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

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.