Changing attitudes toward premarital cohabitation among college students: A multi-source qualitative study

Changing attitudes toward premarital cohabitation among college students: A multi-source qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Changing attitudes toward premarital cohabitation among college students: A multi-source qualitative study Aimei MAO, Uhin CHEANG, Jiaxi XU This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9070712/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Objectives: This study aimed to depict the 20-year trajectory of attitudes toward premarital cohabitation among college nursing students in Macau from 2004 to 2025 and explore their perceptions of cohabitation-related gendered health risks. Further, it intended to elucidate the public health implications of these attitudinal changes for adolescent reproductive health education and gender-based health equity in culturally hybrid urban regions. Methods : A mixed qualitative design was adopted, including a repeated cross-sectional open-ended survey (2004–2025, n=991, second-year nursing students, excluding 2018–2022) and semi-structured interviews (2025, n=26, purposive sampling). Content analysis was used for survey data to track attitudinal trends, and thematic analysis for interview data to explore cohabitation perceptions. Rigor was enhanced via prolonged engagement, member checking, triangulation, and an audit trail, with ethical approval (REC-2024.0708). Results : Positive attitudes toward cohabitation rose from 23% (2004) to nearly 90% (2024–2025). Cohabitation was perceived as a marriage precursor rather than an alternative, with female participants expressing predominant concerns about gendered health risks (unintended pregnancy, abortion-related physical/psychological harms, unprotected domestic violence). Egalitarian financial sharing was the mainstream view, with minor gender differences in cohabitation decision-making criteria. Conclusion : Premarital cohabitation is widely accepted by Macau’s young adults, reflecting westernized egalitarian trends, while gendered health risk concerns remain persistent. These findings provide critical qualitative evidence for public health interventions in Macau and comparable culturally hybrid regions, highlighting the need for targeted reproductive health education and enhanced gender-based health protection systems for young cohabiting adults. premarital cohabitation gender-based health disparities reproductive health adolescent health Macau qualitative research Background Premarital cohabitation – defined as unmarried couples living together in a shared household before formal marriage – has become increasingly common worldwide. In Western societies, cohabitation has largely transitioned from a marginal “trial marriage” option to a normative pathway into union formation. For example, fewer than 5% of adults born before 1970 in the West reported premarital cohabitation, whereas the rate rises sharply among younger cohorts (born in the 1980s and later) (Sassler & Lichter, 2020). This dramatic rise is understood within the framework of the Second Demographic Transition (SDT), which theorizes that changing values of individualism, gender equality, and self-fulfillment and economic factors have led to the postponement of marriage and fertility, sub-replacement fertility, and a proliferation of alternative living arrangements such as cohabitation and nonmarital childbearing (Raymo & Park, 2020). Asian societies have begun to exhibit some SDT trends, but with different cultural contours. East Asian family systems have traditionally been characterized by strong Confucian norms: patriarchal, patrilineal family organization; filial piety; and an emphasis on chastity before marriage. These traditions have long discouraged premarital sexual unions. However, scholars now note that cohabitation has increased markedly among East Asian young adults. In Japan, recent findings from the National Fertility Survey indicate that roughly 20% of first marriages are now preceded by cohabitation (IPSS, 2022). In Taiwan, as of 2020, 57% of the 30–34 age group remained single, and premarital cohabitation is increasingly recognized as a "trial marriage" phase (Cheng, 2023). In China, analyses of recent cohorts show 37.4% of the 1985–1994 birth cohort lived together premaritally (Yu & Xie, 2022). Despite these increases, at any given time, only a small proportion of young Asians are cohabiting, largely because relationships tend to be short and most eventually lead to marriage (Manning et al., 2022). Therefore, cohabitation appears largely as a precursor to marriage rather than an alternative pathway. Attitudes toward premarital cohabitation are changing unevenly across the region. Scholars note that East Asian societies share a deeply entrenched gender division of labor, often disadvantaging women (Raymo et al., 2015). In such contexts, unmarried women risk harsher stigma for premarital sexual activity than men. For example, young women in Vietnam remain acutely aware of parental and societal expectations of chastity, fearing severe consequences if discovered in premarital sexual unions (Song & Lai, 2020). Consistent with this, reports that while Japanese women with lower education are more likely to cohabit, Chinese cohabitors tend to be more educated and urban, suggesting that premarital cohabitation is context-specific(Wang et al., 2022) The Macau context and study rationale Macau is a Special Administrative Region of China known for its unique mix of cultures and advanced economy. Governed by Portugal until 1999, Macau’s population remains overwhelmingly ethnically Chinese (>90%), but its legal and social systems retain Western influences. The city has one of the highest GDPs per capita in the world (around $125,000 PPP as of 2025 (DSEC, 2025)). These factors – a wealthy, urban society with both Chinese traditions and Western exposure – make Macau an interesting case for studying young adults’ family attitudes. The present study documents Macau students’ attitudes toward premarital cohabitation over two decades and the decision-making process behind these attitudes. Aims of the study The primary aim of the study is to depict the trajectory of attitudes toward premarital cohabitation among Macau college students from 2004 through 2025. A secondary aim is to gain in-depth insights into how students perceive specific aspects of cohabitation (e.g., timing of moving in, length of cohabitation, sharing of expenses) through their own words. In doing so, the study seeks to illuminate whether and how Macau’s younger generation diverges from older norms and to identify the contextual factors that shape their views. Methods Study design This study employed a multi-method qualitative design to examine changes in attitudes toward premarital cohabitation over time. Open-ended qualitative surveys were administered to successive cohorts of college students across two decades, allowing analysis of cohort-level shifts in attitudes in the context of broader social change. To complement these findings, semi-structured interviews were conducted in 2025 to explore in greater depth students’ perceptions, decision-making processes, and expectations regarding cohabitation. Together, the two qualitative components provided both temporal perspective and contextual depth without relying on individual-level longitudinal follow-up. Participants and sampling In Part A, the surveys were repeatedly implemented by the instructor of the course Maternal, Infant, and Family Care in the nursing school as part of teaching activities. The instructor of the course was also the primary researcher of the study. This course was compulsory and was taken by all second-year students; therefore, all second-year students in the nursing school attended the course. Annual open-ended surveys were conducted from 2004 through 2025, excluding 2018–2022 due to curriculum changes and the COVID-19 interruption. In Part B, we used purposive sampling to select interview participants in 2025. We deliberately included students with diverse backgrounds to elicit a range of perspectives. While the primary focus was on unmarried students’ views, a few married participants were also invited to provide contrast and depth. Data Collection Surveys (Part A): Each year’s survey was administered online. The survey comprised several open-ended questions asking about students’ personal intentions and attitudes. For example, questions included students’ intentions regarding marriage and childbearing, the personality traits they hoped their future children would have, and their views on premarital cohabitation. Students completed the survey without strict time limits (approximately 15 minutes on average) and submitted it by a set deadline. Interviews (Part B): Guided by the survey results, a semi-structured interview guide was developed. Key questions related to premarital cohabitation included: Attitudes toward premarital cohabitation- “Do you agree or disagree with living together before marriage? Why?” Timing and duration-“When do you think it is appropriate to start cohabiting? How long do you think is long enough to live together before marriage?”; Practical considerations- “How would you and your partner manage financial responsibilities (bills, expenses) if living together before marriage?”Personal experience (If applicable) -“Can you describe your own experience of premarital cohabitation?” Two formats were used to collect interview data: focus group discussions and individual interviews. Four focus groups (each with 2–9 participants), totaling 19 students, were conducted to encourage peer interaction and debate. These group sessions were co-moderated by all three members of the research team and lasted on average 86 minutes (range 79–103 minutes). In parallel, six students chose one-on-one interviews conducted by the primary researcher; these individual interviews allowed in-depth exploration of personal experiences and lasted about 40 minutes on average (range 27–46 minutes). All interviews were audio-recorded with participant permission and transcribed verbatim for analysis. Data Analysis Analysis proceeded concurrently with data collection. Two complementary analytic approaches were used: content analysis and thematic analysis. Content analysis of survey data. The open-ended survey responses were analyzed using content analysis. We systematically coded the text of each response into categories reflecting key concepts (for example, reasons for/against cohabitation). This quantitative–qualitative method allowed us to track the prevalence of certain attitudes and intentions across multiple cohorts over time. For example, recurring themes in students’ written responses, such as “cohabitation as a test of compatibility”, were identified and counted. Content analysis was suited to these structured survey answers because it provides an objective, repeatable way to summarize large amounts of textual data (Krippendorff, 2018) and compare trends year to year. Thematic analysis of interview data . Interview transcripts were analyzed using thematic analysis. We carefully read the transcripts and coded the data line-by-line to identify salient themes and patterns, iteratively refining a coding framework. Major themes were then organized hierarchically into subthemes and categories. Thematic analysis was chosen for its flexibility in capturing the depth and nuance of participants’ perspectives in their own words. This approach was well-suited to the rich, conversational data from focus