous variable.
Independent variables included city in which youth migrant
workers resided, gender, age, education, marital status,
monthly expenditure, monthly income, watching television,
Satisfactory and unsatisfactory refers to youth migrants with a
satisfactory/unsatisfactory health risk awareness, respectively
a Wilcoxon rank sum test was used to compare the sum ranks in the
b v2-test was used to compare the percentages in the two groups
reading newspapers, using the Internet, living environment,
occupation, and occupational training. Of the above,
gender, age, education, reading the newspaper, and occupation
(restaurants and hotels, manufacturing, or construction
sectors, which could provide system management or
occupational training) showed significant influences on health
Findings from this study suggest that many young
rural-tourban migrant workers lack health risk awareness. Our
study revealed that only 26% of participants had a
satisfactory awareness of health risks. Most migrants lacked
knowledge about infectious diseases, NCD, reproduction,
HIV/AIDS, and occupational health hazards, while some
had poor personal hygiene practices.
Score for Xi’an
(n = 708)
Table 5 Results of the multivariate logistic regression analyses on
association between satisfactory health risk awareness and
sociodemographic, living condition, and occupational factors
Gender (male/female; reference: 2.1
Education (reference: primary school)
Middle school 1.3
High school 2.3
Newspaper (reference: no reading)
Occupation (reference: no job)
Hotel and restaurant
Migration is associated with greater risks for poor health
in general. This may be because of situational and
psychosocial factors, such as economic and cultural
transitions, as well as reduced access to health care services [
]. Overall, in our investigation, most youth migrants
had some degree of health awareness, sought useful health
knowledge, and utilized health services when they became
sick. Young migrants in the two cities had a good
understanding of vaccinations, the hazards of smoking and being
overweight, as well as the ways HIV/AIDS is transmitted.
However, they lacked knowledge about TB, anemia,
hypertension, reproduction, contraception, and chemical
poisoning. These results confirmed the findings of other
15, 19, 20
] and suggest that these aspects of
healthrelated knowledge should be strengthened in the future.
Compared to our youth migrants in Tianjin, those in Xi’an
had higher health awareness scores in terms of knowledge,
behaviors, and reproduction, possibly because there was a
relatively larger percentage of respondents with higher
education levels in Xi’an. In addition, the higher
percentage of youth migrants working in the construction and
manufacturing sectors in Tianjin was associated with a
better knowledge of occupational hazards.
Young migrants in general showed a number of risky
behaviors, such as smoking, drinking, unsafe sex, sharing
towels, among others. The smoking rate among the
respondents from Tianjin and Xi’an was about 60.3 and
72.7% respectively, which is higher than that of the
National Prevalence Survey in 2002 (54.8%) [
]. This is
information that should be used to help young migrants
adopt good personal hygiene practices, quit smoking, and
reduce alcohol consumption. Unsafe sexual behaviors in
youth migrants include premarital sex, commercialized
sex, not using a condom, and induced abortions. Chang and
her colleagues also found that the rate of having had a
sexual experience among youth who had left school was
42.6% (62.3% in males, and 37.7% in females) [
] have reported higher rates of unsafe
sexual behaviors among youth migrants. Most youth
migrants work away from their hometown, and they may
behave differently that they would in their hometown.
Young people are a sexually active segment of the
population, and separation from their families, lovers, and
communities may make such youth migrants more prone to
peer pressure and urban life style influences, ultimately
leading them to engage in more risky behaviors. More
efforts and interventions among youth migrants are needed
to control the growing epidemic of sexually transmitted
diseases (STDs) in China [
Although China has an enormous migrant worker
population, occupational diseases and injury epidemiology and
prevention have only recently become heightened
concerns, in an effort to improve workplace safety and prevent
costly injuries. Perry and colleagues [
] reported that
migrant workers had higher rates of work-related injury,
suggesting that unskilled migrant workers from rural
communities and villages may take on more hazardous jobs
and experience more injuries. In our study, we assessed the
knowledge and awareness of occupational hazards among
youth migrants and found that integrated occupational
training courses incorporating occupational health and
safety were necessary for these people. A new multi-sector
cooperation health education system should be established
to implement occupational training. It should be comprised
of members of the health, education, and labor departments
and include employers.
