Sexual Expressions in Jamaica

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Sexual Expressions in Jamaica evaluates particular reproductive health matters in Jamaica. All the chapters are cogently selected in keeping with the general purpose of a comprehensive proposition to forward an understanding of sexual expressions of Jamaicans aged 15-49 years old. Sex education in Jamaica has been, for years, seeking to address lowered aged of sexual debut to no avail, and the consequences of this reality is such that they open socioeconomic challenges for the populace. The sexual expressions of youth may result in cervical cancers, teenage pregnancies and STIs, and these tabs must be borne by the society. It is not the resultant cost of the health and reproductive health matters that is of concern in this book, but the sexual expressions of Jamaicans aged 15-49 years. Many of the sexual expressions that are enlisted in this book are placed herein because they contribute to the broad-spectrum in understanding Jamaicans’ sexual choices, by forwarding peoples’ perspectives these will allow policy makers a better understanding of those issues from the vantage point of the target population and thereby policies can be institute to address particular issues from a research focus

By Dr. Paul A. Bourne

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Sexual Expressions in Jamaica

  1. 1. 1 Chapter 1 Sociodemographic correlates of age at sexual debut among women of the reproductive years in a middle-income developing nation Paul A. Bourne Introduction In 1997, statistics revealed that the median age at first sexual intercourse for Jamaican women was 17.3 years and this fell to 16.0 years in 2002.1 Embedded in this finding is the lowering of premarital sexual relations with the passing of time, and the reproductive health problems associated with early sexual debut among women aged 15-49 years. Early sexual debut poses both health (STIs, HIV, HPV, pregnancy) and social (school drop-outs) risks, and continues to be a public health concern among several nations.1 Inconsistent contraceptive use coupled with the continuous lowering of the age of sexual relations offers an explanation of the failure of public health programmes to effectively address sexual behaviour of females in many developing countries, particularly in Jamaica. This is embedded in statistics which showed that only 43.3% of Jamaican women aged 15-19 years old and about 66% of women aged 15-49 years reported using a condom in the last 30 days1 , indicating not only premarital sexual relations, but also risky lifestyle practices and the likely to the spread of HIV/AIDS and other sexually transmitted infections.1 The lowering of the age at sexual debut further goes beyond unwanted pregnancies to health problems such as cervical cancers, human papillomavirus (HPV) and genital or anal ulceration, unsafe abortions, psychological trauma and the socioeconomic challenges for the society in the future, which makes it a public health problem worth studying.
  2. 2. 2 Almost 2 in every 5 Jamaican women have been pregnant at least once prior to reaching the age of 20; most of pregnancies are unplanned, especially during the adolescent years (80%). 1 The average age at first sexual initiation in Jamaica is 15.8 for females and 13.5 for males,1 much of which is forced and is seen as a direct link with violence, as well as one of the roots of sexual and reproductive health problems in the international community.2 Such problem goes against the principles of the ICPD 1994, which stipulates that when it comes to matters of sexual relations, full respect for the integrity of the individuals involved should be of the utmost.2 “First sexual intercourse almost always take place outside of a formal union”3 and with older men (for the females) 4 , this occurrence is likely to result in health situations relating to STIs and HIV, as well as drug abuse.5 Inspite of the reality of the lowering of age at first sexual debut, particularly with regard to premarital sex of adolescents, the developing societies, in particular Jamaica, do not frown upon this practice.6,7 Although teenage fertility is not actively condoned in the Caribbean,6 the churches and family planning interventions have been actively campaigning against this practice as well as early sexual debut, but the practice continues. Early sexual debut, inconsistent condom usage and teenage pregnancy are not atypical in the developing world, more specifically Jamaica. A study of some sub-Saharan African and South-East Asian nations show similar sexual behaviour and attitude of young people.8 According to Warren et al.,9 the high fertility population in Jamaica was women ages 14-24 years, indicating a high degree of premarital sexual activities and inconsistent condom use within the context of reduced age at first sexual intercourse.10 A study by Henry-Lee11 showed that 66% of Jamaican women used contraceptives, but only 34% of pregnancies were planned indicating that inconsistent contraceptive use is
  3. 3. 3 accounting for increased HIV/AIDS and STIs in Jamaica and on a wider scale in other developing countries, as young adults are engaged in risky sexual practices.12,13 In Antigua and Barbuda, Haiti, Guyana, Trinidad and Tobago and Dominica Republic, one in six women between the ages of 15 and 24 became sexually active before the age of 15 years.14, 15 According to Crawford, McGrowder and Crawford, 16 2 in every 5 Jamaican women have been pregnant at least once, 4 in every 5 adolescent women pregnancies were unplanned and 74% of females ages 15-17 years old were sexually active compared to 47% of males of the same age. Moreover, Crawford and colleagues found that of the sample of adolescents, none of the females were having sexual intercourse with males within their age cohort compared to 39% of adolescent males.16 Ninety-five percentages of adolescent females’ sexual partners were 17+ years old compared to 78.2% of adolescent males. It can be extrapolated from the afore- mentioned findings that premarital sexual relations are on the rise in developing nations, in particular Jamaica, and the lowering of age at first sexual intercourse among young women in the developing world is a public health concern. In a study which looks at sexual initiation of persons within the age range of 15-44 years, it was seen that protestants (similar to those of non-religion) were more likely to have their first sexual initiation within their 16th year, when compared to the Catholics (within their 17th year) and those of other religion (18th year).4 In addition to the factor of religion, the said study pointed out that young individuals who resided with both parents encountered sexual initiation later than those in other family situations.4 Another study conducted by Fatusi & Blum,17 using a sample of 2,070 adolescents who were never married, found that condom efficacy, positive attitude to family planning use, condom access, alcohol use, and higher level of religiosity were associated with age at first sexual debut. Fatusi & Blum’s work concurs with some of the findings of an
  4. 4. 4 earlier study, which found self-efficacy, alcohol and drug use, norms about having sexual intercourse, poor academic performance and gender to be factors that explain sexual initiation among middle-school, inner city youth.18 Penfold et al., 19 using a sample of 4,379 Scottish adolescents, found that family (parental monitoring), school life (enjoyment), gender, self- esteem, religion, and informal sexual health intervention were associated with self-reported first sexual intercourse. Penfold et al.’s work added more variables to the existing body of literature on age at first sexual debut. Rosenthal et al.20 added to the afore-mentioned factors which are also associated with age at first sexual initiation. They found that the perception of greater physical maturity, expectations of earlier autonomy among gender, and the use of illicit drugs to be statistically associated with age at first sexual debut among high schoolers. Inspite of the lowering of age at first sexual relations and statistics showing that HIV, and other malignant neoplasm are among the 10 leading causes of mortality among Jamaican women; 21 as well as the direct association between early age of sexual debut, the increased risk of cervical cancers, 22 the relationship between cervical cancer and STI, in particular human papillomavirus (HPV), and age at first sexual debut23-25. The issue of factors explaining age at first sexual initiation is unresearched in Jamaica. Most studies that have examined factors associated with age at first sexual intercourse have used young people between ages 10-30 years. In this study, we seek to elucidate correlates which account for age at sexual debut of women aged 15-49 years in Jamaica. This study is not far fetched as a previous study in Europe used ages 16-44 years.26 The main objective of this paper was to elucidate the socioeconomic variables which explain age at first sexual initiation of Jamaican women (ages 15-49 years). It explored variables relating to early sexual debut such as age of menarche, contraception, religion, education, crowding, shared sanitary convenience,
  5. 5. 5 forced sexual experience, marital status, employment status, subjective social class, and area of residence among women in the reproductive years. Methods Sample This descriptive cross-sectional study used a secondary dataset from the National Family Planning Board (Reproductive Health Survey, RHS). There are two sets of inclusion criteria, which are females and ages. The eligibility criterion for age was 15 to 49 years at last birthday. Since 1997, the National Family Planning Board (NFPB) has been collecting information on women (aged 15-49 years) in Jamaica regarding contraception usage and/or reproductive health. In 2002, the Reproductive Health Survey (RHS) collected data on Jamaican men ages 15-24 years as well as women 15-49 years old. The current study extracted only females aged 15-49 years from 2002 Reproductive Health Survey to carry out this research. The study population was 7,168 women of the reproductive ages. Stratified random sampling was used to design the sampling frame from which the sample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage sampling design was used. Stage 1 was the use of a selection frame of 659 enumeration areas (or enumeration districts, EDs). This was calculated based on probability proportion to size. Jamaica is classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomas and St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up of Trelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchester and Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica compared to Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8%.1
  6. 6. 6 In stage 2, the households were clustered into primary sampling units (PSUs), and each PSU constituted an ED, which in turn was comprised of 80 households. The previous sampling frame was in need of updating, and so this was performed between January and May 2002. The previous sampling frame was in need of updating, and so this was carried out between January 2002 and May 2002. The new sampling frame formed the basis upon which the sampling size was computed for the interviewers to use. Stage 3 was the final selection of one eligible female from each sampled household and this was done by the interviewer on visiting the household. The Statistical Institute of Jamaica (STATIN) provided the interviewers and supervisors, who were trained by McFarlane Consultancy, to carry out the survey. The instrument administered was a 35-page questionnaire. The data collection began on Saturday, October 26, 2002 and was completed on May 9, 2003. Prior to the date of the final data collection, pre-testing of the instrument was conducted between March 16 and 20, 2002. A total of 175 instruments were pre-tested.. Modifications were made to the pre-tested instrument (questionnaire), after which the final exercise was carried out. Validity and reliability of the data were conducted by many statisticians, statistical agency, and university scholars before the data was used as the data are for national policy planning. After which it was released to the University of the West Indies, Mona, Data Bank for use by scholars. The data was weighted in order to represent the population of female aged 15 to 49 years in the nation.1 Statistical analyses Data were entered, stored and retrieved using SPSS for Window, Version 16.0 (SPSS Inc; Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographic characteristics of the sample (frequency, mean, standard deviation (SD), and range). All metric