groups and interviews, enabling us to uncover underlying motivations and concerns that might not emerge from surveys alone (Braun & Clarke, 2022). The concurrent use of both methods strengthened the study’s rigor. Survey content analysis provided breadth, while interview thematic analysis provided depth. The interview guide itself was informed by the survey analysis, ensuring coherence between phases. Data collection continued until thematic saturation was reached, referring to no new themes appearing (Saunders et al., 2018), which occurred after 26 interview participants. Rigor of the study Several strategies were implemented to enhance the rigor of the study, following qualitative standards in health research (Lincoln & Guba). The detailed strategies are listed in Table 1. Table 1 Measures used to enhance rigour of the study Categories Definition The measures used in this study Credibility Referring to the extent to which research findings accurately represent participants’ meanings and experiences Prolonged engagement: The researchers spent sufficient time immersed in the data during both data collection and analysis. Member checking: (a) Five interview transcripts were returned to participants to verify transcription accuracy; (b) a follow-up focus group with five participants was conducted to confirm the accuracy of data interpretation. Triangulation: (a) Multiple data collection methods were used, including repeated surveys, focus group interviews, and individual interviews; (b) participants with diverse backgrounds were recruited, varying in age, gender, and cohabitation experience. Peer debriefing: The research team held regular discussions during study conduct. Dependability Referring to the stability and consistency of the research process over time. Audit trail: Detailed documentation of research decisions, methodological adjustments, and analytical procedures was maintained throughout the study. Transparent methodological description: Thick description was used to report sampling strategies, data collection processes, and analytical procedures. Reflexive documentation: The primary researcher maintained reflexive records documenting the evolution of methodological decisions over the course of the study. Confirmability Referring to the extent to which the findings are shaped by the participants and data rather than researcher bias, assumptions, or personal interests. Reflexive journaling: The researchers engaged in ongoing reflection on their assumptions, positionality, and analytic decisions throughout data collection and analysis. Audit trail: Described above. Triangulation: Described above. Use of direct quotations: Direct participant quotations were used to clearly link participants’ voices with the researchers’ interpretations. Transferability Referring to the extent to which findings can be applied or resonate in other contexts, populations, or settings Transparent methodological description: Described above. Purposeful sampling: Participants were intentionally selected to ensure information-rich and topic-relevant data. Clear contextual boundaries: The sociocultural context of the research setting was explicitly described to support interpretation and potential transferability. Ethical considerations Ethical approval was obtained from the ethics committee of the nursing school (Ref: REC-2024.0708). Participation was voluntary at all stages. In Part A, all students were informed that completion of the survey implied consent and that declining had no impact on academic performance assessment. In Part B, students were contacted by a research team member not involved in their courses to avoid coercion. Written informed consent was obtained for interviews, including consent to audio-record. We emphasized confidentiality: no names were recorded on transcripts, and interview data were stored securely on password-protected files accessible only to the research team. Approximately half of the students approached declined participation in interviews, indicating that students felt free to refuse. Results Participant characteristics A total of 991 survey responses were analyzed over the past two decades (excluding 2018-2022), with an average yearly number of 62. Gender distribution was typically about 80% female, 20% male in each year’s cohort. For interviews in 2025, 26 students participated: 20 were female and 6 male; their ages ranged from 19 to 43 (median 20.0). Fifteen interviewees were native to Macau, and 11 were from mainland China studying in Macau. Trends in attitudes toward premarital cohabitation Over the study period, support for premarital cohabitation rose dramatically. In the early years (2004), only about 23% of students expressed a positive attitude toward living together before marriage; By contrast, in 2024 and 2025, nearly 90% of respondents endorsed cohabitation. Table 2 shows the percentage of students endorsing cohabitation each year. Students’ open-ended survey comments illustrate this change. Early on, many wrote that cohabitation was unacceptable due to tradition, fear of risks, or fear of parental disapproval. In recent years, however, nearly all survey comments assume cohabitation as normal. In interviews, participants confirmed that “it is now very common for young couples to live together in Macau before they get married.” Table 2: The acceptance of premarital cohabitation among college nursing students in Macau (2004–2025) Number year Total number No of acceptance （%） No of disapproval（%） Neutral（%） 2004 47 11（23%） 36（77%） - 2005 43 24（56%） 18（42%） 1（2%） 2006 45 27（49%） 28（51%） - 2007 55 26（47%） 28（51%） 1（2%） 2008 50 28（56%） 22（44%） - 2010 49 25（51%） 24（49%） - 2011 56 40（71%） 14（24%） 2（5%） 2012 63 42（51%） 21（49%） 0 2013 55 39（71%） 16（29%） 0 2014 65 41（63%） 24（37%） 0 2015 60 43（72%） 17（28%） 0 2016 65 56（86%） 8（12%） 1（2%） 2017 69 53 (76.8%) 13 (18.8%) 3 (4.4%) 2023 132 113 (85.6%) 11 (8.4%) 8 (6.0%) 2024 60 53 (88.3%) 7 (11.7%) 0 2025 76 66 (86.8%) 6 (7.8%) 4 (5.2%) Perceived advantages and disadvantages Participants readily identified reasons for and against premarital cohabitation. Two broad themes emerged: Advantages of cohabitation and disadvantages of cohabitation. Advantages of cohabitation. Among students who accepted cohabitation, the most frequently cited benefits were gaining a deeper understanding of one’s partner and testing compatibility before marriage. For instance, many noted that living together revealed a person’s habits and character in ways that dating did not. As one male student explained during the focus group session: “When you live with someone, you can’t hide your shortcomings. If you live together for some time and see that he will be your future husband, then you get married. This is the last test of your relationship before marriage” .G1 Other students mentioned that cohabiting fostered mutual trust and reduced the risk of discovering major conflicts after marriage. Some viewed cohabitation as a way to ease the transition into marriage by ensuring both partners were ready for the commitment. These advantages correspond to the notion of a “trial marriage” discussed in the literature(Willoughby & James, 2017) Disadvantages of cohabitation. A smaller group of students voiced reservations about cohabitation. Harm to women was frequently cited as a major concern associated with premarital cohabitation, particularly in relation to both physiological and psychological consequences. Participants commonly raised the issue of unintended pregnancy and its potential impact on women’s health and social status. As one participant explained in a group discussion, and others in the group agreed: “Women may become pregnant if they live with their partners, and then have an abortion, which may harm their health. Even if a woman chooses to continue the pregnancy, she may be looked down upon by her future husband or in-laws. They may not respect her after marriage.” G2 Some participants articulated the view that women should exercise particular caution in preventing unintended pregnancy during cohabitation. This perspective reflected prevailing gendered expectations. As one female student in an individual interview stated: “If a girl gets pregnant during cohabitation, you can’t say it is entirely the boy’s neglect. The girl herself bears some responsibility. Therefore, she should be careful not to get pregnant and should take contraceptive measures.” P2 In addition, participants highlighted the lack of legal and social protection during premarital cohabitation, noting that its consequences were perceived to disproportionately affect women. One participant remarked: “If there is domestic abuse during premarital cohabitation, women seem to have nowhere to seek help because premarital cohabitation is not protected by law.” P1 Cohabitation as a precursor to marriage A strong theme was that cohabitation was seen almost exclusively as a precursor to marriage rather than an alternative. Participants, especially women, emphasized that cohabiting should occur only when a couple is “serious” about a future marriage. As one female respondent stated: Cohabitation should happen only when you two have known each other for quite some time and think that he will be your future husband.” G1 Several married students echoed this idea from personal experience. For example, a married interviewee described living with her now-husband for about one year before the wedding, and another said she had spent three years gradually increasing the time cohabiting with her boyfriend before feeling ready to marry. Interestingly, male interviewees occasionally showed less strict criteria. Two male participants expressed less restrictive views regarding cohabiting with a future spouse. They suggested that cohabitation could occur as long as both parties agreed, regardless of how long they had known each other. As one of the participants stated: “As long as I like the girl at the first meeting and she agrees to live with me, I will live with her. I don’t care whether we have known each other for only three days or three months.”G4 In contrast, all female participants rejected the idea of cohabiting with a partner they had known for only a short period. As one female participant explained: “If people are not serious about their relationship and live together only for sex, it will be the girls who bear the adverse impact, not the boys. Therefore, girls should be more careful in deciding when and with whom they live before marriage.”G3 Duration of cohabitation Students discussed how long couples should live together before marriage. There was consensus that the period must be “sufficient” to reveal each partner’s true self. In focus groups, suggestions ranged from a few months to over one or two years. “I think three months is enough. He can’t conceal himself for three months without exposing his shortcomings.” G1 “I think it should be at least half a year.” G1 “Perhaps it should be one or two years before one can know his or her partner quite well. Some people are good at concealing themselves.” G1 Notably, the one married participant reported a one-year cohabitation, whereas another unmarried participant described incrementally living together over three years before feeling certain about marriage. These discussions reflect the attitude that cohabitation is not a brief experiment but a significant commitment requiring ample time. Financial arrangements Another key theme was how couples would share living expenses during cohabitation. Most participants favored an egalitarian approach. The common expectation was that partners