Although there was no statistical significance in
selfreported health status between youth workers with a
satisfactory and those with an unsatisfactory level of health risk
awareness, a higher proportion of good health status and a
lower proportion of bad health status in the satisfactory group
suggests these individuals had a more comprehensive and
correct understanding of health, which help them make an
appropriate assessment of disease and its treatment. The
higher percentages of excellent and bad health status
assessments, respectively, in the group with an unsatisfactory level
of health risk awareness indicated these individuals had an
incorrect and superficial understanding of health and the
treatment of disease. The percentage of common diseases
contracted during the last year was higher in youth migrants
with a satisfactory level of knowledge than in their
‘unsatisfactory’ counterparts. This finding suggests that health risk
awareness may increase after an individual suffers from a
disease(s). Such an individual would then be more concerned
and take action to prevent the disease if he/she believed it
would have potentially serious consequences. These findings
indicated that intervention activities, including providing a
correct and comprehensive understanding of health and the
treatment of disease, are important for youth migrant workers.
The multivariate logistic regression analysis results
showed that age, gender, education, reading newspapers,
and an occupation which could provide system
management or occupational training were beneficial toward
increasing health risk awareness. Health risk awareness
was higher among men, older migrants, those with higher
education levels, those who read newspapers, and those
who worked in a social workplace. Male migrants were
often involved in more dangerous work and were more
likely to engage in unsafe sexual intercourse, so they
showed a higher health risk awareness and more interest in
learning about health-related knowledge. Older migrants
with higher education levels who read newspapers showed
more concern about their health status and wanted to know
how to resolve their health problems. All of these factors
indicate that the urban social environment substantially
influenced youth migrant health behaviors. Youth migrants
can also be significantly impacted by their peers and
]. Reproductive health knowledge levels among
migrants whose friends were local residents were higher
than that of those who had no local friends. This suggests
that both policy and community could play an important
role in migrant health education activities by creating
advantageous living and working conditions.
The study has several limitations. Firstly, the
information collected was self-reported. Respondents’ health risk
awareness levels may be exaggerated because a positive
answer to the question might be perceived by the
participants as socially desirable, whereas risk behaviors,
such as sexual behaviors, might be underreported since risk
behaviors are not socially desirable. Secondly, using only
two study sites and five occupational groups may limit the
findings. The conventional factors found to be significant in
this study may not be applicable to the general public given
the sample size, differential sampling, and lack of
comparability with national surveys. Thirdly, another limitation
may be that no comparison groups were selected in
baseline survey. Finally, because of the cross-sectional nature
of the data, most responses were evaluated retrospectively
and recall bias was therefore unavoidable.
Our study found youth migrants have some health related
knowledge, but are still at high risk of STDs, unplanned
pregnancies, NCD, and occupational diseases. They also
have limited access to social medical insurance and
preventive technology. To change youth migrants’ behavior
and improve their health risk awareness, health related
knowledge communication combined with various
interventions should be introduced. Preventive skills training in
factories and occupational training agencies, activities
based on communities, and social support would all
improve youth migrants’ health behaviors and health risk
awareness development and formation.
Acknowledgments The study was funded by UNFPA China in the
framework of the UN-China 2009–2011 Joint Program (CHN6R51A).
The authors would like to thank the participating investigators at
UNFPA, WHO, Tianjin Maternal Child Health Care Center, TEDA
Health Department, Shaannxi Health Education Institute and CDC of
Xincheng District for their contributions to questionnaire
development and data collection. The authors would also like to thank all
respondents enrolled in our study.
Conflict of interest statement The authors declare that there are no
conflicts of interest.
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