Factors that influence the choice of long-acting reversible contraceptive use among adolescents post-abortion in Chongqing, China: a cross-sectional study

Abstract

Background

Induced abortion can seriously harm the physical and mental health of adolescent women. Long-acting reversible contraception (LARC) can effectively reduce unplanned pregnancies and prevent repeated abortions among adolescents. This study aimed to analyse the factors affecting the choice of LARC among adolescents in Chongqing of China.

Methods

A total of 555 adolescents who underwent induced abortions for unplanned pregnancies between January 2019 and October 2021 were selected as study subjects. Logistic regression analysis was used to determine the factors affecting adolescent LARC choices following induced abortions.

Results

The factors that affected adolescent LARC choices included an average monthly income ≥ ¥3000 (OR = 3.432, 95% CI: 1.429∼8.244), history of previous abortions (OR = 3.141, 95% CI: 1.632∼6.045), worrying about unplanned pregnancy (OR = 0.365, 95% CI: 0.180∼0.740), parental support for using LARC (OR = 3.549, 95% CI: 1.607∼7.839), sexual partners’ support for using LARC (OR = 2.349, 95% CI: 1.068∼5.167), concerns about using LARC (OR = 0.362, 95% CI: 0.176∼0.745), and willingness to use free IUDs (OR = 13.582, 95% CI: 7.173∼25.717).

Conclusion

Cost is one of the factors affecting LARC choices. Parents and sexual partners may play important role in the choice of LARC.

PLAIN LANGUAGE SUMMARY

The study analysed the choice of contraceptive methods and the factors affecting the choice of long-acting reversible contraception methods after induced abortion among adolescents in Chongqing, China. The results showed that the income level, history of previous abortions, extent of worrying about unplanned pregnancy, parents’ and sexual partners’ attitude towards to use long-acting reversible contraception methods, concerns about using long-acting reversible contraception methods, and willingness to use free intrauterine devices were the factors affecting the choice of long-acting reversible contraception methods after induced abortion among adolescents.

Keywords:

• unplanned pregnancy
• adolescents
• long-acting reversible contraception
• a cross-sectional study

Introduction

Of the world’s 1.2 billion adolescents (aged 10–19 years), 90% live in low- and middle-income countries (LMICs) in 2019 (Sachin et al. 2023). In China, female adolescents aged between 15 and 24 account for 17.1% of the total population, nearly 230 million (Gu et al. 2020). In developing countries, only 1 in 3 adolescents choose to get married and become pregnant under the age of 18, while most sexually active adolescents are willing to avoid or postpone pregnancy for academic, work, or other reasons (Wang et al. 2016). As economy grows by leaps and bounds, sexual concept changes gradually and the premarital sexual behaviour increases, an increase in the incidence of unplanned pregnancies amongst teenagers has been noted (Wang et al. 2020). However, globally, approximately 33 million young women aged 15–24 years have unmet contraceptive needs (Wang et al. 2016, Casey et al. 2020). This may increase the number of premature births and miscarriages, including unsafe abortions, as well as maternal and neonatal morbidity (Gui et al. 2015). Long-acting reversible contraception (LARC) is highly effective in reducing the number of unplanned pregnancies and preventing repeated abortions among adolescents (Wang et al. 2020). LARC is recommended by the American College of Obstetrics and Gynaecology (ACOG) and the American Academy of Paediatrics (AAP) as the primary contraceptive method to prevent unplanned pregnancies in adolescents (Ott et al. 2014, Carranco et al. 2018). In order to reduce the incidence of unplanned pregnancy and induced abortion, the health organisations in China jointly launched the ‘Post-abortion Care (PAC)’ public welfare service project in 2011. Free contraceptives, such as condoms, are provided for teens in schools and medical institutions (Yang 2014). However, the LARC utilisation rate among adolescents worldwide remains low (Espey et al. 2019, Aligne et al. 2020). Among Chinese adolescents, the LARC utilisation rate is 7.9∼11.95% (Yu 2012, Cai et al. 2017). This cross-sectional study aimed to evaluate the choice of contraceptive methods after PAC services in adolescents with abortion in Chongqing, analyse the factors affecting the choice of LARC in this population, and provide a clinical reference for improving the formulation of LARC-use strategies for Chinese adolescents.