should equally share rent and daily costs (an “AA” split). One student summarized the view: “If I were living with my boyfriend in a rented apartment, I would pay half of the rent. If he buys the table, I will buy the chairs… I will spend roughly the same amount of money as he does.” G3 Some participants proposed establishing a joint account into which both partners would contribute equal amounts of money. One participant who was currently cohabiting with her boyfriend described doing exactly this. However, because her boyfriend had a well-paid job while she earned much less from her part-time work, he contributed a larger amount to their shared account. A similar situation was reported by another participant with cohabitation experience: she was still a full-time student, whereas her boyfriend was employed full-time, and consequently, he covered most of the household expenses. Male participants interviewed generally supported this arrangement, stating that they were willing to contribute more financially if they genuinely cared about their partners. One male participant explained: “If I really like a girl, I am willing to pay more. Even if I pay all the expenses, it would be okay. I am not doing this to pressure her to marry me; I just want to show my fondness for her.” However, most female participants rejected the assumption that paying more equated to loving their partners more. One participant expressed her feelings as follows: “If my boyfriend pays the whole bill, I may feel a bit uncomfortable. I want to pay my part, and in this way, I feel that we are equal.” Discussion The study illustrates a clear trend toward increasing acceptance of premarital cohabitation among college students in Macau, reflecting broader shifts observed in both Asian and Western societies (Sassler & Lichter, 2020). Globalization and social change have led to more cohabitation across Asia (Raymo et al., 2015). Even so, many young people still view marriage as important. In our study, participants often described cohabitation as a way to confirm compatibility before tying the knot, rather than a substitute for marriage. This dual attitude – open to cohabiting but valuing marriage – reflects the "Marriage Paradox" described by Willoughby and James (2017), where traditional goals are pursued through modern pathways. Participants in our study listed several advantages and disadvantages that parallel findings elsewhere. On the plus side, many cited greater understanding and the ability to “test” the relationship as key benefits. This is consistent with large surveys of Chinese youth in which roughly two-thirds viewed cohabitation as a good way to test compatibility (Yu & Xie, 2022). On the other hand, some disadvantages were noted. In particular, female students emphasized potential harms. They noted that premarital cohabitation increases the chance of an unintended pregnancy. Under social pressure to avoid single motherhood, young women often feel forced to terminate such pregnancies. Participants were acutely aware that abortion can harm the body, and Chinese data support their fears: women who undergo abortion frequently experience medical complications and report high levels of stress and depression (Wang et al., 2022). Moreover, the social stigma of premarital pregnancy compounds these harms. Many young women worried about the possibility that cohabitation might undermine their future marriage prospects or lead to a loss of status. This gendered view aligns with the literature, indicating that Chinese women often see cohabitation as “risk-amplifying” due to the lack of legal protections, whereas men may see it as “risk-reducing” by avoiding premature marriage (Yu, 2021). In short, while both genders acknowledge the practical benefits of living together, women in Macau approach cohabitation with greater caution due to persisting social expectations and biological risks, a disparity that underscores unmet public health needs for gender-based health protection in non-marital intimate relationships. Our findings also reveal gender dynamics within cohabiting relationships. Many female partners insisted on splitting living costs equally, signaling their pursuit of financial and personal equality in the relationship. This reflects an increasingly egalitarian attitude among young women in Chinese cultures (Song & Lai, 2020). Men, for their part, often expressed a desire to maintain a provider role or display traditional masculinity(Oliffe et al., 2024), but overall, most couples negotiated fairly even financial sharing. This combination – women asserting equality while men still valuing traditional roles – echoes broader patterns where cohabiting couples hold more gender-egalitarian views than older generations, even if some traditional expectations persist (Patterson, 2023).For public health practice, this shifting gender dynamic creates a critical window to intervene and promote equitable health norms in intimate relationships, before rigid gendered health behaviors become entrenched. Taken together, the study results suggest a blending of traditional values and Westernized behaviors among young people in Macau. Although earlier studies reported that approximately two-thirds of Chinese students anticipated parental disapproval of premarital cohabitation (Raymo et al., 2015), no explicit parental opposition was observed in the present study, suggesting that the older generation may also be adapting to these changing norms. Moreover, increasingly open societal attitudes toward premarital cohabitation and the rising prevalence of cohabitation among younger generations may reinforce one another. Consistent with this interpretation, previous research has shown that more liberal societal attitudes are commonly found in contexts where premarital cohabitation is more prevalent (Sassler & Lichter, 2020). Previous research has consistently shown that acceptance of premarital cohabitation is higher in metropolitan areas and among individuals with higher levels of education, where exposure to global cultural norms is more pronounced (Yu & Xie, 2022). The Macau findings, therefore, have relevance beyond the local context, offering insight into how young adults in culturally hybrid societies negotiate intimacy, commitment, and risk–and highlighting the need for context-specific public health interventions to address the unique needs of this population. Public Health Implications Against the backdrop of rapidly rising acceptance of premarital cohabitation among Macau’s young adults and persistent gendered health disparities identified in this study, the findings carry meaningful public health implications for Macau and other culturally hybrid East Asian urban regions facing similar shifts in intimate relationship norms. These implications are grounded in the specific perceptions and concerns of the study participants—notably female students’ acute anxiety around unintended pregnancy, abortion-related health harms, and the lack of legal and social protection for cohabitation-related adverse outcomes—and align with the need to translate evolving social norms into equitable and context-responsive public health practice. The pervasive gendered health risk concerns highlighted in this study warrant the integration of cohabitation-specific reproductive health content into mandatory youth health literacy curricula in Macau’s higher education institutions and community-based public health programs. Given that 100% of female interview participants raised fears of unintended pregnancy and its physical and psychological sequelae, such education should center on evidence-based, accessible contraceptive guidance and clear communication about the short- and long-term health impacts of induced abortion, with gender-tailored outreach that addresses the unique vulnerability of young women in cohabiting relationships. Complementarily, curricula should address the gap in health education around non-marital intimate relationship safety, including training on recognizing and responding to domestic violence in cohabitation—a harm participants identified as unaddressed by existing support systems. This targeted education is critical to equipping young adults with the health literacy to navigate cohabitation responsibly, and to mitigating the avoidable health risks that persist despite growing societal acceptance of cohabitation. The study’s findings also highlight the need for expanding public health service coverage and legal safeguards to address the gendered health inequities of cohabitation in Macau. Participants repeatedly noted the legal vacuum surrounding cohabitation-related health harms, from unprotected domestic violence to the social and health consequences of premarital pregnancy, which disproportionately disadvantages women. This points to a critical action for Macau’s public health and policy sectors: establishing free, confidential reproductive health consultation services for young cohabiting adults, and developing specialized psychological counseling for individuals experiencing abortion-related distress—services that are currently lacking for non-marital intimate relationships. Additionally, there is a need to create dedicated reporting and support channels for cohabitation-related domestic violence, and to revise existing social policies to fill legal gaps that leave cohabiting women without formal protection. These steps would directly address the core health equity concerns raised by study participants, and reduce the “risk-amplifying” nature of cohabitation for women in Macau. Macau’s unique Sino-Western cultural integration, a central contextual feature of this study, underscores the importance of culturally adapted public health interventions for premarital cohabitation, rather than the uncritical adoption of Western or mainland Chinese models. Participants framed cohabitation as a precursor to marriage—rather than an alternative—reflecting a blend of traditional marital values and modern egalitarian norms, and this framing should guide community-based health promotion campaigns. Such campaigns should aim to reduce the social stigma associated with premarital cohabitation and its related reproductive health issues, a stigma that participants noted deters young women from seeking timely health care. Framing cohabitation health protection as a component of “responsible intimate relationship behavior” aligns with the study’s finding that young adults in Macau approach cohabitation as a step toward committed marriage, and would make public health outreach more resonant with local cultural norms. Finally, this 20-year longitudinal qualitative study points to the value of establishing a long-term public health monitoring system for young adults’ cohabitation attitudes and associated reproductive health outcomes in Macau. The dramatic attitudinal shift observed over the study period—from 23% to nearly 90% acceptance of cohabitation—demonstrates that social norms around intimate relationships are evolving rapidly, and public health policies need dynamic data to remain responsive. This monitoring system should collect disaggregated data on gendered health risks in cohabiting relationships (e.g., unintended pregnancy rates, abortion-related health complications) across different educational, occupational, and age groups of young adults, moving beyond the nursing student population of this study to capture the broader diversity of Macau’s youth. This data would provide an evidence base for ongoing adjustment of public health interventions, and support the design of universal health