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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 ...

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 Sexual Expressions in Jamaica Document Transcript

  • Chapter 1 Sociodemographic correlates of age at sexual debut among women of the reproductive years in a middle-income developing nation Paul A. BourneIntroductionIn 1997, statistics revealed that the median age at first sexual intercourse for Jamaican womenwas 17.3 years and this fell to 16.0 years in 2002.1 Embedded in this finding is the lowering ofpremarital sexual relations with the passing of time, and the reproductive health problemsassociated with early sexual debut among women aged 15-49 years. Early sexual debut posesboth health (STIs, HIV, HPV, pregnancy) and social (school drop-outs) risks, and continues to bea public health concern among several nations.1 Inconsistent contraceptive use coupled with thecontinuous lowering of the age of sexual relations offers an explanation of the failure of publichealth programmes to effectively address sexual behaviour of females in many developingcountries, 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 reportedusing a condom in the last 30 days1, indicating not only premarital sexual relations, but also riskylifestyle practices and the likely to the spread of HIV/AIDS and other sexually transmittedinfections.1 The lowering of the age at sexual debut further goes beyond unwanted pregnanciesto health problems such as cervical cancers, human papillomavirus (HPV) and genital or analulceration, unsafe abortions, psychological trauma and the socioeconomic challenges for thesociety in the future, which makes it a public health problem worth studying. 1
  • Almost 2 in every 5 Jamaican women have been pregnant at least once prior to reachingthe age of 20; most of pregnancies are unplanned, especially during the adolescent years (80%). 1The average age at first sexual initiation in Jamaica is 15.8 for females and 13.5 for males,1 muchof which is forced and is seen as a direct link with violence, as well as one of the roots of sexualand reproductive health problems in the international community.2 Such problem goes againstthe principles of the ICPD 1994, which stipulates that when it comes to matters of sexualrelations, full respect for the integrity of the individuals involved should be of the utmost.2 “Firstsexual intercourse almost always take place outside of a formal union”3 and with older men (forthe females) 4, this occurrence is likely to result in health situations relating to STIs and HIV, aswell as drug abuse.5 Inspite of the reality of the lowering of age at first sexual debut, particularly with regardto premarital sex of adolescents, the developing societies, in particular Jamaica, do not frownupon this practice.6,7 Although teenage fertility is not actively condoned in the Caribbean,6 thechurches and family planning interventions have been actively campaigning against this practiceas well as early sexual debut, but the practice continues. Early sexual debut, inconsistent condomusage and teenage pregnancy are not atypical in the developing world, more specificallyJamaica. A study of some sub-Saharan African and South-East Asian nations show similarsexual behaviour and attitude of young people.8 According to Warren et al.,9 the high fertilitypopulation in Jamaica was women ages 14-24 years, indicating a high degree of premaritalsexual activities and inconsistent condom use within the context of reduced age at first sexualintercourse.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 2
  • accounting for increased HIV/AIDS and STIs in Jamaica and on a wider scale in otherdeveloping 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 15years.14, 15 According to Crawford, McGrowder and Crawford, 16 2 in every 5 Jamaican womenhave been pregnant at least once, 4 in every 5 adolescent women pregnancies were unplannedand 74% of females ages 15-17 years old were sexually active compared to 47% of males of thesame age. Moreover, Crawford and colleagues found that of the sample of adolescents, none ofthe 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, inparticular Jamaica, and the lowering of age at first sexual intercourse among young women in thedeveloping 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 firstsexual 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 pointedout that young individuals who resided with both parents encountered sexual initiation later thanthose in other family situations.4 Another study conducted by Fatusi & Blum,17 using a sample of2,070 adolescents who were never married, found that condom efficacy, positive attitude tofamily planning use, condom access, alcohol use, and higher level of religiosity were associatedwith age at first sexual debut. Fatusi & Blum’s work concurs with some of the findings of an 3 View slide