  7. 7. 7 variables were tested for normality (age at first sexual debut, crowding, age, and years of schooling). Where skewness was found to be less than 0.5, the variable was used in its current form and a value more than 0.5 was normalized by natural log, or another method. Independent sample t-test was used to examine differences in age at sexual debut between those who frequently attend churches and those who infrequently visit churches and F-statistic was employed for age of respondents by age at sexual debut. Finally, ordinary least square (OLS) regression was used to fit the data because the dependent variable (age at sexual debut) was a continuous one. Stepwise multiple linear regression was used to fit the one outcome measure (age at first sexual debut) by different sociodemographic variables. Thus, only explanatory variables (i.e. statistically significant variables) are shown in Table 1.3. Where collinearity existed (r > 0.7), variables were entered independently into the model to determine those that should be retained during the final model construction.27 To derive accurate tests of statistical significance, we used SUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), and this adjusted for the survey’s complex sampling design. A p-value < 0.05 (two-tailed) was used to establish statistical significance. Measures Age at first sexual debut (or initiation or intercourse) was measured based on a respondent’s answer to the question “At what age did you have your first intercourse? Crowding is the total number of persons in a dwelling (excluding kitchen, bathroom and verandah). Age is the number of years a person is alive up to his/her last birthday (in years). Contraceptive method comes from the question “Are you and your partner currently using a method of contraception? …”, and if the answer is yes “Which method of contraception do you use?” Age at which began using contraception was taken from “How old were you when you first used contraception? Area of
  8. 8. 8 residence is measured from “In which area do you reside?” The options were rural, semi-urban and urban (1 = rural, 0 = otherwise; 1 = semi-urban, 0 = otherwise, and urban is the reference group). Currently having sex is measured from “Have you had sexual intercourse in the last 30 days?” (1=yes, 0 = otherwise). Education is measured from the question “How many years did you attend school?” Marital status is measured from the following question “Are you legally married now?”, “Are you living with a common-law partner now? (that is, are you living as man and wife now with a partner to whom you are not legally married?)”, “Do you have a visiting partner, that is, a more or less steady partner with whom you have sexual relations?”, and “Are you currently single?” Age at menarche is measured from “How old were you when your first period started (first started menstruation)?” Gynaecological examination is taken from “Have you ever had a gynaecological examination?” (1 = yes, 0 = no). Pregnancy was assessed by “Are you pregnant now?” (1=yes, 0 = otherwise or no). Religiosity was evaluated from the question “With what frequency do you attend religious services?” The options range from at least once per week to only on special occasions (such as weddings, funerals, christenings et cetera) (1=frequent attendance from response of at least once per week, 0 = otherwise). Subjective social class is measured from “In which class do you belong?” The options are lower, middle or upper social hierarchy (1 = middle class, 0 = otherwise; 1 = upper class, 0 = otherwise; reference group is lower class). Forced to have sexual relations was assessed from the question “Were you forced to have sex at your first intercourse?” and the options were yes, no, don’t know and refused to answer (1= yes, 0 = otherwise). Age at first sexual debut, age at menarche, age at first contraceptive use, and years of schooling were used as continuous variables. Early sexual debut is having sexual intercourse before the statutory legal age to do so (in Jamaica, this is 16 years old).
  9. 9. 9 Result Table 1.1 presents the demographic characteristics of the sample, which comprises 7,168 respondents (women who are ages 15-49 years at their last birthday). Most of the women in the survey have been pregnant (84.3%) prior to this study and (4.4%) were pregnant at the time of the study. Only 40.6% of the sample indicated that they had wanted to become pregnant, when they realized they were. The mean age of menarche was 13.5 years (SD = 4.4 years), with the median age of first sexual relations being 16.0 years (Range = 36 years). The mean age at which the sample began using a contraceptive method was 19.8 years (SD = 4.3 years). Twenty-five percentages of women began having sex at 15 years, fifty percentages at 16 years and seventy- five percentages at 18 years. One-half of the sample indicated that they began learning about sex education at 13.0 years (Range: 10, 29 years). The mean age for those who had their first sexual intercourse was 15.2 years (SD = 5.9). One-half of the sample stated that they were dating their partners for 2 years (Range: 0, 15 years) prior to their first sexual encounter. Almost 38% of the sample attended church at least once per week; 19% at least once per month and 7.3% attended church even on special occasions such as christening, wedding, funerals or graduation. Eight-four percent (84%) of those who were married were living with their husbands at the time of this study, five percent (5%) of those who have been pregnant had still births, 12.1% had miscarriages, and 11.4% have been forced to have sexual relations with another person. Fifty-six percentages of the respondents are currently using a contraceptive to prevent pregnancy. The study also shows that the condom was the most prevalent contraceptive method (40.5%) among the respondents. This result was followed by the pill (32.9%), tubal ligation (23.8%) and injection (22.9%).
  10. 10. 10 Figure 1.1 provides information on the relations between the respondents and the persons with whom they (respondents) had her first sexual encounter. Majority of the sample indicated that they used a contraceptive method on their first sexual relations (64.1%). These methods include the condom (95.1%); rhythm or knaus-ogino method (2.3%); pill (1.9%); injection and intra-uterine device (0.1%) each. Two percent of the sample who had an abortion did so once (13.6%), twice (2.4%), thrice (0.8%) and four times (0.0%). The reasons given for the abortion were risk to mother’s health (22.5%); risk of birth defects (2.9%); financial challenges (29.4%); unwanted pregnancy by mother (12.7%); unwanted pregnancy by partner (4.9%); the absence of a partner (2.0%) and other issues (22.5%). Thirty-five percentage of the respondents indicated that they became pregnant while attending school, of which 28.3% continued their education after the birth of their child. When the respondents were asked ‘How many weeks after _________ birth of [last child] did you resume sexual relations?, 25% of them said 2 weeks, 50% indicated 3 weeks and 75% claimed at most 14 weeks. Two-thirds of the sample used private health care facilities (private clinician, 64.6%; private hospitals, 0.7% and private clinics, 1.3%) when compared with 31.1% of those who used public/government facilities (public hospitals, 8.9%; government clinics, 22.2%). Frequent attendees to church begin having sexual relations on average (mean) at 17.4 years (SD = 3.2) compared to 16.4 years (SD = 2.4 years) for non-frequent attendees – t-test = - 12.6, P < 0.0001. A significant statistical difference emerged among age at sexual relations of residence of particular geographical areas (F-statistic = 32.4, P < 0.0001). On average rural women began having sexual intercourse at 16.5 years (SD = 2.6 years) compared to 1.7 years (should this be
  11. 11. 11 17.4 years or another year) (SD = 2.9 years) for residence of semi-urban areas and 17.2 years (SD = 3.0) for those in urban zones. Table 1.2 shows information on the age of the respondents and age at sexual debut. Statistical difference was found among the age of respondents and age at sexual debut of the studied population (F statistic = 47.3, P < 0.0001). Table 1.3 examines factors that are associated with the age of first sexual relations of women ages 15 to 49 years in Jamaica. Using multiple regressions analyses, of the 17 variables that were tested in the model, 11 variables emerged as statistically significant predictors of age of first sexual relations (F-statistic [11, 5720] = 176.2, P-value < 0.0001). The factors explained 27.8% of the variability in age of first sexual relations. Discussion The sociodemographic related evidence of early sexual initiation has been put forward in this study and shows consonance with the literature. It is realized that sexual intercourse at an early age is usually by someone older and who is outside of a union. The risk associated with this factor is that “older male partner presents a greater HIV transmission risk because they are more likely than adolescent men to have had multiple partners; to have had varied sexual and drug use experience and to be infected with HIV.”5 Sometimes the young female is persuaded by the their older male perpetrators or partner, from using condom because of varying personal ideologies and are therefore, less likely to use condom at first sexual intercourse (82%),5 unlike the findings of this study (64.1%). This not only result in STIs but also unwanted pregnancy (which affects more than 80 million people worldwide 28 ), thus the high possibility of school drop-out, most times after receiving up to approximately 12 years of formal education (similar to the findings of
  12. 12. 12 this study). Where females are persuaded from using condom at first sexual intercourse, this may be explained by the fact that males tend to be more casual about sexual relations and are more willing to emphasize sexual aspects than their female counterparts, who are more likely to romanticize sexual relationships. This view point bears consistency with the findings of this study, whereby drop-outs were more prevalent among those who became pregnant while attending school (35%) when compared to those who continued their education after the pregnancy (28.3%). Other schools of thought postulated that sexual activity and pregnancy among adolescents or teenagers in Jamaica, Guatemala, and Latin America have been thought to be associated with poor education, poverty and other social factors.10, 29, 30 The current findings highlighted that rural women on average began having sex 8 months earlier than other women (at 16.5 years) that is the age in which they would be in grades 10 and/or 11. Those grades are pivotal for the completion of secondary level education, which means that lower level education will be greater among rural women than those in other geographic areas. It is this lowered age of sexual debut and ignorance of contraception that accounts for higher fertility and unwanted pregnancies among rural women. Research has shown that at least 120 million women would have used contraceptives if information was available.2 Therefore, “the lack of knowledge and available options undermines the right of couples and individuals to exercise control over their fertility and to have children in health and by choice”.2 Knowledge about contraception and the various services available regarding its access is considered an obligation of national governments, especially from a human rights perspective.31 In Jamaica, many youths lack accurate sexual health information, especially with regard to the possibility of pregnancy at first intercourse; protection against STIs via the correct use of the correct contraceptives; the effectiveness of oral