services that address the cohabitation-related health needs of all young adults in Macau. Concurrently, expanding public health research on cohabitation to include non-health major students and working young adults would address the sample limitations of the present study, and ensure that interventions are equitable and generalizable to the broader population. Limitations Several limitations of this study should be acknowledged. First, the data were drawn from students at a single nursing school in Macau, which may limit the generalizability of the findings to other educational institutions or student populations. In addition, the participant cohort reflected a gender imbalance, with female students disproportionately represented, which may have influenced the perspectives captured, particularly regarding gendered experiences of premarital cohabitation. Second, although this was a repeated study spanning more than two decades, data collection was interrupted for several years due to curriculum changes and the COVID-19 pandemic. These gaps may have affected the continuity of trend analysis across the full study period. Third, the qualitative interviews were conducted only in 2025. As a result, the interview findings may not fully capture or contextualize attitudes expressed in earlier survey cohorts. While the interviews provided in-depth insight into contemporary perspectives, they cannot retrospectively represent experiences or interpretations from previous periods. Future research could address these limitations by extending qualitative interviews across multiple time points alongside ongoing survey data collection. Intentionally recruiting a larger number of participants with premarital cohabitation experience would further enrich the understanding of lived experiences and decision-making processes. Expanding the study to include students from diverse institutions and academic disciplines would also enhance the transferability of the findings. Conclusion Premarital cohabitation has become widely accepted among younger generations in Macau, reflecting trends observed among highly educated youth in modern urban societies. The primary motivations identified in this study highlight the role of cohabitation as a form of “trial marriage” in a context of ongoing cultural change. At the same time, students remain attentive to the gendered dimensions of cohabitation. By documenting the conditions, rationales, and constraints articulated by students, this study provides in-depth insight into the psychological and social processes underlying decisions about premarital cohabitation. Future research should continue to monitor these trends and examine their implications for marriage patterns, gender relations, and family dynamics in Macau and comparable societies. Declarations Ethical Considerations Ethical approval was obtained from the Ethics Committee of Kiang Wu Nursing College of Macau (Ref: REC-2024.0708). The study conforms to the provisions of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000). Consent to Participate Informed consent to participate was obtained in writing from all participants. Consent for Publication Not applicable Declaration of Conflicting Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding Statement The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Foundation of Macau [Ref:0597/DGAF/2025-06]. Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Authorship Statement Aimei MAO : Conceptualization; Data curation; Investigation; Writing – original draft; Supervision; Methodology; Software; Formal analysis; Writing – review and editing. Uhin CHEANG : Investigation; Software; Writing – review and editing Jiaxi XU : Data curation; Investigation; Software; Writing – review and editing. Acknowledgments Not applicable References Cheng, Y.-h. A. (2023). The changing face of intimate premarital relationships in Taiwan. Journal of Marriage and Family , 85 (4), 987–1001. https://doi.org/10.1111/jomf.12915 Manning, W. D., Westrick-Payne, K. K., & Gates, G. J. (2022). Cohabitation and Marriage Among Same-Sex Couples in the 2019 ACS and CPS: A Research Note. Demography , 59 (5), 1595–1605. https://doi.org/10.1215/00703370-10181474 Oliffe, J., Gao, N., Kelly, M., Shim, A., Yap, C., Sharp, P., & McKenzie, S. (2024). Picture this: Men building intimate partner relationships. Health Education Journal , 84 . https://doi.org/10.1177/00178969241281157 Patterson, S. E. (2023). Cohabiting Adult Children's Transfers to Parents in the United States. J Marriage Fam , 85 (1), 321–336. https://doi.org/10.1111/jomf.12879 Raymo, J. M., & Park, H. (2020). Marriage Decline in Korea: Changing Composition of the Domestic Marriage Market and Growth in International Marriage. Demography , 57 (1), 171–194. https://doi.org/10.1007/s13524-019-00844-9 Raymo, J. M., Park, H., Xie, Y., & Yeung, W. J. (2015). Marriage and Family in East Asia: Continuity and Change. Annu Rev Sociol , 41 , 471–492. https://doi.org/10.1146/annurev-soc-073014-112428 Sassler, S., & Lichter, D. T. (2020). Cohabitation and marriage: Complexity and diversity in union‐formation patterns. Journal of Marriage and Family , 82 (1), 35–61. https://doi.org/10.1111/jomf.12617 Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., & Jinks, C. (2018). Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant , 52 (4), 1893–1907. https://doi.org/10.1007/s11135-017-0574-8 Song, J., & Lai, W. (2020). Cohabitation and Gender Equality: Ideal and Real Division of Household Labor among Chinese Youth. The China Review: An Interdisciplinary Journal on Greater China , 20 (2), 53–80. Wang, N., Zhu, X., Gamble, J., Elder, E., Allen, J., & Creedy, D. K. (2022). The STress-And-Coping suppoRT Intervention (START) for Chinese Women Undergoing Abortion: A Randomized Controlled Trial Protocol. Int J Environ Res Public Health , 19 (11). https://doi.org/10.3390/ijerph19116611 Willoughby, B. J., & James, S. L. (2017). The Marriage Paradox: Why Emerging Adults Love Marriage Yet Push it Aside . Oxford University Press. https://doi.org/10.1093/acprof:oso/9780190296650.001.0001 Yu, J. (2021). Union formation and childbearing among Chinese youth: Trends and socioeconomic differentials. Chinese Journal of Sociology , 7 , 2057150X2110409. https://doi.org/10.1177/2057150X211040936 Yu, J., & Xie, Y. (2022). Is there a Chinese pattern of the second demographic transition? China Population and Development Studies , 6 (3), 237–266. https://doi.org/10.1007/s42379-022-00113-0 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 08 Apr, 2026 Editor invited by journal 19 Mar, 2026 Editor assigned by journal 19 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 09 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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In Western societies, cohabitation has largely transitioned from a marginal \u0026ldquo;trial marriage\u0026rdquo; option to a normative pathway into union formation. For example, fewer than 5% of adults born before 1970 in the West reported premarital cohabitation, whereas the rate rises sharply among younger cohorts (born in the 1980s and later) (Sassler \u0026amp; Lichter, 2020). This dramatic rise is understood within the framework of the Second Demographic Transition (SDT), which theorizes that changing values of individualism, gender equality, and self-fulfillment and economic factors have led to the postponement of marriage and fertility, sub-replacement fertility, and a proliferation of alternative living arrangements such as cohabitation and nonmarital childbearing (Raymo \u0026amp; Park, 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAsian societies have begun to exhibit some SDT trends, but with different cultural contours. East Asian family systems have traditionally been characterized by strong Confucian norms: patriarchal, patrilineal family organization; filial piety; and an emphasis on chastity before marriage. These traditions have long discouraged premarital sexual unions. However, scholars now note that cohabitation has increased markedly among East Asian young adults. In Japan, recent findings from the National Fertility Survey indicate that roughly 20% of first marriages are now preceded by cohabitation (IPSS, 2022). In Taiwan, as of 2020, 57% of the 30\u0026ndash;34 age group remained single, and premarital cohabitation is increasingly recognized as a \u0026quot;trial marriage\u0026quot; phase (Cheng, 2023). In China, analyses of recent cohorts show 37.4% of the 1985\u0026ndash;1994 birth cohort lived together premaritally (Yu \u0026amp; Xie, 2022). Despite these increases, at any given time, only a small proportion of young Asians are cohabiting, largely because relationships tend to be short and most eventually lead to marriage (Manning et al., 2022). Therefore, cohabitation appears largely as a precursor to marriage rather than an alternative pathway.\u003c/p\u003e\n\u003cp\u003eAttitudes toward premarital cohabitation are changing unevenly across the region. Scholars note that East Asian societies share a deeply entrenched gender division of labor, often disadvantaging women (Raymo et al., 2015). In such contexts, unmarried women risk harsher stigma for premarital sexual activity than men. For example, young women in Vietnam remain acutely aware of parental and societal expectations of chastity, fearing severe consequences if discovered in premarital sexual unions \u0026nbsp;(Song \u0026amp; Lai, 2020). Consistent with this, reports that while Japanese women with lower education are more likely to cohabit, Chinese cohabitors tend to be more educated and urban, suggesting that premarital cohabitation is context-specific(Wang et al., 2022)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Macau context and study rationale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMacau is a Special Administrative Region of China known for its unique mix of cultures and advanced economy. Governed by Portugal until 1999, Macau\u0026rsquo;s population remains overwhelmingly ethnically Chinese (\u0026gt;90%), but its legal and social systems retain Western influences. The city has one of the highest GDPs per capita in the world (around $125,000 PPP as of 2025 (DSEC, 2025)). These factors \u0026ndash; a wealthy, urban society with both Chinese traditions and Western exposure \u0026ndash; make Macau an interesting case for studying young adults\u0026rsquo; family attitudes. The present study documents Macau students\u0026rsquo; attitudes toward premarital cohabitation over two decades and the decision-making process behind these attitudes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary aim of the study is to depict the trajectory of attitudes toward premarital cohabitation among Macau college students from 2004 through 2025. A secondary aim is to gain in-depth insights into how students perceive specific aspects of cohabitation (e.g., timing of moving in, length of cohabitation, sharing of expenses) through their own words. In doing so, the study seeks to illuminate whether and how Macau\u0026rsquo;s younger generation diverges from older norms and to identify the contextual factors that shape their views.