Materials and methods

Participants

Adolescents with unplanned pregnancies who had undergone induced abortions at the Chongqing Health Centre for Women and Children between January 2019 and October 2021 were included in the study. The selection criteria were as follows: (1) adolescent women aged 15–24 years, (2) diagnosed with intrauterine early pregnancy by ultrasound, (3) pregnancy ≤10 weeks, (4) no contraindications to use the contraceptive methods which we provided, (5) seeking abortion because of unplanned pregnancy, and (6) provided informed consent. The exclusion criteria were as follows: (1) the diagnosis of early pregnancy was unclear, (2) pregnancy >10 weeks, (3) there were contraindications to use the contraceptive methods which we provided, (4) seeking abortion because of medical reasons, (5) did not consent to participate in the research. All participants individually provided oral informed consent prior to being enrolled in the study to ensure protection of privacy. For those aged under 18, informed consent was also obtained from their guardian. A total of 555 adolescents who underwent induced abortions for unplanned pregnancies between January 2019 and October 2021 were finally selected as study subjects. The study was approved by the Ethics Committee of Chongqing Health Centre for Women and Children (QSNBY20181020.046).

Setting

All participants underwent the standardised surgical abortion procedure and received PAC quality services, with a coverage rate of 100%. PAC is a standardised medical service process that includes group health education, one-on-one consultation, contraceptive implementation, follow-up, and other professional services. According to the results of PAC consultation, the participants were divided into the LARC and short-acting reversible contraception (SARC) groups. The contraceptive methods available to adolescents in our hospital include Cu-IUDs, Mirena (levonorgestrel-releasing intrauterine system, LNG-IUS), the subcutaneous contraceptive drug implants, short-acting combination oral contraceptives (COC), condoms, etc. (Table 1). Among them, the LARC methods include Cu-IUDs, LNG-IUS and the subcutaneous contraceptive drug implants. The unit price of the Cu-IUDs is between 300∼500 RMB, while Mirena is paid for at 1100 RMB. The subcutaneous contraceptive drug implants include levonorgestrel subcutaneous implants and etonogestrel subcutaneous implants (implanon), priced at 700 RMB per unit. Since there is no medroxy-progesterone intramuscular, patches, or vaginal rings, the SARC methods in our hospital mainly refer to the short-acting combination oral contraceptives, which cost 150 RMB per unit (Table 2). Contraceptives for adolescents should provide safety, reliable results, ease of use, and acceptable prices. After being provided with information on the various contraceptive methods, adolescents have the right to use or refuse to use any, according to their own wishes. The participants who chose LARC received subcutaneous contraceptive drug implants or IUDs after the exclusion of contraindications. Those who chose SARC were reminded to use oral contraceptives from the day of abortion. The status of post-abortion recovery, contraceptive use, and re-pregnancy were followed up in the 1st and 3rd months after abortion.

Table 1. The choices of contraceptive methods based on PAC [samples (%)].

Contraceptive method	Cu-IUDs	LING-IUS	Subcutaneous Implants	COC	Condoms	Safe period	Extracorporeal sperm drainage	None
Before PAC	0	0	0	0	103(18.56)	127(22.88)	82(14.78)	243(43.78)
After PAC	67(12.07)	9(1.62)	17(3.07)	462(83.25)	0	0	0	0

PAC: post-abortion care; Cu-IUDs: copper intrauterine devices; LING-IUS: levonorgestrel releasing intrauterine system; COC: short-acting combination oral contraceptives.

Table 2. The choices and costs of different contraceptive methods [samples (%)].

Classification	Cost (RMB)	∼15 (n = 3)	16∼19 (n = 160)	20∼24 (n = 392)	Total (n = 555)
Cu-IUDs	300∼500	0 (0)	17 (10.62)	50 (12.76)	67 (12.07)
LING-IUS	1100	0 (0)	2 (1.25)	7 (1.78)	9 (1.62)
Subcutaneous Implants	700	0 (0)	9 (5.63)	8 (2.04)	17 (3.06)
COC	150	3 (0)	132 (82.50)	327 (83.42)	462 (83.25)

Cu-IUDs: copper intrauterine devices; LING-IUS: levonorgestrel releasing intrauterine system; COC: short-acting combination oral contraceptives.