  13. 13. 13 contraceptives against pregnancy; fallacies relating to contraceptive methods.32 Such asymmetric information result in unintended pregnancies, STIs, and abortion. Where abortion is illegal and access to contraception is limited, more than half of the pregnancies end in abortion.28 Take for instance, in the cases of Chile, Hungary, Russia, Turkey, Czech Republic, abortion rates declined significantly owing to access to modern forms of contraception.28 Similarly, in Canada, access to user-friendly reproductive health services, high quality sex education and the increase use of oral contraception has resulted in a decline in teen pregnancy rate.33 In Jamaica, a research by McNeil concurs with the aforementioned studies that teenage pregnancy fell by 14.6% (from 1997 to 2000) because of sex education programmes, training, counseling, skills training and increased contraceptive use.34 Many scholars view early pregnancies as a potential population problem as this increases the chance of larger family size. This has contributed to 30% birth in islands such as St. Kitts and Nevis, Dominica, St. Lucia and 32% for Jamaica.35 In an effort to avoid poor education or school drop-outs, pregnancies are sometimes interrupted (induced abortion), which is about 60% among the average teenager.14 In South Africa, a study found that 32% of pregnant teenagers complete high school,36 suggesting and agreeing that medical or surgical abortions reduce the probability of poor educational attainment. Another study shows that “adolescent girls contribute 55% of all clandestine abortions” in Nigeria.37 While abortion still remains a public policy and public health debate, in some countries it is considered a human right (Sweden), 31 legal (Guyana and Haiti and illegal (Jamaica, Nicaragua and Chile). The reality is “Over 19 million women globally resort to unsafe abortion each year, largely among the world’s poorest and most vulnerable women, especially young women”,38 indicating that the illegality of abortion does not abate its practices, but it becomes a public health concern. In Jamaica, abortion is considered a serious
  14. 14. 14 offence under the Offences Against the Person Act 1973, Section 73, 39 and this goes to reducing their reproductive health choice and open avenues of them seeking the service in unsafe conditions. The reality is, with poverty being greater in rural areas and among females in Jamaica,40 unwanted pregnancies which are arising from ignorance of contraception and earlier sexual initiation means that educational disparity and income inequality if not abated will see a higher fertility, adoption and unsafe abortions among those women. Worldwide, “more than half a million women die every year from pregnancy-related causes”.2 Many deaths resulted from approximately 20 million unsafe abortions that occur yearly, especially among adolescent girls and young women in developing countries.2 In many developing countries, abortion (if unsafe) is considered a common cause of maternal mortality, hence a serious social problem.31 Nevertheless, “a lack of access to safe and legal abortions is an obstacle to their enjoyment of human rights”.31 The goal of the World Summit on Social Development (WSSD) Declaration and Programme of Action 1995, the ICPD 1994 and the World Conference on Human Rights (WCHR), Declaration and Programme of Action 1993 is to “…….reduce maternal mortality and morbidity and greatly reduce the number of deaths from unsafe abortion”.2 Women in Jamaica like other Caribbean islands (such as Antigua and Barbuda, Haiti, Guyana, Trinidad and Tobago and Dominica Republic) show a similar age of sexual debut. One in six women in other Caribbean nations between the ages of 15 and 24 became sexually active before the age of 15 years, 14,15 and 1 in 4 women in Jamaica begin at 15 years, and this is even lower among non-frequent religious women (14.7 years). The current research shows a marginal difference in the Crawford, McGrowder and Crawford’s16 which had that the mean age of sexual debut for female was 15.8 years in Jamaica. Disaggregating the age at which women aged 15-49
  15. 15. 15 years had their first sexual intercourse, we found that the mean age at sexual debut was lowest for women aged 15-19 years old (15.2 years (SD = 1.6)) compared to other aged women. While Crawford, McGrowder and Crawford found that much of earlier sexual debut was out of violence, this research disagrees as we found that only 11.4% of those who have had earlier sexual intercourse were raped,16 which indicates that the majority of first sexual debut was a consensual act although by statutes all sexual relations below 16 years is a rape.41 A study in New Zealand found that 7% of first sexual intercourse was forced, 42 which is marginally lower than that of Jamaica. The time difference may account for this dissimilarity as Dickson et al.’s work 42 was in 1993-1994, while the current study used data for 2004. Moreover, “First sexual intercourse almost always took place outside of a formal union”3 and with older men (for the females).4 We found that the majority of first sexual relations took place with a boy friend in a visiting relationship with the respondent. Based on the foregoing, “The timing of sexual debut among adolescents is influenced by a wide range of factors including: age, gender, poverty, family structure, educational level, pubertal timing, socio-economic status, self-efficacy, peer influences, religiosity, knowledge and perceived risk of sexually transmitted infections, parenting practices and parental supervision, community, media and health inequalities”.43 Outside of those factors which explain early first coitus in the developing nations, particularly the Caribbean is the masculine orientation and culture.44 Research demonstrates that the role of culture in the socialization of children is critical to fashioning the adult, and as soon as females begin to grow breast and to menstruate there is a perception of womanhood. During this growth and development process, the female adolescents’ physiology of reproduction sometimes begins in order to establish womanhood.
  16. 16. 16 The validity of recall of age of first sexual intercourse has been established by a group of researchers in 1997. They found that the test-retest correlations for the recall of age at first sexual relations was 0.85 for females and 0.91 for males,45 which indicates the validity of usage of recall data to measure the phenomenon. Hence, there is legitimacy in the use of cross-sectional survey data to examine age at first sexual intercourse in Jamaica, and the findings therefore provide invaluable insight into the attitude, behaviour and practices of women in Jamaica and those factors which are associated with age at first sexual debut. The current study, therefore, have added variables to the literature: gender, ethnicity, income, mother’s education, family structure, interpersonal relationship and other socioeconomic conditions are associated with age at first sexual intercourse.46-48 It also concurs with other studies that sexual activity is no longer strongly predicted by marriage49-52 as the majority of women who had their first sexual experience, engaged in such activity with a boy friend, stranger or mere acquaintance (87 out of every 100 women). With the low condom usage on first sexual intercourse found in this research, young women are open to the risk of STI, pregnancy and psychological challenges of early sexual relations, and therefore this justifies the rationale for wanting to modify sexual practices of adolescents.53,54 While the current reality of age at first sexual intercourse in Jamaica appears low, this is equally the case in other nations as we found that 80% of a recent cohort of youths who had sex did so become 20 years.55 The image that is embodied in these figures is the sexual complaints which are likely to result from the adult sexual decision that will be taken by adolescents, 56, 57 and the possible life changing situations that are likely to result from a sexual encounter. Clearly, the current public health intervention programmes in Jamaica, as well as other geopolitical areas in the world are not reaching adolescents as they are have committed (under the ICPD 1994), and
  17. 17. 17 by extension have failed to reduce the lowering of age of first sexual intercourse. With the factors which emerged from the current study as accounting for age at first sexual intercourse, as well as those from other studies, 58-60 like McGrath and colleagues, 61 we believe that a multisectoral approach is needed to address these growing public health and legislative problems – not as a single variable (age at first sexual intercourse) but other factors that are purported in the reviewed studies, 62-64 as well as the evidentiary support of Jamaica. Within the context of lowered age at first sexual intercourse of Jamaican women as well as the association between forced sexual relations and early age of sexual debut, 65 this would be contributing to the current public health problems of teenage pregnancies, high fertility, STIs, increased maternal and child mortality, and psychologically challenged young people as they undergo the difficulty of the experience.66-68 Clearly, this study highlighted the finding that the average age at first sexual debut for Jamaican women (median age was 16.0 years) was lower than that of women in rural South African (median age was 18.5 years)69 and eastern Zimbabwe (median age was 18.5 years).70 A study, using European women ages 16-44, found that the average age of first sexual debut was less than 16 years, and offers little solace for public health practitioners in Jamaica.23 Although South Africa had the highest HIV infection rate in the world69 and an age at first sexual debut lower than that of Jamaican women, public health specialists need to use the current findings to ensure that the premarital sexual relations, inconsistent condom use and STI infections, especially HIV, do not reach the levels of those in South Africa as previous studies have shown the association between age at first sexual intercourse and having an STI.70 The rationale for this prescriptive recommendation for public health specialists is embedded in the association between early sexual debut and sexually transmitted infections as well as evidence which shows that STIs
  18. 18. 18 are a gateway to complications such as pelvic inflammatory infections, infertility, ectopic pregnancy, fetal abnormality and HIV/AIDS.70-72 Those are not the only issues of concerns at age at first sexual debut as many studies have shown that gender, illicit drugs, age at menarche, religiosity, area of residence and other factors are associated with this phenomenon.19,20,22,25,69,70,73 This study concurs with the literature and added more variables such as age at contraceptive use, forced sexual relations, employment status, shared sanitary convenience, area of residence, and marital status, indicating that multi-variables are associated with age at first sexual initiation of Jamaican women. Conclusion Public health policies have failed to effectively increase the age at first sexual intercourse for women in Jamaica. This study shows that a multisectorial philosophy to the intervention is needed in order to address the multidimensional nature of the factors which are associated with age at first sexual debut. Sexual intercourse is commonly initiated in the adolescence years, and with the increased risk of sexually transmitted infections, teenage pregnancy and adoption with early sexual initiation, the public health consequences will be dire if they are felt unabated or the age at sexual debut allowed to fall lower than current value. Disclosures The author report no conflict of interest with this work.
