Mahjong: A routine activity that has chronically harmed the health of land-lost peasants in Southwest China

Background: Mahjong is a four-player gambling game that originated in China. It is a very popular recreational hobby among land-lost Chinese peasants who have moved to the city due to urbanization. This study aims to identify the influencing factors of Mahjong playing behaviors and their effects on the health of land-lost peasants. Method: A cross-sectional study was conducted in two districts of Chongqing (Southwest China), which is the first pilot area of the urban–rural integration in China. Researchers recruited 539 land-lost peasants to implement a self-report questionnaire survey. Logistic regression was conducted to identify the key factors associated with Mahjong playing behaviors. Result: This study found that age is a crucial factor affecting the Mahjong playing behaviors of land-lost peasants. The middle-aged (30–49 years old) and elderly (>= 50 years old) are extremely prone to be problematic Mahjong players when compared with young people (18–29 years old). Moreover, people with a high monthly income are more likely to be problematic Mahjong players compared with those with a low monthly income. In addition, the high frequency of playing and long duration of sessions in the enclosed, smoky environment of Mahjong parlors introduce significant hazards to the health of land-lost peasants. However, Mahjong can help them build a social network, provide them with spiritual comfort, and ultimately integrate them into a new environment. Conclusion: Therefore, we call for measures that can make Mahjong an activity for entertainment rather than gambling and reduce the adverse effects of Mahjong playing behaviors on the players’ health. of the Mahjong playing behaviors in land-lost peasants by on Chongqing, Southwest China. The authors aim to provide a useful strategy for improving the health of land-lost peasants throughout China.

peasants are defined as individuals who have surrendered their land and moved into a city environment due to urbanization. Land-lost peasants account for a significant portion of the ruralurban migrant population. Chongqing has become the first pilot area for Chinese urban-rural integration. From 2012 to 2020, between 800,000 and 900,000 peasants a year are anticipated to become urban residents (Hong and Ling-yun, 2010). Up to 2015, approximately 277 million people had left their hometown in rural areas to seek job opportunities and pursue better lives in rapidly growing cities (Li and Rose, 2017;Zhong et al., 2018).
Although urbanization is a driving force behind economic and social developments, the process also brings a range of issues. Rural-urban migrants encounter more obstacles than urban residents. In such a large country with great variation in regional geography, culture, and lifestyles, China's internal migrants are likely to encounter diverse challenges in adapting to their new environments.
Epidemiological research has documented that migration and the urban city contribute to the risks of mental illness, associated with particular features of the urban environment or difficulties encountered in migration (Li and Rose, 2017). A study indicated that rural respondents suffered from a significantly higher risk of depression and took less social participation than their urban counterparts (Wang et al. 2019), that would be even worse when they enter a new environment. At the same time, another study also proposed a similar point of view that migrants endure rapid changes in their working and living conditions and weakened family support systems with fragile social support networks. These factors negatively affect their overall well-being (Li, 2013). In addition, rural-urban migration is considered to be a risk factor for chronic diseases. One Indian study has documented that rural-urban migrants have higher rates of obesity and diabetes than non-migrants (Ebrahim et al., 2010). Besides, the burden of cardiovascular (CV) disease is very high in China, due to highly prevalent and poorly controlled risk factors resulting from changing sociodemographic structure and lifestyles in its large population (Du et al. 2019). According to another study, between 2010 and 2030, Chinese urbanization is projected to raise the rates of age-standardized coronary heart diseases by 73-81 per 100,000 and increase the incidence of stroke from 790.1 to 801. 1-830.9 per 100,000 (Mou et al., 2013). Rural-urban migrants experience more mental health problems than urban residents.  Mahjong is not only a recreational game, but it has also made problem gambling popular in China.
The Mahjong playing behaviors of land-lost peasants in China have rarely been investigated. This cross-sectional study aims to identify the key factors of the Mahjong playing behaviors in land-lost peasants by focusing on Chongqing, Southwest China. The authors aim to provide a useful strategy for improving the health of land-lost peasants throughout China.

Study setting
A cross-sectional study was conducted in Shapingba and Bishan districts of Chongqing from July 15 to 26,2013. Two resettlement residential communities were randomly selected among 149 communities in the two districts. A resettlement residential community is a place where the government has built homes to address the housing issue of the land-lost peasants.

Study population
This study included land-lost peasants who were aged 18 years or older and living in the community.
Land-lost peasants are defined as those who have lost their land holdings according to the law within the last five years. The participants were recruited from the randomly selected communities using convenience sampling methods and required to complete a two-part questionnaire.

Self-completed questionnaire
The questionnaire is comprised of nine questions on background data, such as gender, age, and monthly income; 12 questions on Mahjong playing behaviors, including Mahjong playing frequency, bet for Mahjong gambling, smoking situation, and impact of playing Mahjong (positive and negative effects); and 11 questions on health conditions. The questionnaire survey was conducted in the parks or squares of resettlement residential areas, where land-lost peasants often gather together. The participants completed a paper survey after being interviewed by the researchers. Upon completion of the investigation, each participant was provided with a small gift as an incentive. A pilot study was conducted prior to the survey to test and refine the questionnaire.

Quality assurance
The questionnaire was developed through a comprehensive literature review and refined after the pilot study. The investigators were experienced in the related research fields and received professional training (including training on investigational methods and quality control measures) prior to participating in this study. To ensure high-quality data collection, the research team examined the questionnaires daily during the whole study period to correct any logical mistakes and to doublecheck the transcriptions of the data through EpiData 3.0.