Data collection

This study was conducted by questionnaire survey. The investigators consulted the relevant literature and designed a questionnaire based on their clinical experience in China. There were 21 questions (Tables 3 and 4), as follows: (1) age (2) marital status (3) profession (4) Have you used contraception to prevent pregnancy? If ‘yes’, what kinds of contraceptive methods have you used and why? If ‘no’, why haven’t you? (5) Do you have a history of abortion? If ‘yes’, how many times? (6) Do your parents support you in using LARC methods? (7) Do your sexual partners support you in using LARC methods?, etc. The responses about partner or parental approval included the participants’ own statements and those from their partner or parents. The selection criteria for the income cut-off level were based on the average income of Chongqing area. Teenagers were evaluated by psychologists for psychological factors, including anxiety. The Self-rating Anxiety Scale (SAS) was used to assessed the extent of worrying about unplanned pregnancy for the participants. The SAS consisted of 20 items, which were scored at 4 levels from 1 to 4 based on the criteria of: ‘1’ no or little time, ‘2’ a small part of the time, ‘3’ a considerable amount of time, ‘4’ most or all of the time. The total score was multiplied by 1.25 to take the integral part for standardisation. Higher scores indicate more serious anxiety (Wang et al. 1999). No patients with a history of anxiety disorders or treatment were included in the study. The questionnaire was administered by uniformly trained personnel. The four-hour training session included information on courtesy language, introductory words, and instructions for filling out forms. Before issuing the questionnaire, the investigators provided detailed explanations of the purpose and significance of the questionnaire and introduced the questionnaire contents to each participant. In accordance with the principles of informed consent and voluntariness, the respondents filled out the questionnaires by themselves, typically within 10 minutes. The questionnaires of participants who did not meet the inclusion criteria were excluded (Figure 1). The information was entered into the Electronic Data Capture following the principle of double entry.

Figure 1. Subject enrolment/screening log.

Table 3. Basic information of the LARC and SARC groups [samples (%)].

Indicator	Classification	SARC (n = 462)	LARC (n = 93)	Total (n = 555)
Age (years)	∼15	3 (0.65)	0 (0)	3
	16∼19	132 (28.57)	28 (30.11)	160
	20∼24	327 (70.78)	65 (69.89)	392
Marital status	Unmarried	308 (66.67)	55 (59.14)	363
	Married	154 (33.33)	38 (40.86)	192
History of previous pregnancy	No	320 (69.26)	40 (43.01)	360
	Yes	142 (30.74)	53 (56.99)	195
History of previous abortions	0	320 (69.26)	40 (43.01)	360
	1	83 (17.97)	23 (24.73)	106
	2	28 (6.06)	13 (13.98)	41
	3	23 (4.98)	14 (15.05)	37
	4	8 (1.73)	3 (3.2)	11

LARC: long-acting reversible contraception; SARC: short-acting reversible contraception.

Table 4. Univariate analysis of the LARC and SARC groups [samples (%)].