  19. 19. 19 Disclaimer The researcher would like to note that while this study used secondary data from the Reproductive Health Survey, none of the errors in this paper should be ascribed to the National Family Planning Board, but to the researcher. Acknowledgement The author thank the Data Bank in Sir Arthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona, Jamaica for making the dataset (2002 Reproductive Health Survey, RHS) available for use in this study, and the National Family Planning Board for commissioning the survey.
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  24. 24. 24 Table 1.1. Demographic characteristic of studied population, n = 7, 168 Characteristic n % Shared sanitary convenience with other household No 5907 82.9 Yes 1219 17.1 Employment status Employed 3025 42.2 Unemployed (including students) 4143 57.8 Main source of financial support Partner 4129 57.6 Other 3039 42.4 Marital status Legally married 1542 21.5 Common-law 1733 24.2 Visiting 1959 27.3 Not currently in union 1934 27.0 Currently pregnant Yes 288 4.4 No 6219 94.6 Ever been pregnant Yes 5301 84.3 No 985 15.7 Forced to have sex Yes 747 11.4 No 5707 86.8 Health conditions Diabetes 284 12.2 Anemia 438 18.8 Heart disease 94 4.0 Pelvic inflammatory disease 125 5.4 Urinary tract infection 800 34.3 Asthma 587 25.0 Hepatitis B 6 0.3 Area of residence Urban 1144 16.0 Semi-urban 2079 29.0 Rural 3945 55.0 Socioeconomic class Lower 1705 23.8 Middle 3079 43.0 Upper 2384 33.2 No. of pregnancies that resulted in live births median (range) 2.0 (0, 14) Years of schooling mean (SD) 13.0 years (3.0 years) Age mean (SD) 31.3 years (9.3 years) Age at sexual debut median (Range) 16.0 years (29 years; max age 36 years)
  25. 25. 25 Figure 1.1 Person with whom respondents had their first sexual relations
  26. 26. 26 Table 1.2. Age cohort of respondents by age at sexual debut Age cohort of respondents (in years) Age at sexual debut (in years) Mean (SD1 ) 15 – 19 15.2 (1.6) 20 – 24 16.2 (2.0) 25 – 29 16.8 (2.4) 30 – 34 17.1 (2.9) 35 – 39 17.2 (3.1) 40 – 44 17.2 (3.2) 45 – 49 17.1 (3.0) Sample 16.8 (2.8) 1 SD denotes standard deviation F statistic = 47.3, P < 0.0001
  27. 27. 27 Table 1.3. Multiple linear regression analyses: Explanatory variables of age at first sexual debut, n = 5,732 Explanatory variable β Coefficient CI (95%) R2 Constant 8.377 7.852 - 8.903 NA Age began using contraceptive method 0.266 0.250 - 0.283 0.179 Years of schooling 0.166 0.141 - 0.190 0.048 Lower class (reference group) Upper class 0.560 0.385 - 0.735 0.021 Forced sexual relations (1= yes) -0.650 -0.820 - -0.481 0.009 Frequent church attendance (1= once or less per week) 0.511 0.364 - 0.659 0.006 Crowding 0.409 0.240 - 0.579 0.005 Employment status (1= employed) 0.347 0.206 - 0.489 0.003 Age of first menarche 0.048 0.027 - 0.069 0.003 Shared sanitary convenience (1=yes) -0.325 -0.504 - -0.147 0.002 Married or common-law union -0.175 -0.315 - -0.035 0.001 Urban area (reference group) Rural -0.654 -0.856 - -0.452 0.001 NA – Not applicable
  28. 28. 28 Chapter 2 Young males whose first coitus began at most 15 years old Paul A. Bourne Introduction For decades, public health practitioners have been designing intervention programmes geared towards addressing (1) teenage pregnancy, (2) high fertility, (3) HIV/AIDS epidemic, and (4) age at first coitus in developing nations, particularly in Jamaica. Inspite of their efforts to make behavioural changes in those societies, the aforementioned issues continue to linger and are still public health problems [1-5], for policy makers. Thousands of dollars have been spent on intervention programmes that are structured towards sexual behaviour modifications, but (1) HIV/AIDS continue to increase [6, 7] and (2) age of sexual debut keeps on falling over the last decade in Jamaica [8-12]. In 2002 statistics showed that the mean age at first coitus among females Jamaicans was 15.8 years and 13.5 years for males [8]. With 1 in every 50 people in the Caribbean being infected with the HIV/AIDS virus; AIDS being the main cause of deaths among people aged 15- 44 years [7]; HIV virus being among the 5 leading cause of mortality of those aged 10-19 years old in Jamaica; coupled with the promiscuous lifestyle of Caribbean males [13], in Jamaica, 3 out of every 4 males aged 15-24 years old had sexual intercourse at least once per week and that 11 out of every 50 young males aged 15-24 years old had have coitus in their lifetime [4], then unsafe sexual practices are a major public health problem that cannot go unresearched. The World Health Organization (WHO) opined that unsafe sexual practices are a part of risk factors which account for increased mortality and morbidity in the world [14]. Clearly from the aforementioned issues, the continuously lowering of the age of coitus and its association with
  29. 29. 29 unsafe sexual behaviour, it is a cause for concern in public health. Many studies have investigated age at sexual debut and factors associated with it in order to provide a comprehensive framework for addressing those issues [9-12]. Coitus continues to commence during the adolescence years in many developing nations as well as the United States [15], while researchers understandably so continue to examine age at first sexual intercourse and multiple sexual relationships among these individuals, no study has explored the reproductive health practices of those aged ≤ 15 years who are having sexual relations. While it is valuable to inquire the sexual behaviour of older aged males in a society to provide information on unsafe sexual practices that can be used to guide public health policy framework, understanding the aged ≤ 15 years may produce somewhat of different information that other aged cohorts would have give. Thus, the current study seeks to elucidate information on the reproductive health practices of males aged ≤ 15 years as this is the aged in which many of them commenced sexual relations. The rationale of this paper is provide policy makers with research evidence that can be used to structure framework for intervention programmes for those males aged ≤ 15 years who are have sexual intercourse. Methods Sample This descriptive cross-sectional study used a secondary dataset, 2002 Reproductive Health Survey. Since 1997, the National Family Planning Board (NFPB) has been collecting information from Jamaican men (ages 15-24 years) and women (ages 15-49 years) regarding contraception usage and/or reproductive health for the purpose of aiding government policies. In 2002, the Reproductive Health Survey (RHS) collected data on Jamaican men ages 15-24 years
  30. 30. 30 and women 15-49 years. For this research, there are two sets of inclusion criteria. These are male and age of first coital activity by at most 15 years. The current study extracted a sample of 1,083 males who had their first sexual coital activity by at most 15 years old from the initial sample of 2,437 men aged 15-24 years old. Stratified random sampling was used to design the sampling frame from which the sample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage sampling design was used. Stage 1 was the use of a selection frame of 659 enumeration areas (or enumeration districts, EDs). This was calculated based on probability proportion to size. Jamaica is classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomas and St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up of Trelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchester and Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica compared to Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8% [10] In stage 2 the households were clustered into primary sampling units (PSUs), and each PSU constituted an ED, which in turn was comprised of 80 households. The previous sampling frame was in need of updating, and so this was performed between January and May 2002. On completion of the exercise, the total number of households visited was 15,950 of which 17.5% of the inhabitants dwelled in urban areas, 27.7% resided in semi-urban zones and 54.8% lived in rural areas. Almost 18% of the households had eligible men (ages 15-24 years old, n = 2,795 men). Sixteen percent of the eligible men resided in urban areas, 27.7% lived in semi-urban areas and 56.4% dwelled in rural areas. The new sampling frame formed the basis upon which the sampling size was computed for the interviewers to use. The sample represents a response rate of
  31. 31. 31 87.2%: 88.3% of eligible urban men, 88.0% of semi-urban and 86.7% of eligible rural respondents. Stage 3 was the final selection of one eligible male from each sampled household and this was done by the interviewer on visiting the household. The Statistical Institute of Jamaica (STATIN) provided the interviewers and supervisors, who were trained by McFarlane Consultancy, to carry out the survey. The instrument administered was a 35-page questionnaire [10]. The data collection began on Saturday, October 26, 2002 and was completed on May 9, 2003. Prior to the date of the final data collection, pre- testing of the instrument was conducted between March 16 and 20, 2002. A total of 175 instruments were pre-tested, of which 40.6% were given to eligible men. Modifications were made to the pre-tested instrument (questionnaire), after which the final exercise was carried out. The data was weighted in order to represent the population of men ages 15 to 24 years in the nation. Statistical methods For this paper, the Statistical Packages for the Social Sciences (SPSS) for Windows, Version 16.0 (SPSS Inc; Chicago, IL, USA) was used to examine the data. Frequencies and means were computed on the sociodemographic characteristics. Chi-square (χ2 ) tests and independent sample-test were used to evaluate associations and differences among mean scores of variables, respectively. Stepwise multiple logistic regressions were used to analyze factors that explain (1) had sex, (2) frequency of church attendance, (3) in sexual union and (4) used a condom on the last sexual encounter.