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a multi-method qualitative design to examine changes in attitudes toward premarital cohabitation over time. Open-ended qualitative surveys were administered to successive cohorts of college students across two decades, allowing analysis of cohort-level shifts in attitudes in the context of broader social change. To complement these findings, semi-structured interviews were conducted in 2025 to explore in greater depth students\u0026rsquo; perceptions, decision-making processes, and expectations regarding cohabitation. Together, the two qualitative components provided both temporal perspective and contextual depth without relying on individual-level longitudinal follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Part A, the surveys were repeatedly implemented by the instructor of the course Maternal, Infant, and Family Care in the nursing school as part of teaching activities. The instructor of the course was also the primary researcher of the study. This course was compulsory and was taken by all second-year students; therefore, all second-year students in the nursing school attended the course.\u0026nbsp;Annual open-ended surveys were conducted from 2004 through 2025, excluding 2018\u0026ndash;2022 due to curriculum changes and the COVID-19 interruption.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Part B, we used purposive sampling to select interview participants in 2025. We deliberately included students with diverse backgrounds to elicit a range of perspectives. While the primary focus was on unmarried students\u0026rsquo; views, a few married participants were also invited to provide contrast and depth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurveys (Part A): Each year\u0026rsquo;s survey was administered online. The survey comprised several open-ended questions asking about students\u0026rsquo; personal intentions and attitudes. For example, questions included students\u0026rsquo; intentions regarding marriage and childbearing, the personality traits they hoped their future children would have, and their views on premarital cohabitation. Students completed the survey without strict time limits (approximately 15 minutes on average) and submitted it by a set deadline.\u003c/p\u003e\n\u003cp\u003eInterviews (Part B): Guided by the survey results, a semi-structured interview guide was developed. Key questions related to premarital cohabitation included:\u0026nbsp;Attitudes toward premarital cohabitation- \u0026ldquo;Do you agree or disagree with living together before marriage? Why?\u0026rdquo; Timing and duration-\u0026ldquo;When do you think it is appropriate to start cohabiting? How long do you think is long enough to live together before marriage?\u0026rdquo;; Practical considerations- \u0026ldquo;How would you and your partner manage financial responsibilities (bills, expenses) if living together before marriage?\u0026rdquo;Personal experience (If applicable) -\u0026ldquo;Can you describe your own experience of premarital cohabitation?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eTwo formats were used to collect interview data: focus group discussions and individual interviews. Four focus groups (each with 2\u0026ndash;9 participants), totaling 19 students, were conducted to encourage peer interaction and debate. These group sessions were co-moderated by all three members of the research team and lasted on average 86 minutes (range 79\u0026ndash;103 minutes). In parallel, six students chose one-on-one interviews conducted by the primary researcher; these individual interviews allowed in-depth exploration of personal experiences and lasted about 40 minutes on average (range 27\u0026ndash;46 minutes). All interviews were audio-recorded with participant permission and transcribed verbatim for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis proceeded concurrently with data collection. Two complementary analytic approaches were used: content analysis and thematic analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContent analysis of survey data.\u003c/strong\u003e The open-ended survey responses were analyzed using content analysis. We systematically coded the text of each response into categories reflecting key concepts (for example, reasons for/against cohabitation). This quantitative\u0026ndash;qualitative method allowed us to track the prevalence of certain attitudes and intentions across multiple cohorts over time. For example, recurring themes in students\u0026rsquo; written responses, such as \u0026ldquo;cohabitation as a test of compatibility\u0026rdquo;, were identified and counted. Content analysis was suited to these structured survey answers because it provides an objective, repeatable way to summarize large amounts of textual data (Krippendorff, 2018) and compare trends year to year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThematic analysis of interview data\u003c/strong\u003e. Interview transcripts were analyzed using thematic analysis. We carefully read the transcripts and coded the data line-by-line to identify salient themes and patterns, iteratively refining a coding framework. Major themes were then organized hierarchically into subthemes and categories. Thematic analysis was chosen for its flexibility in capturing the depth and nuance of participants\u0026rsquo; perspectives in their own words. This approach was well-suited to the rich, conversational data from focus groups and interviews, enabling us to uncover underlying motivations and concerns that might not emerge from surveys alone (Braun \u0026amp; Clarke, 2022).\u003c/p\u003e\n\u003cp\u003eThe concurrent use of both methods strengthened the study\u0026rsquo;s rigor. Survey content analysis provided breadth, while interview thematic analysis provided depth. The interview guide itself was informed by the survey analysis, ensuring coherence between phases. Data collection continued until thematic saturation was reached, referring to no new themes appearing (Saunders et al., 2018), which occurred after 26 interview participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRigor of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral strategies were implemented to enhance the rigor of the study, following qualitative standards in health research (Lincoln \u0026amp; Guba). The detailed strategies are listed in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1 Measures used to enhance rigour of the study\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8915%;\"\u003e\n \u003cp\u003eCategories\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2315%;\"\u003e\n \u003cp\u003eDefinition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.877%;\"\u003e\n \u003cp\u003eThe measures used in this study\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8915%;\"\u003e\n \u003cp\u003eCredibility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2315%;\"\u003e\n \u003cp\u003eReferring to the extent to which research findings accurately represent participants\u0026rsquo; meanings and experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.877%;\"\u003e\n \u003cp\u003eProlonged engagement:\u0026nbsp;The researchers spent sufficient time immersed in the data during both data collection and analysis.\u003c/p\u003e\n \u003cp\u003eMember checking:\u0026nbsp;(a) Five interview transcripts were returned to participants to verify transcription accuracy; (b) a follow-up focus group with five participants was conducted to confirm the accuracy of data interpretation.\u003c/p\u003e\n \u003cp\u003eTriangulation:\u0026nbsp;(a) Multiple data collection methods were used, including repeated surveys, focus group interviews, and individual interviews; (b) participants with diverse backgrounds were recruited, varying in age, gender, and cohabitation experience.\u003c/p\u003e\n \u003cp\u003ePeer debriefing:\u0026nbsp;The research team held regular discussions during study conduct.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8915%;\"\u003e\n \u003cp\u003eDependability\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2315%;\"\u003e\n \u003cp\u003eReferring to the stability and consistency of the research process over time.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.877%;\"\u003e\n \u003cp\u003eAudit trail:\u0026nbsp;Detailed documentation of research decisions, methodological adjustments, and analytical procedures was maintained throughout the study.\u003c/p\u003e\n \u003cp\u003eTransparent methodological description:\u0026nbsp;Thick description was used to report sampling strategies, data collection processes, and analytical procedures.\u003c/p\u003e\n \u003cp\u003eReflexive documentation:\u0026nbsp;The primary researcher maintained reflexive records documenting the evolution of methodological decisions over the course of the study.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8915%;\"\u003e\n \u003cp\u003eConfirmability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2315%;\"\u003e\n \u003cp\u003eReferring to the extent to which the findings are shaped by the participants and data rather than researcher bias, assumptions, or personal interests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.877%;\"\u003e\n \u003cp\u003eReflexive journaling:\u0026nbsp;The researchers engaged in ongoing reflection on their assumptions, positionality, and analytic decisions throughout data collection and analysis.\u003c/p\u003e\n \u003cp\u003eAudit trail:\u0026nbsp;Described above.\u003c/p\u003e\n \u003cp\u003eTriangulation:\u0026nbsp;Described above.\u003c/p\u003e\n \u003cp\u003eUse of direct quotations:\u0026nbsp;Direct participant quotations were used to clearly link participants\u0026rsquo; voices with the researchers\u0026rsquo; interpretations.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8915%;\"\u003e\n \u003cp\u003eTransferability\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2315%;\"\u003e\n \u003cp\u003eReferring to the extent to which findings can be applied or resonate in other contexts, populations, or settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.877%;\"\u003e\n \u003cp\u003eTransparent methodological description:\u0026nbsp;Described above.\u003c/p\u003e\n \u003cp\u003ePurposeful sampling:\u0026nbsp;Participants were intentionally selected to ensure information-rich and topic-relevant data.\u003c/p\u003e\n \u003cp\u003eClear contextual boundaries:\u0026nbsp;The sociocultural context of the research setting was explicitly described to support interpretation and potential transferability.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the ethics committee of the nursing school (Ref: REC-2024.0708). Participation was voluntary at all stages. In Part A, all students were informed that completion of the survey implied consent and that declining had no impact on academic performance assessment. In Part B, students were contacted by a research team member not involved in their courses to avoid coercion. Written informed consent was obtained for interviews, including consent to audio-record. We emphasized confidentiality: no names were recorded on transcripts, and interview data were stored securely on password-protected files accessible only to the research team. Approximately half of the students approached declined participation in interviews, indicating that students felt free to refuse.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 991 survey responses were analyzed over the past two decades (excluding 2018-2022), with an average yearly number of 62. Gender distribution was typically about 80% female, 20% male in each year\u0026rsquo;s cohort. For interviews in 2025, 26 students participated: 20 were female and 6 male; their ages ranged from 19 to 43 (median 20.0). Fifteen interviewees were native to Macau, and 11 were from mainland China studying in Macau.