Indicator	Classification	SARC (n = 462)	LARC (n = 93)	χ^2	p
Age (years)	≤19	131 (28.35)	29 (31.18)	0.180	0.672
	20∼24	331 (71.65)	64 (68.82)
Occupation	Student	59 (12.77)	22 (23.66)	6.512	0.011
	Other	403 (87.23)	71 (76.34)
Habitual residence	City	403 (87.23)	84 (90.32)	2.224	0.329
	County	40 (8.66)	4 (4.30)
	Village	19 (4.11)	5 (5.38)
Monthly income	Null	72 (15.58)	10 (10.75)	14.515	0.001
	< ¥3000	45 (9.74)	22 (23.65)
	≥¥3000	345 (74.68)	61 (65.60)
Education level	Junior high school and below	29 (6.28)	11 (11.83)	3.582	0.167
	High school	135 (29.22)	25 (26.88)
	Junior college and above	298 (64.50)	57 (61.29)
History of previous abortions	Yes	143 (30.95)	52 (55.91)	20.084	0.000
	No	319 (69.05)	41 (44.09)
Extent of worrying about unplanned pregnancy	No	59 (12.77)	4 (4.30)	31.379	0.000
	A little	216 (46.75)	22 (23.66)
	Very	187 (40.48)	67 (72.04)
Multiple sexual partners	Yes	15 (3.25)	3 (3.22)	0.000	1.00
	No	447 (96.75)	90 (96.77)
Previous contraceptive measures	Yes	364 (78.79)	80 (86.02)	2.100	0.147
	No	98 (21.21)	13 (13.98)
Parents’ attitude towards to use LARC	Yes	130 (28.14)	73 (78.49)	82.465	0.000
	No	332 (71.86)	20 (21.51)
Sexual partners’ attitude towards to use LARC	Yes	143 (30.95)	69 (74.19)	59.499	0.000
	No	319 (69.05)	24 (25.81)
Concerns about using LARC	Yes	398 (86.15)	56 (60.22)	33.251	0.000
	No	64 (13.85)	37 (39.78)
Concerns about pain	Yes	174 (37.66)	31 (33.33)	0.451	0.502
	No	288 (62.34)	62 (66.67)
Concerns about gaining weight	Yes	44 (9.52)	9 (9.68)	0.000	1.00
	No	418 (90.48)	84 (90.32)
Concerns about infection	Yes	150 (32.47)	26 (27.96)	0.534	0.465
	No	312 (67.53)	67 (72.04)
Concerns about affecting sex life	Yes	28 (6.06)	4 (4.30)	0.177	0.674
	No	434 (93.94)	89 (95.70)
Concerns about affecting reproductive function	Yes	216 (46.75)	28 (30.11)	8.045	0.005
	No	246 (53.25)	65 (69.89)
Concerns about the surgery risk	Yes	117 (25.32)	14 (15.05)	3.977	0.046
	No	345 (74.68)	79 (84.95)
Reluctance to use IUDs	Yes	147 (31.82)	12 (12.90)	12.640	0.000
	No	315 (68.18)	81 (87.10)
Concerns about the privacy	Yes	28 (6.06)	2 (2.15)	1.613	0.204
	No	434 (93.94)	91 (97.85)
Willingness to use free IUDs	Yes	51 (11.04)	70 (75.27)	183.586	0.000
	No	411 (88.96)	23 (24.73)

LARC: long-acting reversible contraception; SARC: short-acting reversible contraception; IUDs: intrauterine devices.

Statistical methods

Data analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Percentages, means and standard deviations were used to describe demographic characteristics. The chi-square (χ²) test was used to compare the differences between the LARC and SARC groups in terms of age, occupation, income level, education level, history of previous abortions, extent of worrying about unplanned pregnancy, parents’ attitude towards to use LARC, sexual partners’ attitude towards to use LARC, concerns about using LARC, willingness to use free IUDs, and other factors. Before data were entered into the multivariate analysis model, the collinearity of the significant indicators in the univariate analysis was analysed, and the results showed that there were no indicators of severe collinearity (Table 4). A multivariate logistic regression model was used to estimate odds ratio (OR) and 95% confidence intervals (CIs) for the differences between LARC and SARC groups, with LARC as the dependent variable (LARC = 1 and SARC = 0) (Tables 5 and 6). p Values, OR and 95% CIs were used to describe statistical significance. Significance was set at p < 0.05.

Table 5. Variable assignment table.

Index	Assignment
Whether to choose LARC	No = 0, Yes = 1
Occupation	Student = 0, Other = 1
Monthly income	Null = 0, < ¥3000 = 1, ≥ ¥3000 = 2
History of previous abortions	No = 0, Yes = 1
Extent of worrying about unplanned pregnancy	No = 0, A little = 1, Very = 2
Parents’ attitude towards to use LARC	No = 0, Yes = 1
Sexual partners’ attitude towards to use LARC	No = 0, Yes = 1
Concerns about using LARC	No = 0, Yes = 1
Concerns about affecting reproductive function	No = 0, Yes = 1
Concerns about the surgery risk	No = 0, Yes = 1
Reluctance to use IUDs	No = 0, Yes = 1
Willingness to use free IUDs	No = 0, Yes = 1

LARC: long-acting reversible contraception; IUDs: intrauterine devices.

Table 6. Multivariate analysis of the LARC and SARC groups.