  32. 32. 32 Odds ratios were determined from the use of a binary logistic regression model, and Wald statistic will be used to determine the strength of variable. Where collinearity existed (r > 0.7), variables were entered independently into the model to determine those that should be retained during the final construction of the model. To derive accurate tests of statistical significance, we used SUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), and this was adjusted for the survey’s complex sampling design. A P-value < 0.05 (two-tailed) was used to determine statistical significance. Measure Crowding is the total number of persons in a dwelling (excluding kitchen, bathroom and verandah). Age is the number of years a person is alive up to his/her last birthday (in years). Contraceptive method is any device or approach that is used to prevent pregnancy. These methods include tubal ligation, vasectomy, implant (norplant), injection, emergency contraceptive protection, pill, condom, foaming tablets, creams, jellies, diaphragm, abstinence, withdrawal, the rhythm method, calendar or Billings (1= yes, 0 = otherwise). Non-steady sexual partner denotes casual sexual relations with someone with whom the individual is not having a common-law sexual relationship, visiting relationship or to whom the individual is legally married (1 = yes, 0 = otherwise). Education is taken from the question, ‘How many years did you attend school?’ Shared facility is taken from ‘Are these [sanitary conveniences] shared with another household? The options are shared, not shared or not stated. This was coded as 1 = shared and 0 = otherwise. Woman (female) pregnant for is taken from the question, “Is a women pregnant for you?” (1= yes, 0 = otherwise). Had sex is taken from the question “Have you had sexual intercourse in the last 30 days?” (1= yes, 0 = otherwise). Frequent church attendance is derived from, “With what frequency do you attend religious services? The options are at least
  33. 33. 33 once per week; at least once per month; less than once a month; only for special occasions (wedding, funerals, christening, etc); doesn’t attend at all, and no response (1= at least once per week, 0 = otherwise). Model Using logistic regression, this study seeks to examine factors associated with (1) had sex, (2) frequency of church attendance, (3) in sexual union and (4) used a condom on the last sexual encounter among Jamaican males whose first sexual coitus was ≤ 15 years. Different social factors influence men’s choices, and their decision to (1) have sexual relations, (2) frequently church attendance, (3) in sexual union and (4) used a condom on the last sexual encounter. Bourne and Charles [16] have established a connection between particular social and reproductive factors and contraceptive use among young males aged 15-25s. Econometric analysis was used to establish multifactorial determinants. The current research will use the theoretical framework of Bourne and Charles’ econometric analysis to examine factors that are associated with (1) had sex, (2) frequency of church attendance, (3) in sexual union and (4) used a condom on the last sexual encounter among males whose first sexual coital activity occurred at most 15 years old in Jamaica. The variables used in this econometric model are based on the literature as well as the dataset. Based on the literature, the following variables were examined using logistic regression: Dependent – (1) had sex, (2) frequency of church attendance, (3) in sexual union and (4) used a condom on the last sexual encounter. Independent - age of respondents; educational level; employment status of young adult man; social class of young adult man; area of residence; someone currently pregnant for respondent; shared sanitary convenience with non-household members; age of first sexual relations; currently had sexual intercourse in the last 30 days;
  34. 34. 34 number of sexual partners; religiosity; currently in a sexual union; hearing family planning message; extracurricular activities; crowding in household; condom usage; in sexual union, frequency in church attendance, involvement in family planning programme and having had sexual intercourse in the last 30 days with a non-steady partner. Results Demographic characteristic of studied population Table 2.1 presents information on the demographic characteristics of the studied population as well as particular reproductive health issues. Bivariate analyses Table 2.2 examines particular demographic characteristics as well as condom usage, non- partner sex, involvement in extracurricular activities and involvement in family planning education by had sex (in the last 30 days). The findings revealed a significant statistical association between involvement in extracurricular activities and had sex (χ2 = 4.19, P = 0.041, Table 2.2): Twenty-four percentages of those who had sex reported being engaged in extracurricular activities compared with 29% of those who did not have sexual relations. Eleven out of every 25 young adults aged ≤ 15 years were in multiple concurrent relationships (44%). Multivariate analyses Six variables emerged as statistically significant predictors of had sex (in the last 30 days) - Model chi-square = 225.28, P < 0.0001; -2 Log likelihood = 1130.62; Nagelkerke r-squared =
  35. 35. 35 0.274 (Table 2.3). The data correctly classified 71.3% of those who had sexual relations in the last 30 days. Using logistic regression analyses, four variables emerged as statistically correlated with frequency of church attendance among the studied population (Table 2.4, Model chi-square = 225.28, P < 0.0001; -2 Log likelihood = 1130.62; Nagelkerke r-squared = 0.274). Table 2.5 presents information on factors which account for in sexual unions. Three variables emerged as significant correlates of in sexual union (Model chi-square = 176.45, P < 0.0001, -2 Log likelihood = 1180.41, Nagelkerke r-squared = 0.219). Table 2.6, using logistic regression analyses, non-partner sex, had sex and women being pregnant for emerged as factors accounting for having used a condom on the last sexual encounter (Model chi-square = 63.72, P < 0.0001; -2 Log likelihood = 686.18; Nagelkerke r- squared = 0.119; Hosmer and Lemeshow test, χ2 = 0.62, P = 0.734). Discussion Sexual promiscuity is a feature of many developing nations, particularly in the English-speaking Caribbean countries [13]. It is well documented in the literature that age at first sexual intercourse is occurring during the adolescence years in many societies [9-12], and this is even lower among males than females [8]. Chevannes opined that sexuality and sexual behaviour among Caribbean males is partly owing to the traditional values of the society on masculine, manhood and machoism [13]. The social setting of Caribbean societies is such that males are expected to be promiscuous, but this is not equally defined for females. The culture and social structure of Caribbean societies have it that “A man I not a real man unless he is sexually active” [13, p. 217] which justifies first coitus at puberty and not adulthood. With 31% of the Jamaican
  36. 36. 36 population being less than 15 years old [14] and about one half being males, the present study is critical to public health initiatives and framework as it will unearth key research findings. Another social reality in Caribbean societies is not merely multiple partnerships which are engaged in more by younger than older males, but that “… sexual awareness begins quite early in life.” [13, p.192]. According to Chevannes, “By the time small children reach the age of seven or eight, and are in primary school, their sexual socialization would have begun in earnest, though it is probably in the immediate prepubescent period that they begin to exhibit personal, emotional interest in sex” [13, 193]. In a nationally representative probability survey of 2, 843 Jamaicans aged 15-74 years old, Wilks et al. [4] found that 96.2% of males had sex compared with 93.3% of females; 40.9% of male sample had multiple sexual relationships (2+ partners) compared to 8.4% of females; and of those aged 15-24 years old, 36.1% of males had multiple partners to 15.4% of females. The aforementioned figures on Jamaicans may appear alarming, but a study conducted by Santelli et al [15] noted that adolescents and young Americas are also engaged in multiple relationships, particularly more males than females, 12.8% of females had multiple partners compared with 26.2% of males. Polygamy seems to be a male phenomenon across the world, which is supported by the culture that men’s sexual drives indicate prowess and women’s sexual drive should be passive and highly controllable [17]. Even among female undergraduate students in China, Yan [5] found that 5.3% had multiple sexual partners and 38.1% inconsistently used a condom, suggesting that risky sexual behaviour among adolescents in the world is a reality. The current study found that 51.2% of Jamaicans males aged ≤ 15 years old had sex in the last 30 days, 53.7% were in sexual unions, 82.6% were had sexual relations with a non-steady partner, 55.5% dwelled in rural zones and19% were frequent church attendees. Furthermore, 11 out of every 25
  37. 37. 37 male adults who had their first sexual encounter did so ≤ 15 years old. This paper will comprehensively examined the aforementioned aged cohort in order to provide public health policy makers with useful research evidence that can be utilize to frame intervention programmes. Many factors have been identified in the literature as explaining age at first sexual intercourse [9, 18-20], but no study specifically examined a sample of those at the mean age at sexual debut and particular reproductive health matters. In this research, it was revealed that frequency in church attendance, involvement in extracurricular activities, non-partner sexual relations, in sexual union, employment status and age influence males who had sex in the last 30 days. The findings highlighted that those who are frequent church attendees were 47% less likely to have reported having had sex, and involvement in extracurricular activities reduced sexual relations by 32%. The cultural values of the churches continue to lower sexual relationships. This finding concurs with literature which showed that protestants (similar to those of non-religion) were more likely to have their first sexual initiation within their 16th year, when compared to the Catholics (within their 17th year) and those of other religion (18th year) [21]. While the difference in age at first sexual intercourse among the aforementioned cohorts may not seems to be great, the current research found that 6.4 times more sexual relations occurred by those who are infrequent church attendees than frequent church attendees (sexual relations by frequent church attendees, 13.5%). Among the factors which reduce sexual relations is extracurricular involvement. This paper found that those who are engaged in extracurricular activities were 32% less likely to have had sex in the last 30 days compared with those who were no involved in extracurricular measures. Clearly the church is not only a place for biblical teaching as in this research it was