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrends in attitudes toward premarital cohabitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver the study period, support for premarital cohabitation rose dramatically. In the early years (2004), only about 23% of students expressed a positive attitude toward living together before marriage; By contrast, in 2024 and 2025, nearly 90% of respondents endorsed cohabitation. Table 2 shows the percentage of students endorsing cohabitation each year.\u003c/p\u003e\n\u003cp\u003eStudents\u0026rsquo; open-ended survey comments illustrate this change. Early on, many wrote that cohabitation was unacceptable due to tradition, fear of risks, or fear of parental disapproval. In recent years, however, nearly all survey comments assume cohabitation as normal. In interviews, participants confirmed that \u0026ldquo;it is now very common for young couples to live together in Macau before they get married.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eTable 2: The acceptance of premarital cohabitation among college nursing students in Macau (2004\u0026ndash;2025)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"548\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003cp\u003eyear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eTotal number\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eNo of acceptance\u0026nbsp;（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eNo of disapproval（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;Neutral（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e11（23%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e36（77%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e24（56%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e18（42%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e1（2%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e27（49%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e28（51%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e26（47%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e28（51%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e1（2%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e28（56%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e22（44%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e25（51%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e24（49%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e40（71%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e14（24%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2（5%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e42（51%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e21（49%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e39（71%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e16（29%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e41（63%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e24（37%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e43（72%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e17（28%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2016\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e56（86%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e8（12%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e1（2%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e53\u0026nbsp;(76.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e13\u0026nbsp;(18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e3\u0026nbsp;(4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e113\u0026nbsp;(85.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e11\u0026nbsp;(8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e8\u0026nbsp;(6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e53\u0026nbsp;(88.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e7\u0026nbsp;(11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e66\u0026nbsp;(86.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e6\u0026nbsp;(7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e4\u0026nbsp;(5.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived advantages and disadvantages\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants readily identified reasons for and against premarital cohabitation. Two broad themes emerged: Advantages of cohabitation and disadvantages of cohabitation.\u003c/p\u003e\n\u003cp\u003eAdvantages of cohabitation. Among students who accepted cohabitation, the most frequently cited benefits were gaining a deeper understanding of one\u0026rsquo;s partner and testing compatibility before marriage. For instance, many noted that living together revealed a person\u0026rsquo;s habits and character in ways that dating did not. \u0026nbsp;As one male student explained during the focus group session:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When you live with someone, you can\u0026rsquo;t hide your shortcomings. If you live together for some time and see that he will be your future husband, then you get married. This is the last test of your relationship before marriage\u0026rdquo; .G1\u003c/p\u003e\n\u003cp\u003eOther students mentioned that cohabiting fostered mutual trust and reduced the risk of discovering major conflicts after marriage. Some viewed cohabitation as a way to ease the transition into marriage by ensuring both partners were ready for the commitment. These advantages correspond to the notion of a \u0026ldquo;trial marriage\u0026rdquo; discussed in the literature(Willoughby \u0026amp; James, 2017)\u003c/p\u003e\n\u003cp\u003eDisadvantages of cohabitation. A smaller group of students voiced reservations about cohabitation.\u0026nbsp;Harm to women was frequently cited as a major concern associated with premarital cohabitation, particularly in relation to both physiological and psychological consequences. Participants commonly raised the issue of unintended pregnancy and its potential impact on women\u0026rsquo;s health and social status. As one participant explained in a group discussion, and others in the group agreed:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Women may become pregnant if they live with their partners, and then have an abortion, which may harm their health. Even if a woman chooses to continue the pregnancy, she may be looked down upon by her future husband or in-laws. They may not respect her after marriage.\u0026rdquo; G2\u003c/p\u003e\n\u003cp\u003eSome participants articulated the view that women should exercise particular caution in preventing unintended pregnancy during cohabitation. This perspective reflected prevailing gendered expectations. As one female student in an individual interview stated:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If a girl gets pregnant during cohabitation, you can\u0026rsquo;t say it is entirely the boy\u0026rsquo;s neglect. The girl herself bears some responsibility. Therefore, she should be careful not to get pregnant and should take contraceptive measures.\u0026rdquo; P2\u003c/p\u003e\n\u003cp\u003eIn addition, participants highlighted the lack of legal and social protection during premarital cohabitation, noting that its consequences were perceived to disproportionately affect women. One participant remarked:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If there is domestic abuse during premarital cohabitation, women seem to have nowhere to seek help because premarital cohabitation is not protected by law.\u0026rdquo; P1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCohabitation as a precursor to marriage\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA strong theme was that cohabitation was seen almost exclusively as a precursor to marriage rather than an alternative. Participants, especially women, emphasized that cohabiting should occur only when a couple is \u0026ldquo;serious\u0026rdquo; about a future marriage. As one female respondent stated:\u003c/p\u003e\n\u003cp\u003eCohabitation should happen only when you two have known each other for quite some time and think that he will be your future husband.\u0026rdquo; G1\u003c/p\u003e\n\u003cp\u003eSeveral married students echoed this idea from personal experience. For example, a married interviewee described living with her now-husband for about one year before the wedding, and another said she had spent three years gradually increasing the time cohabiting with her boyfriend before feeling ready to marry.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterestingly, male interviewees occasionally showed less strict criteria. Two male participants expressed less restrictive views regarding cohabiting with a future spouse. They suggested that cohabitation could occur as long as both parties agreed, regardless of how long they had known each other. As one of the participants stated:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;As long as I like the girl at the first meeting and she agrees to live with me, I will live with her. I don\u0026rsquo;t care whether we have known each other for only three days or three months.\u0026rdquo;G4\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast, all female participants rejected the idea of cohabiting with a partner they had known for only a short period. As one female participant explained:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If people are not serious about their relationship and live together only for sex, it will be the girls who bear the adverse impact, not the boys. Therefore, girls should be more careful in deciding when and with whom they live before marriage.\u0026rdquo;G3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDuration of cohabitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents discussed how long couples should live together before marriage. There was consensus that the period must be \u0026ldquo;sufficient\u0026rdquo; to reveal each partner\u0026rsquo;s true self. In focus groups, suggestions ranged from a few months to over one or two years.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think three months is enough. He can\u0026rsquo;t conceal himself for three months without exposing his shortcomings.\u0026rdquo; G1\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think it should be at least half a year.\u0026rdquo; G1\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Perhaps it should be one or two years before one can know his or her partner quite well. Some people are good at concealing themselves.\u0026rdquo; G1\u003c/p\u003e\n\u003cp\u003eNotably, the one married participant reported a one-year cohabitation, whereas another unmarried participant described incrementally living together over three years before feeling certain about marriage. These discussions reflect the attitude that cohabitation is not a brief experiment but a significant commitment requiring ample time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial arrangements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnother key theme was how couples would share living expenses during cohabitation. Most participants favored an egalitarian approach. The common expectation was that partners should equally share rent and daily costs (an \u0026ldquo;AA\u0026rdquo; split). One student summarized the view:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If I were living with my boyfriend in a rented apartment, I would pay half of the rent. If he buys the table, I will buy the chairs\u0026hellip; I will spend roughly the same amount of money as he does.