	B	SE	Wald	p	Exp(B)	95% CI Exp(B)
						Lower limit	Upper limit
Monthly income			8.653	0.013
< ¥3000	−0.199	0.475	0.177	0.674	0.819	0.323	2.077
≥ ¥3000	1.233	0.447	7.606	0.006	3.432	1.429	8.244
History of previous abortions	1.145	0.334	11.743	0.001	3.141	1.632	6.045
Extent of worrying about unplanned pregnancy			8.721	0.013
A little	−0.937	0.641	2.136	0.144	0.392	0.112	1.376
No	−1.007	0.360	7.812	0.005	0.365	0.180	0.740
Parents’ attitude towards to use LARC	1.267	0.404	9.817	0.002	3.549	1.607	7.839
Sexual partners’ attitude towards to use LARC	0.854	0.402	4.510	0.034	2.349	1.068	5.167
Concerns about using LARC	−1.016	0.368	7.610	0.006	0.362	0.176	0.745
Willingness to use free IUDs	2.609	0.326	6.149	0.000	13.582	7.173	25.717
Constant	−3.232	0.488	43.888	0.000	0.039

CI: confidence interval; LARC: long-acting reversible contraception; SARC: short-acting reversible contraception; IUDs: intrauterine devices.

Note: Reference categories for the monthly income was ‘null’; history of previous abortions was ‘no’; extent of worrying about unplanned pregnancy was ‘very’; whether parents support to choose LARC was ‘no’; whether sexual partners support to choose LARC was ‘no’; concerns about using LARC was ‘no’; and whether willing to use free IUDs was ‘no’.

Results

General

A total of 555 adolescents who underwent induced abortions for unplanned pregnancies between January 2019 and October 2021 were finally selected as study subjects. All participants were Han Chinese ethnicity and under the age of 24 (mean: 20.88 ± 1.01). Three were under the age of 15, 160 were aged 16–19, and 392 were aged 20–24. Of the 555 participants, 195 (35.14%) had a history of abortion (Table 3). Among those using LARC, 67 chose Cu-IUDs (12.07%), 9 chose LING-IUS (1.62%), and 17 chose subcutaneous contraceptive drug implants (3.06%) (Table 2).

Univariate analysis

The participants were divided into the LARC (thoses who received subcutaneous contraceptive drug implants or IUDs, n = 93) and SARC (those who chose short-acting oral contraceptives, n = 462) groups. A univariate analysis was performed using χ² test to determine the factors influencing adolescent LARC use. Significant differences were noted between the two groups in occupation, income level, history of previous abortions, extent of worrying about unplanned pregnancy, parents’ attitude towards to use LARC, sexual partners’ attitude towards to use LARC, concerns about using LARC, concerns about affecting reproductive function, concerns about the surgical risks, reluctance to use IUDs, and willingness to use free IUDs (p < 0.05; Table 4).

Multivariate analysis

Multivariate logistic regression analysis was performed with LARC as the dependent variable (LARC = 1 and SARC = 0, Table 5). It showed that an average monthly income ≥ ¥3000 (OR = 3.432, 95% CI: 1.429∼8.244), history of previous abortions (OR = 3.141, 95% CI: 1.632∼6.045), no worrying about unplanned pregnancy (OR = 0.365, 95% CI: 0.180∼0.740), parental support for using LARC (OR = 3.549, 95% CI: 1.607∼7.839), sexual partners’ support for using LARC (OR = 2.349, 95% CI: 1.068∼5.167), concerns about using LARC (OR = 0.362, 95% CI: 0.176∼0.745), and willingness to use free IUDs (OR = 13.582, 95% CI: 7.173∼25.717) were the factors independently related to the choice of LARC (p < 0.05; Table 6). Among them, controllable variables were the monthly income, history of previous abortions, and willingness to use free IUDs, while uncontrollable variables were the extent of worrying about unplanned pregnancy, parents’ and sexual partners’ attitude towards to use LARC, and concerns about using LARC.

Discussion

In this study, Logistic analysis was performed on the factors related to the choice of LARCs among adolescents with induced abortion in Chongqing, China. The results indicate that cost is a main factor affecting LARC choices among teenagers. Parents and sexual partners may play an important role in the choice of LARC among adolescents.

According to WHO statistics, approximately 80 million women worldwide have unplanned pregnancies each year, and 48 million women choose induced abortion (Cai 2017). As of 2019, the number of abortions in China each year is close to 10 million, more than 50% of which occur in adolescents, and the repeat abortion rate in this population is over 30% (Qin et al. 2018, National Health and Family Planning Commission 2019). Induced abortion can seriously harm the physical and mental health of adolescent women. Reducing unplanned pregnancies and abortions among adolescents has become a primary public health target in China.