  38. 38. 38 discovered that extracurricular activities was 1.9 times more engaged in by frequent church attendees and those who had sex were 41% less likely to be frequent attendees. The church is acting as social agency against sexual involvement through its teaching and responsibilities that it thrust on young males. The church is also imparting self-esteem which is allowing young males to delay sexual intercourse, but that this garnered and practiced by frequent attendees. Using a sample of 4,379 Scottish adolescents, Penfold et al. [9] found that family (parental monitoring), school life (enjoyment), gender, self-esteem, religion, and informal sexual health intervention were associated with self-reported first sexual intercourse. Another group of scholars found that the perception of greater physical maturity, expectations of earlier autonomy among gender, and the use of illicit drugs to be statistically associated with age at first sexual debut among high schoolers [19]. The churches seem to embodying in young males who are frequent attendees, greater self autonomy as well as self-esteem that they use to delay age at sexual intercourse which is not the case among non-frequent attendees. Embedded in the findings of this research is that frequent church attendees’ as well as their families are less likely to share sanitary convenience, suggesting that the socioeconomic status of this cohort is better than non-frequent attendees. The church is therefore an institution which is frequent by the middle and upper class families of young males, indicating that it apart of the socialization of those socioeconomic strata more than the lower socioeconomic stratum. Those socioeconomic classes are more able to afford the other amenities such as golfing, skeeing, swimming, badminton, chess, extra tutoring, as well as other programmes offered by the church as extracurricular activities that become engaging for the young males, and so reduce the likeliness of sexual involvement. Then, with increased probability of sharing sanitary
  39. 39. 39 convenience for poor family, sexual activities are increased as they are introduced by other individuals. With the engagement in social activities, children are introduced to others who have been socialized within a different sub-culture. It is the other agents of socialization, that when the male children are exposed, he is likely to change from the teaching and values of the church or the family. It emerged in this study that as males get older he is more likely to be involved in sexual union and this is also foster by more years of schooling. While education provides greater knowledge of issues including reproductive health matters, self-esteem, and an opportunity for socioeconomic advancement, it increases sexual unions, sexual activities and risky sexual practices. Those who engaged in sexual relations in the last 30 days were 3.9 times more likely to be in a sexual union, which is a side effect of exposure to other agents of socialization such as the peer groups and schools. It was revealed here that increased schooling is providing more than education, as it opens social relationships and some of these are likely to sexual. Yan et al. provide an understanding of the peer groups influence while at school, when they said that “Students who agree or accept multiple sex partner behavior are 3 times more likely to report more sex partners. Peer influences are important, and students whose friends live with boyfriends and who work at places of entertainment (where alcohol and sex are likely present) are 2 times more likely to report more sex partners” [5, p. 9]. One of the good issues which emerged from the current finding is that 41 out of every 50 of the studied population reported having used a condom the last time a sexual activity was performed, which is greater than contraceptive prevalence, globally (65% or 23 out of every 50) [14]. Those who reported having had sex (n = 554, 51.2%), were 1.6 times more likely to use a condom and this even greater among non-steady sexual partners (2.3 times). Wilks et al. found
  40. 40. 40 that among males aged 15-24 years old, condom usage was 65.8% [4], which means that young males in this study were less of a sexual risk-taker compared with those aged 15-24 years old. Although the sexual practice among young males ≤ 15 years old is the un-desirous event as it contravenes the law of Jamaica, it opens young males to adult activities and responsibilities before time such as the pregnancy of female partner(s). Condom usage is high among the studied population, but with little information about consistent usage, it is difficult to rightfully determine unsafe sexual practices. Using statistics from PAHO [6, pp. 452-453], HIV is the fourth dealing cause of mortality among Jamaicans aged 10-19 years. Extrapolating from the PAHO’s data, clearly ignorance about sexual practices, proper condom usage, and unfitted condoms are accounts for the high prevalence of HIV virus and that there is high risk sexual behaviour among the present study population. Multiple sexual relationships, therefore, are account for the high prevalence of HIV among young male adolescents in Jamaica. By extrapolation, this study is in agreement with researchers in Africa who argued that multiple sexual relations are the root of the HIV epidemic in southern and eastern Africa [22]. The high sexual promiscuity among the studied population is embedded in the findings which showed that 41 out of every 50 had sex with a non-steady partner, and 11 out of every 25 had multiple concurrent relationships, which is reinforcing Chevannes’ work that Caribbean males are socialized to be sexually adventurous [13]. Chevannes captured this adequately when he stated that we loose the bull and tie the heifer, meaning that we allow the males to be sexually free and expects this not to be the case from the females. The promiscuity of males in the Caribbean, particularly in Jamaica, appears to have some African antecedents [23-26] as we the same lineage, cultural settings, and general cosmology. It must be modified that the Afro- Caribbean peoples share some history of the European slave masters, this means for a melting
  41. 41. 41 pot of cultures with the dominant one being from the African traditions. Even non-Afro- Caribbean males, share the same sexual promiscuity cosmology as those in Caribbean [15, 27]. According to Santelli [15], “Adolescent males [Americans] are more likely than adolescent females to report multiple sexual partners and multiple concurrent partners” [15, p. 271]. Globally, therefore, the cultural setting and socialization of males share similar tenants. Thus, the findings of this paper have widely implications for public health intervention initiations and policy framework. Conclusion Public health intervention programmes need to have a new thrust of extracurricular activities for young males as a medium of increasing age at first coitus. The gains of extracurricular activities for young males include (1) social engagement, (2) time consumption, (3) reduced sexual involvement, (4) built self-esteem, and (5) social capital. The church, which is an agent of socialization, provides young males with the aforementioned positives as well as ethics and morals that justify the delay of coitus. The issues of ethics and moral coupled with extracurricular activities are forging a self-confident, sexually autonomous and responsibility. Young males, despite the cultural values of sexual freedom among males in Caribbean societies, social engagement within educational advancements is not all positive. There is a negative side to the social engagement which is accommodated by schooling, as peer groups are encouraging sexual unions. These sexual unions are fostering sexual unions, sexual activities and the lowering of age at coitus which must be taken into the intervention programmes and educational system to lower the probability of sexual engagement. Furthermore, any new intervention programme must include economic survivability of family, extracurricular activities, building self-esteem, social capital, values and morals in order to effectively change the current state of first coitus among
  42. 42. 42 young males. Because people are prisoners to the beliefs, practices, values and customs (vices or otherwise), merely providing young males with knowledge about reproductive health matters and/or abstinence will continue to be ineffective as this research showed those factors which are likely to cause increased age at first coitus must take a multisectoral approach as the factors are different and not focused on a single theme. Merely bombarding the airwave with middle class values when young people have not absorbed these aspiring values, as is the case used by traditional and contemporary public health practitioners, will be useless to direct health educational programmes at these individuals. In summary, the best public health intervention programmes to address the present young male population away from first coitus before 16 years must include values from an early age, games and other extracurricular activities and not the traditional outer-directed approach to health education. While education, undoubtedly provide many positives for young males, programmes must be geared towards peer pressure, social engagement, and sexual relationships which are likely to occur in educational institutions. The research findings are in, and should be use to frame health promotion that will aggressively address the current challenges which emerged from this study. Using fear to sell sexual behaviour modifications may be dangerous and counterproductive as positive ideas, messages and imagery are more effective than negative ones. Using this study’s results, young males need opportunities, values, self-esteem and outlets of releasing sexual urges which are likely during adolescents. Then, while health promotion is good it must incorporate those issues within it policy framework. Otherwise, public health will continue to ineffective and useless in address the lowering of age at first coitus among young people, particularly males. Disclosures
  43. 43. 43 The authors report not conflict of interest with this work. Disclaimer The researchers would like to note that while this study used secondary data from the Reproductive Health Survey, none of the errors in this paper should be ascribed to the National Family Planning Board, but to the researchers. Acknowledgement The authors thank the Data Bank in Sir Arthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona, Jamaica for making the dataset (2002 Reproductive Health Survey, RHS) available for use in this study, and the National Family Planning Board for commissioning the survey. References 1. Frederick J, Hamilton P, Jackson J, et al. Issues affecting reproductive health in Caribbean. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. 41-50. 2. McNeil P. Coping with Teenage pregnancy. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. 51-57. 3. Bain B. HIV/AIDS – the rude awakening/stemming the tide. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. 62-76. 4. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. Jamaica health and lifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies, Mona; 2008. 5. Yan H, Chen W, Wu H, et al. Multiple sex partner behavior in female undergraduate students in China: A multi-campus survey. BMC Public Health 2009; 9:305. 6. Pan American Health Organization (PAHO). Health in the Americas 2007 volume II – Countries. Washington D.C.: PAHO; 2007. 7. Douglas DL. Perspectives on HIV/AIDS in the Caribbean. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. xv. 8. Jamaica National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston: NFPB; 2005. 9. Penfold SC, Teijlingen ERV, Tucker JS. Factors associated with self-reported first sexual intercourse in Scottish adolescents. BMC Research Notes 2009; 2:42. 10. Santelli JS, Kaiser J, Hirsch L, Radosh A, Simkin L, Middlestadt S: Initiation of sexual intercourse among middle school adolescents: the influence of psychosocial factors. J Adolesc Health 2004, 34:200-208. 11. Slaymaker, E, Bwanika, J B, Kasamba, I, Lutalo, T, Maher, D, Todd, J (2009). Trends in age at first sex in Uganda: evidence from Demographic and Health Survey data and longitudinal cohorts in Masaka and Rakai. Sex. Transm. Infect. 85: i12-i19 12. Louie KS, de Sanjose S, Diaz M, et al. Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries. Br J Cancer 2009; 100(7):119-7. 13. Chevannes B. Learning to be a man: Culture, socialization and gender identity in five Caribbean communities. Kingston, Jamaica: The Univer. of the West Indies Press; 2001.