\u0026rdquo; G3\u003c/p\u003e\n\u003cp\u003eSome participants proposed establishing a joint account into which both partners would contribute equal amounts of money. One participant who was currently cohabiting with her boyfriend described doing exactly this. However, because her boyfriend had a well-paid job while she earned much less from her part-time work, he contributed a larger amount to their shared account. A similar situation was reported by another participant with cohabitation experience: she was still a full-time student, whereas her boyfriend was employed full-time, and consequently, he covered most of the household expenses.\u003c/p\u003e\n\u003cp\u003eMale participants interviewed generally supported this arrangement, stating that they were willing to contribute more financially if they genuinely cared about their partners. One male participant explained:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If I really like a girl, I am willing to pay more. Even if I pay all the expenses, it would be okay. I am not doing this to pressure her to marry me; I just want to show my fondness for her.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eHowever, most female participants rejected the assumption that paying more equated to loving their partners more. One participant expressed her feelings as follows:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If my boyfriend pays the whole bill, I may feel a bit uncomfortable. I want to pay my part, and in this way, I feel that we are equal.\u0026rdquo;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study illustrates a clear trend toward increasing acceptance of premarital cohabitation among college students in Macau, reflecting broader shifts observed in both Asian and Western societies (Sassler \u0026amp; Lichter, 2020). Globalization and social change have led to more cohabitation across Asia (Raymo et al., 2015). Even so, many young people still view marriage as important. In our study, participants often described cohabitation as a way to confirm compatibility before tying the knot, rather than a substitute for marriage. This dual attitude \u0026ndash; open to cohabiting but valuing marriage \u0026ndash; reflects the \u0026quot;Marriage Paradox\u0026quot; described by Willoughby and James (2017), where traditional goals are pursued through modern pathways.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants in our study listed several advantages and disadvantages that parallel findings elsewhere. On the plus side, many cited greater understanding and the ability to \u0026ldquo;test\u0026rdquo; the relationship as key benefits. This is consistent with large surveys of Chinese youth in which roughly two-thirds viewed cohabitation as a good way to test compatibility (Yu \u0026amp; Xie, 2022). On the other hand, some disadvantages were noted. In particular, female students emphasized potential harms. They noted that premarital cohabitation increases the chance of an unintended pregnancy. Under social pressure to avoid single motherhood, young women often feel forced to terminate such pregnancies. Participants were acutely aware that abortion can harm the body, and Chinese data support their fears: women who undergo abortion frequently experience medical complications and report high levels of stress and depression\u0026nbsp;(Wang et al., 2022).\u003c/p\u003e\n\u003cp\u003eMoreover, the social stigma of premarital pregnancy compounds these harms. Many young women worried about the possibility that cohabitation might undermine their future marriage prospects or lead to a loss of status. This gendered view aligns with the literature, indicating that Chinese women often see cohabitation as \u0026ldquo;risk-amplifying\u0026rdquo; due to the lack of legal protections, whereas men may see it as \u0026ldquo;risk-reducing\u0026rdquo; by avoiding premature marriage (Yu, 2021). In short, while both genders acknowledge the practical benefits of living together, women in Macau approach cohabitation with greater caution due to persisting social expectations and biological risks, a disparity that underscores unmet public health needs for gender-based health protection in non-marital intimate relationships.\u003c/p\u003e\n\u003cp\u003eOur findings also reveal gender dynamics within cohabiting relationships. Many female partners insisted on splitting living costs equally, signaling their pursuit of financial and personal equality in the relationship. This reflects an increasingly egalitarian attitude among young women in Chinese cultures (Song \u0026amp; Lai, 2020). Men, for their part, often expressed a desire to maintain a provider role or display traditional masculinity(Oliffe et al., 2024), but overall, most couples negotiated fairly even financial sharing. This combination \u0026ndash; women asserting equality while men still valuing traditional roles \u0026ndash; echoes broader patterns where cohabiting couples hold more gender-egalitarian views than older generations, even if some traditional expectations persist (Patterson, 2023).For public health practice, this shifting gender dynamic creates a critical window to intervene and promote equitable health norms in intimate relationships, before rigid gendered health behaviors become entrenched.\u003c/p\u003e\n\u003cp\u003eTaken together, the study results suggest a blending of traditional values and Westernized behaviors among young people in Macau. Although earlier studies reported that approximately two-thirds of Chinese students anticipated parental disapproval of premarital cohabitation (Raymo et al., 2015), no explicit parental opposition was observed in the present study, suggesting that the older generation may also be adapting to these changing norms. Moreover, increasingly open societal attitudes toward premarital cohabitation and the rising prevalence of cohabitation among younger generations may reinforce one another. Consistent with this interpretation, previous research has shown that more liberal societal attitudes are commonly found in contexts where premarital cohabitation is more prevalent (Sassler \u0026amp; Lichter, 2020). Previous research has consistently shown that acceptance of premarital cohabitation is higher in metropolitan areas and among individuals with higher levels of education, where exposure to global cultural norms is more pronounced (Yu \u0026amp; Xie, 2022). The Macau findings, therefore, have relevance beyond the local context, offering insight into how young adults in culturally hybrid societies negotiate intimacy, commitment, and risk\u0026ndash;and highlighting the need for context-specific public health interventions to address the unique needs of this population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublic Health Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAgainst the backdrop of rapidly rising acceptance of premarital cohabitation among Macau\u0026rsquo;s young adults and persistent gendered health disparities identified in this study, the findings carry meaningful public health implications for Macau and other culturally hybrid East Asian urban regions facing similar shifts in intimate relationship norms. These implications are grounded in the specific perceptions and concerns of the study participants\u0026mdash;notably female students\u0026rsquo; acute anxiety around unintended pregnancy, abortion-related health harms, and the lack of legal and social protection for cohabitation-related adverse outcomes\u0026mdash;and align with the need to translate evolving social norms into equitable and context-responsive public health practice.\u003c/p\u003e\n\u003cp\u003eThe pervasive gendered health risk concerns highlighted in this study warrant the integration of cohabitation-specific reproductive health content into mandatory youth health literacy curricula in Macau\u0026rsquo;s higher education institutions and community-based public health programs. Given that 100% of female interview participants raised fears of unintended pregnancy and its physical and psychological sequelae, such education should center on evidence-based, accessible contraceptive guidance and clear communication about the short- and long-term health impacts of induced abortion, with gender-tailored outreach that addresses the unique vulnerability of young women in cohabiting relationships. Complementarily, curricula should address the gap in health education around non-marital intimate relationship safety, including training on recognizing and responding to domestic violence in cohabitation\u0026mdash;a harm participants identified as unaddressed by existing support systems. This targeted education is critical to equipping young adults with the health literacy to navigate cohabitation responsibly, and to mitigating the avoidable health risks that persist despite growing societal acceptance of cohabitation.\u003c/p\u003e\n\u003cp\u003eThe study\u0026rsquo;s findings also highlight the need for expanding public health service coverage and legal safeguards to address the gendered health inequities of cohabitation in Macau. Participants repeatedly noted the legal vacuum surrounding cohabitation-related health harms, from unprotected domestic violence to the social and health consequences of premarital pregnancy, which disproportionately disadvantages women. This points to a critical action for Macau\u0026rsquo;s public health and policy sectors: establishing free, confidential reproductive health consultation services for young cohabiting adults, and developing specialized psychological counseling for individuals experiencing abortion-related distress\u0026mdash;services that are currently lacking for non-marital intimate relationships. Additionally, there is a need to create dedicated reporting and support channels for cohabitation-related domestic violence, and to revise existing social policies to fill legal gaps that leave cohabiting women without formal protection. These steps would directly address the core health equity concerns raised by study participants, and reduce the \u0026ldquo;risk-amplifying\u0026rdquo; nature of cohabitation for women in Macau.\u003c/p\u003e\n\u003cp\u003eMacau\u0026rsquo;s unique Sino-Western cultural integration, a central contextual feature of this study, underscores the importance of culturally adapted public health interventions for premarital cohabitation, rather than the uncritical adoption of Western or mainland Chinese models. Participants framed cohabitation as a precursor to marriage\u0026mdash;rather than an alternative\u0026mdash;reflecting a blend of traditional marital values and modern egalitarian norms, and this framing should guide community-based health promotion campaigns. Such campaigns should aim to reduce the social stigma associated with premarital cohabitation and its related reproductive health issues, a stigma that participants noted deters young women from seeking timely health care. Framing cohabitation health protection as a component of \u0026ldquo;responsible intimate relationship behavior\u0026rdquo; aligns with the study\u0026rsquo;s finding that young adults in Macau approach cohabitation as a step toward committed marriage, and would make public health outreach more resonant with local cultural norms.