Since there is no medroxy-progesterone intramuscular, patches, or vaginal rings in Chongqing area of China, COC is the only SARC method available. As we know, the compliance of COC among adolescents is poor, increasing the utilisation of LARC is important in reducing unplanned pregnancies and abortions in adolescents. LARC methods include Cu-IUDs, LNG-IUS, and the subcutaneous contraceptive drug implants. The utilisation of LARC among adolescents has increased in recent years, but is still low worldwide due to misunderstandings about LARC, high cost, lack of follow-up conditions, and other factors (Russo et al. 2013, Payne et al. 2016, Pritt et al. 2017). In our study, despite detailed PAC education before participants underwent induced abortion, the rate of teenagers who chose LARC was 16.76% (93/555) and the repeated abortion rate was 35.14% (195/555). The proportion of adolescents who chose LARC with monthly income ≥3000 CNY was significantly higher than that of the adolescents with no income. The results also showed that adolescents were more willing to choose LARC if free IUDs were provided. The provision of free IUDs could promote LARC use among no- and low-income adolescents. It suggested that cost was one of the main factors affecting LARC choices among teenagers. In addition, teens with prior abortions were more likely to choose LARC than teens without prior abortions. The extent of worrying about unplanned pregnancy was also a factor influencing adolescents to choose LARC. Because adolescents are not yet fully mature physically and mentally, abortions can be more harmful in this population. Many unmarried adolescents with unplanned pregnancies expressed concerns and anxieties about public opinion, family condemnation, complications of surgery, and medical expenses, which prompted them to choose LARC after induced abortion. However, teenagers in China have not received comprehensive sex education and scientific contraception guidance (Zheng 2019). The univariate analysis showed that adolescents were concerned that LARC would affect their reproductive function, which suggested that some teenagers still had misunderstandings and prejudices about LARC. Additionally, for those aged under 18, the consent of the guardian must be obtained before abortion or the use of contraceptive methods. Teens are more likely to choose LARC if their parents and sexual partners support their choice. Thus, their parents and sexual partners may play an important role in the choice of LARC.

We propose the following changes to increase the use of LARC among adolescents. Firstly, strengthening reproductive health education will help adolescents understand the benefit of LARC and the harm of induced abortion, and encourage them to choose LARC. Secondly, comprehensive scientific contraceptive counselling for teenagers should be implemented to eliminate misunderstanding and prejudice about LARC. Additionally, effort should be made to inform parents and sexual partners of teens about the importance of LARC.

To our knowledge, this is the first study on the influencing factors of LARC choices among adolescents with induced abortion in Chongqing, China. Moreover, this study analysed the factors affecting LARC choices among Chinese adolescents from the perspectives of adolescents themselves, their parents, and their sexual partners. However, this study also has limitations. First, as a hospital-based cross-sectional study, selection bias could not be excluded. Second, the research data was obtained through questionnaire survey, which might cause recall bias and information loss. Third, it was a single-centre study with limitation of sample and restriction of race and region.

In future, larger multi-centre investigation studies should explore how to improve the utilisation of LARC among adolescents. The specific role of parents and sexual partners in the adolescent contraceptive choice should be further explored.

Conclusion

In conclusion, the results of this study show that the income level, history of previous abortions, extent of worrying about unplanned pregnancy, parents’ attitude towards to use LARC, sexual partners’ attitude towards to use LARC, concerns about using LARC, and willingness to use free IUDs are the independent factors to influence adolescents’ choice of LARC. It also suggests that cost is one of the main factors affecting LARC choices of teenagers. Moreover, parents and sexual partners may play an important role in the choice of LARC among adolescents.

Ethical approval

The study was reviewed and approved by the Ethics Committee of the Chongqing Health Centre for Women and Children. All participants were informed of the purpose of the study and given verbal informed consent.

Author contributions

Jin Fengzhen: concept, design, proposal, data collection, analysis and writing. Yang Yuanpei: concept, data collection, analysis and writing. Sun Junjie: design, data collection, analysis and writing. Li Ruiyue: design, concept, analysis and writing. Yao Fei: concept, design, analysis and writing. Liu Xiaoli: concept, design, proposal, data collection, analysis and writing.

Acknowledgement

We thank our colleagues for their assistance with the survey and Kaikesi (Shanghai) Business Information Consulting Co., Ltd. for editing. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Data availability statement

The raw data required to reproduce these findings cannot be shared at this time as the data also forms part of an ongoing study.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.