  44. 44. 44 14. World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009. 15. Santelli JS, Brener ND, Lowry R, Bhatt A, Zabin LS. Multiple sexual partners among U.S. adolescents and young adults. Family Planning Perspectives 1998; 30:271-275. 16. Bourne PA, Charles CAD. Contraception usage among young adult men in a developing country. Open Access J of Contraception 2010; 1:51-59. 17. Shelton JD. Why multiple sexual partners? Lancet 2009; 374: 367-369. 18. Fatusi AO, and Blum, RW. Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC Public Health; 8, 2008. 19. Rosenthal DA, Smith AMA, De Visser R. Personal and social factors influencing age at first sexual intercourse. Archives of Social Behavior 1999; 28(4):319-333. 20. Mardh PA, Creatsas G, Guaschino S, et al. Correlation between early sexual debut, and reproductive health and behavioral factors: a multinational European study. Eur J Contracept Reprod Health Care 2000; 5:177-82. 21. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010). 22. Halperin D, Epstein H. Concurrent sexual partnerships help explain Africa’s high HIV prevalence: implications for prevention. Lancet 2004; 364: 4–6. 23. Tawfi k L, Watkins SC. Sex in Geneva, sex in Lilongwe, and sex in Balaka. Soc Sci Med 2007; 64: 1090–101. 24. Swidler A, Watkins SC. Ties of dependence: AIDS and transactional sex in rural Malawi. Stud Fam Plan 2007; 38: 147–62. 25. Leclerc-Madlala S. Transactional sex and the pursuit of modernity. Soc Dynam 2004; 29: 1–21. 26. Watkins SC. Navigating the AIDS epidemic in rural Malawi. Pop Devel Rev 2004; 30: 673–705. 27. Smith TW. Adult sexual behavior in 1989: number of partners, frequency of intercourse and risk of AIDS, Family Planning Perspectives 1991; 23:102–107.
  45. 45. 45 Table 2.1: Demographic characteristics of studied population, n = 1, 083 Characteristic n % Had sex (in last 30 days) No 529 48.2 Yes 554 51.2 In sexual union No 501 46.3 Yes 582 53.7 Non-partner sexual relation No 175 17.4 Yes 831 82.6 Frequent church attendance No 877 81.0 Yes 206 19.0 Involvement in extra-curricular activities No 796 73.8 Yes 283 26.2 Involvement in family planning education programme No 995 91.9 Yes 88 8.1 Educational levels Primary or below 82 7.6 Secondary 469 43.3 Tertiary 522 48.2 Female pregnant for No 1040 97.0 Yes 32 3.0 Shared sanitary convenience No 891 83.3 Yes 178 16.7 Employment status Employed 448 41.6 Not working but have a job 2 0.2 Unemployed 276 25.6 Student 351 32.6 Used condom last time had sex No 199 18.4 Yes 884 81.6 Area of residence Urban 188 17.4 Semiurban 294 27.1 Rural 601 55.5 No. of child/ren want to have, median(range) 3 (0 – 10) Crowding, median (range) 2 persons (1 – 2)
  46. 46. 46 Table 2.2: Particular demographic and reproductive health variables by had sex (in last 30 days) Characteristic Had sex (in last 30 days) χ2 , P valueNo Yes n (%) n (%) In sexual union 164.77, < 0.0001 No 350 (66.2) 151 (27.3) Yes 179 (33.8) 403 (72.7) Area of residence 1.48, 0.476 Urban 92 (17.4) 96 (17.3) Semiurban 135 (25.5) 159 (28.7) Rural 302 (57.1) 299 (54.0) Involvement in extracurricular activities 4.19, 0.041 No 374 (71.0) 422 (76.4) Yes 153 (29.0) 130 (23.6) Involvement in family planning education 0.051, 0.821 No 485 (91.7) 510 (92.1) Yes 44 (8.3) 44 (7.9) Employed 57.68, < 0.0001 No 393 (74.3) 288 (52.0) Yes 136 (25.7) 266 (48.0) Frequent church attendance 22.14, < 0.0001 No 398 (75.2) 479 (86.5) Yes 131 (24.8) 75 (13.5) Used condom last time 13.96, < 0.0001 No 121 (22.9) 78 (14.1) Yes 408 (77.1) 476 (86.9) Shared sanitary convenience 0.450, 0.502 No 440 (84.1) 451 (82.6) Yes 83 (15.9) 95 (17.4) Marital status 171.88, < 0.0001 Common-law 5 (0.9) 38 (6.9) Visiting 174 (32.9) 365 (65.9) Previously in union 147 (27.8) 59 (10.6) Single 203 (38.4) 92 (16.6) Non-partner sex 15.87, < 0.0001 No 106 (22.5) 69 (12.9) Yes 366 (77.5) 465 (87.1) Years of education, mean (SD) 1.6 yrs (2.5) 12.8 yrs (2.6) t = -1.297, P = 0.195 SD denotes standard deviation
  47. 47. 47 Table 2.3: Logistic regression analyses: Explanatory variable of had sex (in last 30 days), n = 981 Dependent: Had sex β coefficient Std error Wald statistic Odds ratio CI (95%) Frequent church attendance (1=yes) -0.47 0.19 5.80 0.63 0.43 - 0.92 Non-partner sex 0.64 0.19 11.01 1.90 1.30 - 2.77 Involvement in extracurricular activities -0.39 0.16 5.61 0.68 0.49 - 0.94 In sexual union 1.35 0.15 84.25 3.85 2.89 - 5.14 Employment status (1=employed) 0.41 0.17 5.76 1.50 1.08 - 2.09 Age 0.16 0.03 25.76 1.18 1.10 - 1.25 Constant -4.18 0.60 48.57 0.02 Model chi-square = 225.28, P < 0.0001 -2 Log likelihood = 1130.62 Nagelkerke r-squared = 0.274 Hosmer and Lemeshow test, χ2 = 7.44, P = 0.49 Overall correct classification = 71.3% Correct classification of cases that had sex = 75.9% Correct classification of cases that did not have sex = 66.0%
  48. 48. 48 Table 2.4: Logistic regression analyses: Explanatory variable of frequent church attendance, n = 946 Dependent: Frequent church attendance β coefficient Std error Wald statistic Odds ratio CI (95%) Involvement in extracurricular activities 0.64 0.28 5.34 1.89 1.10 - 3.24 Shared sanitary facility -0.62 0.28 5.00 0.54 0.32 - 0.93 Age -0.11 0.04 9.01 0.90 0.84 - 0.96 Had sex -0.53 0.18 8.36 0.59 0.41 - 0.84 Constant 0.71 0.64 1.22 2.03 Model chi-square = 75.13, P < 0.0001 -2 Log likelihood = 1792.84 Nagelkerke r-squared = 0.06 Hosmer and Lemeshow test, χ2 = 6.44, P = 0.60 Overall correct classification = 81.0% Correct classification of cases, frequent church attendance = 60.0% Correct classification of cases, infrequent church attendance = 100.0%
  49. 49. 49 Table 2.5: Logistic regression analyses: Explanatory variable of in sexual union, n = 990 Dependent variable: In sexual union β coefficient Std error Wald statistic Odds ratio CI (95%) Age 0.15 0.03 29.55 1.16 1.10 - 1.23 Years of schooling 0.31 0.11 7.64 1.36 1.09 - 1.69 Had sex (1=yes) 1.35 0.14 87.15 3.85 2.90 - 5.10 Constant -4.34 0.63 46.87 0.01 Model chi-square = 176.45, P < 0.0001 -2 Log likelihood = 1180.41 Nagelkerke r-squared = 0.219 Hosmer and Lemeshow test, χ2 = 4.58, P = 0.801 Overall correct classification = 68.7% Correct classification of cases in sexual union = 74.1% Correct classification of cases not in sexual union = 61.7%
  50. 50. 50 Table 2.6: Logistic regression analyses: Explanatory variable of used condom on last sexual encounter, n = 946 Dependent variable: Used condom on last sexual encounter β coefficient Std error Wald statistic Odds ratio CI (95%) Non-partner sex 0.81 0.23 12.99 2.26 1.45 - 3.51 Had sex (1=yes) 0.47 0.21 4.97 1.60 1.06 - 2.40 Woman pregnant for me -3.06 0.46 45.00 0.05 0.02 - 0.12 Constant 1.15 0.20 32.32 3.16 Model chi-square = 63.72, P < 0.0001 -2 Log likelihood = 686.18 Nagelkerke r-squared = 0.119 Hosmer and Lemeshow test, χ2 = 0.62, P = 0.734 Overall correct classification = 87.5% Correct classification of cases in used condom on last sexual encounter = 99.0% Correct classification of cases did not used a condom on last sexual encounter = 14.1%
  51. 51. 51 Chapter 3 Factor Differentials in contraceptive use and demographic profile among females who had their first coital activity at most 16 years versus those at 16 + years old in a developing nation Paul A. Bourne Introduction For decades, the developing countries like the developed nations have been experiencing lowered age at first coital activity, which commences during the adolescence years. Young people (ie. adolescents) continue to be engaged in sexual activities outside of marriage and even the statutes. The continuity of early sexual debut means that there are some health and social matters that will face the society because of early sexual relationships. It is well documented that early sexual initiation is associated with increased HIV, human papillomavirus (HPV), cervical cancers, teenage pregnancy, unwanted pregnancies, abortion (safe and unsafe), and lowered levels of education and financial opportunities [1-6]. While the developing nations have been plagued by the HIV/AIDS epidemic and lowered age at sexual debut, the developed world is more so experiencing lowered age at first sexual debut than the prevalence and incidence of HIV/AIDS epidemic faced by the developing societies. A previous study established that the lowering of the age of first coital activity has been so for the past 3 decades in developed nations, and particularly in New Zealand [7]. Furthermore, Dickson et al.’s work [7]; using a longitudinal study of a cohort born in Dunedin in 1972-3, found that there were young people who were engaged in sexual activities before 13 years old. This concurs with a five community ethnographic study carried out by Chevannes in the Caribbean [8], which found that sex among adolescents’ starts as early as 14 years. The aforementioned early sexual debut in the Caribbean