\u003c/p\u003e\n\u003cp\u003eFinally, this 20-year longitudinal qualitative study points to the value of establishing a long-term public health monitoring system for young adults\u0026rsquo; cohabitation attitudes and associated reproductive health outcomes in Macau. The dramatic attitudinal shift observed over the study period\u0026mdash;from 23% to nearly 90% acceptance of cohabitation\u0026mdash;demonstrates that social norms around intimate relationships are evolving rapidly, and public health policies need dynamic data to remain responsive. This monitoring system should collect disaggregated data on gendered health risks in cohabiting relationships (e.g., unintended pregnancy rates, abortion-related health complications) across different educational, occupational, and age groups of young adults, moving beyond the nursing student population of this study to capture the broader diversity of Macau\u0026rsquo;s youth. This data would provide an evidence base for ongoing adjustment of public health interventions, and support the design of universal health services that address the cohabitation-related health needs of all young adults in Macau. Concurrently, expanding public health research on cohabitation to include non-health major students and working young adults would address the sample limitations of the present study, and ensure that interventions are equitable and generalizable to the broader population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations of this study should be acknowledged. First, the data were drawn from students at a single nursing school in Macau, which may limit the generalizability of the findings to other educational institutions or student populations. In addition, the participant cohort reflected a gender imbalance, with female students disproportionately represented, which may have influenced the perspectives captured, particularly regarding gendered experiences of premarital cohabitation. Second, although this was a repeated study spanning more than two decades, data collection was interrupted for several years due to curriculum changes and the COVID-19 pandemic. These gaps may have affected the continuity of trend analysis across the full study period. Third, the qualitative interviews were conducted only in 2025. As a result, the interview findings may not fully capture or contextualize attitudes expressed in earlier survey cohorts. While the interviews provided in-depth insight into contemporary perspectives, they cannot retrospectively represent experiences or interpretations from previous periods.\u003c/p\u003e\n\u003cp\u003eFuture research could address these limitations by extending qualitative interviews across multiple time points alongside ongoing survey data collection. Intentionally recruiting a larger number of participants with premarital cohabitation experience would further enrich the understanding of lived experiences and decision-making processes. Expanding the study to include students from diverse institutions and academic disciplines would also enhance the transferability of the findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePremarital cohabitation has become widely accepted among younger generations in Macau, reflecting trends observed among highly educated youth in modern urban societies. The primary motivations identified in this study highlight the role of cohabitation as a form of \u0026ldquo;trial marriage\u0026rdquo; in a context of ongoing cultural change. At the same time, students remain attentive to the gendered dimensions of cohabitation. By documenting the conditions, rationales, and constraints articulated by students, this study provides in-depth insight into the psychological and social processes underlying decisions about premarital cohabitation. Future research should continue to monitor these trends and examine their implications for marriage patterns, gender relations, and family dynamics in Macau and comparable societies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of Kiang Wu Nursing College of Macau (Ref: REC-2024.0708). The study conforms to the provisions of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent to participate was obtained in writing from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Foundation of Macau [Ref:0597/DGAF/2025-06].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAimei MAO\u003c/strong\u003e: Conceptualization; Data curation; Investigation; Writing \u0026ndash; original draft; Supervision; Methodology; Software; Formal analysis; Writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUhin CHEANG\u003c/strong\u003e: Investigation; Software; Writing \u0026ndash; review and editing\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJiaxi XU\u003c/strong\u003e: \u0026nbsp;Data curation; Investigation; Software; Writing \u0026ndash; review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCheng, Y.-h. A. (2023). The changing face of intimate premarital relationships in Taiwan. \u003cem\u003eJournal of Marriage and Family\u003c/em\u003e,\u003cem\u003e 85\u003c/em\u003e(4), 987\u0026ndash;1001. https://doi.org/10.1111/jomf.12915 \u003c/li\u003e\n\u003cli\u003eManning, W. D., Westrick-Payne, K. K., \u0026amp; Gates, G. J. (2022). Cohabitation and Marriage Among Same-Sex Couples in the 2019 ACS and CPS: A Research Note. \u003cem\u003eDemography\u003c/em\u003e,\u003cem\u003e 59\u003c/em\u003e(5), 1595\u0026ndash;1605. https://doi.org/10.1215/00703370-10181474 \u003c/li\u003e\n\u003cli\u003eOliffe, J., Gao, N., Kelly, M., Shim, A., Yap, C., Sharp, P., \u0026amp; McKenzie, S. (2024). Picture this: Men building intimate partner relationships. \u003cem\u003eHealth Education Journal\u003c/em\u003e,\u003cem\u003e 84\u003c/em\u003e. https://doi.org/10.1177/00178969241281157 \u003c/li\u003e\n\u003cli\u003ePatterson, S. E. (2023). Cohabiting Adult Children\u0026apos;s Transfers to Parents in the United States. \u003cem\u003eJ Marriage Fam\u003c/em\u003e,\u003cem\u003e 85\u003c/em\u003e(1), 321\u0026ndash;336. https://doi.org/10.1111/jomf.12879 \u003c/li\u003e\n\u003cli\u003eRaymo, J. M., \u0026amp; Park, H. (2020). Marriage Decline in Korea: Changing Composition of the Domestic Marriage Market and Growth in International Marriage. \u003cem\u003eDemography\u003c/em\u003e,\u003cem\u003e 57\u003c/em\u003e(1), 171\u0026ndash;194. https://doi.org/10.1007/s13524-019-00844-9 \u003c/li\u003e\n\u003cli\u003eRaymo, J. M., Park, H., Xie, Y., \u0026amp; Yeung, W. J. (2015). Marriage and Family in East Asia: Continuity and Change. \u003cem\u003eAnnu Rev Sociol\u003c/em\u003e,\u003cem\u003e 41\u003c/em\u003e, 471\u0026ndash;492. https://doi.org/10.1146/annurev-soc-073014-112428 \u003c/li\u003e\n\u003cli\u003eSassler, S., \u0026amp; Lichter, D. T. (2020). Cohabitation and marriage: Complexity and diversity in union‐formation patterns. \u003cem\u003eJournal of Marriage and Family\u003c/em\u003e,\u003cem\u003e 82\u003c/em\u003e(1), 35\u0026ndash;61. https://doi.org/10.1111/jomf.12617 \u003c/li\u003e\n\u003cli\u003eSaunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., \u0026amp; Jinks, C. (2018). Saturation in qualitative research: exploring its conceptualization and operationalization. \u003cem\u003eQual Quant\u003c/em\u003e,\u003cem\u003e 52\u003c/em\u003e(4), 1893\u0026ndash;1907. https://doi.org/10.1007/s11135-017-0574-8 \u003c/li\u003e\n\u003cli\u003eSong, J., \u0026amp; Lai, W. (2020). Cohabitation and Gender Equality: Ideal and Real Division of Household Labor among Chinese Youth. \u003cem\u003eThe China Review: An Interdisciplinary Journal on Greater China\u003c/em\u003e,\u003cem\u003e 20\u003c/em\u003e(2), 53\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eWang, N., Zhu, X., Gamble, J., Elder, E., Allen, J., \u0026amp; Creedy, D. K. (2022). The STress-And-Coping suppoRT Intervention (START) for Chinese Women Undergoing Abortion: A Randomized Controlled Trial Protocol. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e,\u003cem\u003e 19\u003c/em\u003e(11). https://doi.org/10.3390/ijerph19116611 \u003c/li\u003e\n\u003cli\u003eWilloughby, B. J., \u0026amp; James, S. L. (2017). \u003cem\u003eThe Marriage Paradox: Why Emerging Adults Love Marriage Yet Push it Aside\u003c/em\u003e. Oxford University Press. https://doi.org/10.1093/acprof:oso/9780190296650.001.0001 \u003c/li\u003e\n\u003cli\u003eYu, J. (2021). Union formation and childbearing among Chinese youth: Trends and socioeconomic differentials. \u003cem\u003eChinese Journal of Sociology\u003c/em\u003e,\u003cem\u003e 7\u003c/em\u003e, 2057150X2110409. https://doi.org/10.1177/2057150X211040936 \u003c/li\u003e\n\u003cli\u003eYu, J., \u0026amp; Xie, Y. (2022). Is there a Chinese pattern of the second demographic transition? \u003cem\u003eChina Population and Development Studies\u003c/em\u003e,\u003cem\u003e 6\u003c/em\u003e(3), 237\u0026ndash;266. https://doi.org/10.1007/s42379-022-00113-0 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"premarital cohabitation, gender-based health disparities, reproductive health, adolescent health, Macau, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-9070712/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9070712/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThis study aimed to depict the 20-year trajectory of attitudes toward premarital cohabitation among college nursing students in Macau from 2004 to 2025 and explore their perceptions of cohabitation-related gendered health risks. Further, it intended to elucidate the public health implications of these attitudinal changes for adolescent reproductive health education and gender-based health equity in culturally hybrid urban regions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A mixed qualitative design was adopted, including a repeated cross-sectional open-ended survey (2004–2025, n=991, second-year nursing students, excluding 2018–2022) and semi-structured interviews (2025, n=26, purposive sampling). Content analysis was used for survey data to track attitudinal trends, and thematic analysis for interview data to explore cohabitation perceptions. Rigor was enhanced via prolonged engagement, member checking, triangulation, and an audit trail, with ethical approval (REC-2024.0708).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Positive attitudes toward cohabitation rose from 23% (2004) to nearly 90% (2024–2025). Cohabitation was perceived as a marriage precursor rather than an alternative, with female participants expressing predominant concerns about gendered health risks (unintended pregnancy, abortion-related physical/psychological harms, unprotected domestic violence). Egalitarian financial sharing was the mainstream view, with minor gender differences in cohabitation decision-making criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Premarital cohabitation is widely accepted by Macau’s young adults, reflecting westernized egalitarian trends, while gendered health risk concerns remain persistent. These findings provide critical qualitative evidence for public health interventions in Macau and comparable culturally hybrid regions, highlighting the need for targeted reproductive health education and enhanced gender-based health protection systems for young cohabiting adults.\u003c/p\u003e","manuscriptTitle":"Changing attitudes toward premarital cohabitation among college students: A multi-source qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-16 15:30:18","doi":"10.21203/rs.3.rs-9070712/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-08T13:19:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-19T12:02:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-19T07:53:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T07:52:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-09T08:42:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"46ad95e9-0c55-4304-80b4-556ae927e3d2","owner":[],"postedDate":"April 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-16T15:30:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-16 15:30:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9070712","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9070712","identity":"rs-9070712","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}