Definition of occasional and problematic player
In accordance with the data on Mahjong playing behaviors derived from the self-completed questionnaires, the participants in this study were classified into three categories. "Non-players" refer to those who do not play Mahjong at all. "Occasional players" have all the following characteristics: Mahjong playing frequency is less than three times a week, duration of each time is less than six hours, have not been quarreling with family members due to Mahjong, and betting is less than 10 RMB. "Problematic players" have one of the following characteristics: Mahjong frequency is more than three times a week, duration of each time is more than six hours; have been quarreling with family members due to Mahjong, and betting is more than 10 RMB. The problematic players are more likely to suffer some adverse effects due to Mahjong. Sex, age, current marital status, highest educational attainment, and monthly income were also included in the analysis.

Data analysis
The questionnaires were transcribed using EpiData 3.0, and data analysis was carried out using Stata (version 13, StataCorp, College Station, TX). Chi-square tests were used to compare differences in the categorical variables. The association between sociodemographic factors and Mahjong playing status was analyzed using logistic regression models or multinominal logistic regression depending on the outcome variables (binary or more than binary), adjusting for multiple covariates. The multivariable models controlled for gender, age (continuous), education, marriage, and income.

Ethical approval
The study was reviewed and approved by the Institutional Review Board of Chongqing Medical University. All participants provided verbal consent, participating in this study was associated with minimal risk, and non-biological samples were collected.   Table 3 Sociodemographic factors associated with mahjong play status (reference: none player); relative risk ratios and 95% CI in unadjusted and adjusted using multinominal logistic regression.

Mahjong playing behaviors
As shown in Considering that this research uses a convenient sampling method, these frequency results are not representative of the whole land-lost peasants and may reflect some problems.

Influencing factors of Mahjong playing behaviors
As shown in Table 3 between "junior and senior" and lower education, the interaction between education and Mahjong playing behaviors failed to reach a significance level (p=0.073). In this study, "junior and senior" refers to junior high school and high school. Gender and marital status are not statistically significant in this study.

Discussion
We have several interesting findings on the sociodemographic factors affecting Mahjong playing behaviors. One of the most important conclusions is that the age of land-lost peasants has a significant association with Mahjong playing behaviors. The results show that the middle-aged and elderly are extremely prone to be problematic Mahjong players when compared with young people The middle-aged are usually the economic cornerstones of the family, especially for land-lost peasants. Thus, they are under great pressure to support their families due to urbanization. Their Mahjong bet is also bigger than that of the younger and older players. This finding may indicate that the middle-aged participants regard Mahjong as a gambling project, and they want to win money or chase losses instead of playing just for entertainment. Our study also found that the bet level had a significant positive association with family disputes possibly because individuals who become addicted to Mahjong may neglect their responsibilities to school, work, childrearing, and family commitments (Blaszczynski et al., 1998;Zheng et al., 2010). Hence, a middle-aged player becoming addicted to Mahjong will cause a family crisis as he does not work hard and even loses money because of gambling (Subramaniam et al. 2017). At the same time, a study in Singapore  reported that middle-aged people has significantly high rates of pathological gambling. The analysis results in our study show that land-lost peasants who play Mahjong with high stakes are likely to play for a long duration and the frequency of Mahjong is positively correlated with the stake, which suggests a pathological addiction to Mahjong in this population. This result may be the case because the winner wants to win more, whereas the loser does not want to lose in gambling. This finding also reminds us that we should be aware of the Mahjong gambling problem in this population.
Our survey found that people with high monthly incomes are more likely to be problematic Mahjong players compared with those with low monthly incomes. This finding may be attributed to the fact that they have more free time and experience less pressure to support their families. On the contrary, Mahjong participants with low monthly incomes have to face the pressure of supporting their families and are likely to quarrel with their family if they ignore this responsibility, so they do not have the time to play Mahjong. Moreover, those with a high monthly income may play Mahjong in a "small" bet and just play for entertainment. However, in the context of this study, the bet of those with a high monthly income was considered "large". Such inconsistency is also a flaw in this research. In any case, monthly income affects land-lost peasants' Mahjong playing behaviors, and the association between monthly income and Mahjong playing behaviors need further exploration. also argues that Mahjong participation can increase an elderly player's blood pressure and heart rate. Participants can reduce their playing duration and take enough breaks to help avoid being sedentary.
In addition, the Mahjong room can post a "no smoking" notice, which has been confirmed effective in reducing smoking rates(Jin-xiang et al., 2012), and add a ventilation system. Lastly, the stakes can be regulated as it has a significant positive association with Mahjong playing duration. Controlling the stake can help decrease the risk of Mahjong gambling problems.

Limitations
This study still have several potential limitations. First, only 539 participants were investigated out of the large number of land-lost peasants. Second, the participants were recruited by convenience sampling and represented mainly the middle-aged and elderly of the community. Thus, the data may be subject to selection bias. Third, the self-report questionnaire lacks validity and reliability analysis, which limit the in-depth understanding of Mahjong playing behaviors. Fourth, this research work is a cross-sectional study that cannot confirm the causal relationship between Mahjong playing behavior and the related variables.

Conclusion
As most land-lost peasants were middle-aged, had a lower educational level, and had to care for family members on a tight income, this population group seemed to face more substantial challenges in life than the urban residents. Mahjong participation carries potential risks to the players' health and may have significant negative effects on their lives. We have discovered that age and monthly income are crucial factors affecting the Mahjong playing behaviors of land-lost peasants. In addition, although playing Mahjong is harmful to health, it can help immigrants adapt to the new environment.
This study represents one of the first efforts to examine the relationship between Mahjong playing behaviors and health among land-lost peasants in China. When properly utilized, the results from this study may help promote the integration of land-lost peasants into the urban environment and improve their health conditions.