  52. 52. 52 and New Zealand is also obtained in the United States [9], and a group of researchers found that almost 12 out of every 25 individuals aged 15-19 years in the United States reported having had sexual intercourse at least once [10]. In United States, the median age at first sexual debut was 17 years, which is higher than that in Jamaica (15.0 years) [11, 12]. Like United States, New Zealand and Jamaica, some African nations (such as Uganda, Kenya, Ghana, Tanzania, Zambia and Zimbabwe) had a median age which is statistical the same, suggesting that premarital sexual behaviour is similar in many developing and particular developed societies. A previous study conducted by Wilks et al [13], using a national probability same survey of 2,848 Jamaicans aged 15-74 years, found that 22 out of every 25 people aged 15-24 years have had sexual intercourse - 21 out of every 25 males aged 15-24 years and 19 out of every 25 females of the same age [13]. The sexual expression and practices of young Jamaicans (aged 15-24 years) is embedded in the fact that 11 out of every 25 have sex at least once per week - 11 out of every 25 males and 10 out of every 25 females [13]. Statistics also showed that 2.6% of Jamaicans aged 15-24 years had a STI in the last 12 months compared with 2.4% of Jamaicans aged 15-74 years old. Comparatively between the United States and Jamaica, less Americans aged 14-22 years were sexually active compared to Jamaicans aged 15-24 years [9, 13]. However, there were similarities between Jamaica and the United States as the age at sexual debut for males and females was relatively close [9, 13], suggesting congruency in sexual expressions. Using dataset for the 2002 Reproductive Health Survey in Jamaica [12], the mean age at first coitus was 14.7 years (SD = 3.1, median age at first intercourse = 15.0, range = 13 – 16 years) [14], and the median age of first coitus among females aged 16-49 years was 16.0 years in 2001, this fell from 17.3 years in 1997 [12]. The rationales for using < 16 years and 16+ are (1)
  53. 53. 53 the age of individual sexual consent is 16 years, and (2) the median age of first coitus among females aged 15-49 years was 16 years. Inspite of public health campaigns to address (1) the lowering of age of sexual intercourse, (2) HIV/AIDS among the population, particularly among adolescents and young adults, (3) sexual promiscuity, (4) inconsistent condom usage, (5) unwanted pregnancies and (6) better sexual practices in the world, particularly in Jamaica, the society has seen the continuous erosion of values because the aforementioned matters continue unabated and there seems to be no end in sight. Many developed nations such as New Zealand and the United States is experiencing the early age of sexual debut epidemic like Jamaica. Apart of the justification of this public health challenge is that lifestyle practices, cultural values and expectation as well as orientations which are changing in the 21st century. Although females in world have been living longer than males (life expectancy or healthy life expectancy), which is the case in Jamaica, statistics revealed that the incidence of STIs among female for 2007/2008 in Jamaica were greater for them than their male counterparts [13]. This is within context of increased public health education campaigns on sexual responsibility and the rise of HIV/AIDS in the nation. Embedded in the incidence of STIs are the cultural values, lifestyle, norms, beliefs and sexual practices of females, which will not easily change because external agents such as health educators and professionals say that they are to do this. The literature on age at first sexual intercourse is extensive but recent and factors that determine contraceptive use of female [2-7, 15, 16], but no research existed that examined differentials in factors of contraceptive use between females whose first coital activity was < 16 years and 16+ years old. Bourne et al. [16] eight factors were statistical associated with contraceptive use among females aged 15-49 years. The factors were age (OR = 0.95, 95%CI =
  54. 54. 54 0.98 – 0.99); social class (upper class, OR = 0.83, 95%CI = 0.73 – 0.95); area of residence (rural, OR = 1.16, 95%CI = 1.02 – 1.32); currently pregnant (OR = 0.01, 95%CI = 0.00 – 0.02); had sex in last 30 days (OR = 2.29, 95%CI = 1.95 – 2.70); number of sexual partners (OR = 1.85, 95%CI = 1.57 – 2.17); age began using method of contraception (OR = 0.99, 95%CI = 0.98 – 1.00), and crowding (OR = 1.4, 95%CI = 1.21 – 1.60). If research provides an understanding of issues in our physical and social milieu, then, a study on the aforementioned is critical and timely as it would provide insights into their behaviour, thereby allowing health practitioners and educator to better understand how to address the increasing HIV/AIDS virus and other public health problems such as unwanted pregnancies and unsafe abortions. With previous studies having demonstrated that early sexual activities are associated with increased HIV/AIDS infections, cervical cancers and other health problems [1-6, 15], understanding early sexual activity (before the statutory age 16 years in Jamaica) and post the statutory age will provide invaluable insights into practices and measure that can be formulated to address the lifestyle of these individuals. This current study, recognizing limitations of previous research on the aforementioned issue within the context of the increased HIV/AIDS virus, unwanted pregnancy, abortions and high fertility [17-19] coupled with the continuous lowering of age of sexual debut over the decades, can add value to public health by studying factor differentials in contraceptive use between females whose first coital activity was < 16 years and those 16+ years old as well as their demographic profile. Such a research is timely and will guide policy formulation and intervention programmes. The rationales for the study are primarily based on (1) females vulnerability in contracting HIV/AIDS and other STI, (2) females being less economic independent than their male counterparts, (3) the vetoing power of males over females’ reproductive health choices in developing nations, (4) income inequalities between the genders,
  55. 55. 55 and (5) the issue of survivability. This research aims to elucidate information on the differentials in factors of contraceptive use between females whose first coital activity was < 16 years and 16+ years old and to provide a socio-demographic and reproductive health profile of these individuals. Methods Sample (participants) and procedures A descriptive cross-sectional study was carried out by the National Family Planning Board (Reproductive Health Survey or RHS). There are two sets of inclusion criteria, which are females and ages. The eligibility criterion for age was 15 to 49 years at last birthday. In 2002, RHS collected data on Jamaican men ages 15-24 years as well as women 15-49 years old. The current study extracted only females aged 15-49 years from 2002 Reproductive Health Survey (RHS) dataset to carry out this research. The female sample for the 2002 RHS was 7,168 women of the reproductive ages, with a response rate of 77.6%. Of those who responded (n=5, 565), 32.5% had first coitus before 16 years old compared with 67.5% who began at 16+ years old. Thus, the entire female sample for the 2002 RHS that responded to the survey was used for this study. Stratified random sampling was used to design the sampling frame from which the sample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage sampling design was used. Stage 1 was the use of a selection frame of 659 enumeration areas (or enumeration districts, EDs). This was calculated based on probability proportion to size. Jamaica is classified into four health regions, which constitute particular parishes (there are 14 parishes). Region 1 is composed of Kingston, St. Andrew, St. Thomas and St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up of Trelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchester and Clarendon. The 2001

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