  • earlier study, which found self-efficacy, alcohol and drug use, norms about having sexualintercourse, poor academic performance and gender to be factors that explain sexual initiationamong middle-school, inner city youth.18 Penfold et al., 19 using a sample of 4,379 Scottishadolescents, found that family (parental monitoring), school life (enjoyment), gender, self-esteem, religion, and informal sexual health intervention were associated with self-reported firstsexual intercourse. Penfold et al.’s work added more variables to the existing body of literatureon age at first sexual debut. Rosenthal et al.20 added to the afore-mentioned factors which arealso associated with age at first sexual initiation. They found that the perception of greaterphysical maturity, expectations of earlier autonomy among gender, and the use of illicit drugs tobe 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, andother malignant neoplasm are among the 10 leading causes of mortality among Jamaicanwomen; 21 as well as the direct association between early age of sexual debut, the increased risk 22of cervical cancers, the relationship between cervical cancer and STI, in particular humanpapillomavirus (HPV), and age at first sexual debut23-25. The issue of factors explaining age atfirst sexual initiation is unresearched in Jamaica. Most studies that have examined factors associated with age at first sexual intercoursehave used young people between ages 10-30 years. In this study, we seek to elucidate correlateswhich account for age at sexual debut of women aged 15-49 years in Jamaica. This study is notfar fetched as a previous study in Europe used ages 16-44 years.26 The main objective of thispaper was to elucidate the socioeconomic variables which explain age at first sexual initiation ofJamaican women (ages 15-49 years). It explored variables relating to early sexual debut such asage of menarche, contraception, religion, education, crowding, shared sanitary convenience, 4 View slide
  • forced sexual experience, marital status, employment status, subjective social class, and area ofresidence among women in the reproductive years.MethodsSampleThis descriptive cross-sectional study used a secondary dataset from the National FamilyPlanning 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 onwomen (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 15-24years as well as women 15-49 years old. The current study extracted only females aged 15-49years from 2002 Reproductive Health Survey to carry out this research. The study populationwas 7,168 women of the reproductive ages. Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomasand St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica comparedto Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8%.1 5
  • In stage 2, the households were clustered into primary sampling units (PSUs), and eachPSU constituted an ED, which in turn was comprised of 80 households. The previous samplingframe was in need of updating, and so this was performed between January and May 2002. Theprevious sampling frame was in need of updating, and so this was carried out between January2002 and May 2002. The new sampling frame formed the basis upon which the sampling sizewas computed for the interviewers to use. Stage 3 was the final selection of one eligible female from each sampled household andthis 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 instrumentadministered 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-testingof the instrument was conducted between March 16 and 20, 2002. A total of 175 instrumentswere pre-tested.. Modifications were made to the pre-tested instrument (questionnaire), afterwhich the final exercise was carried out. Validity and reliability of the data were conducted bymany statisticians, statistical agency, and university scholars before the data was used as the dataare 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 populationof female aged 15 to 49 years in the nation.1Statistical analysesData were entered, stored and retrieved using SPSS for Window, Version 16.0 (SPSS Inc;Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographiccharacteristics of the sample (frequency, mean, standard deviation (SD), and range). All metric 6
  • variables were tested for normality (age at first sexual debut, crowding, age, and years ofschooling). Where skewness was found to be less than 0.5, the variable was used in its currentform and a value more than 0.5 was normalized by natural log, or another method. Independentsample t-test was used to examine differences in age at sexual debut between those whofrequently attend churches and those who infrequently visit churches and F-statistic wasemployed 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 acontinuous one. Stepwise multiple linear regression was used to fit the one outcome measure(age at first sexual debut) by different sociodemographic variables. Thus, only explanatoryvariables (i.e. statistically significant variables) are shown in Table 1.3. Where collinearityexisted (r > 0.7), variables were entered independently into the model to determine those thatshould be retained during the final model construction.27 To derive accurate tests of statisticalsignificance, we used SUDDAN statistical software (Research Triangle Institute, ResearchTriangle 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.MeasuresAge at first sexual debut (or initiation or intercourse) was measured based on a respondent’sanswer to the question “At what age did you have your first intercourse? Crowding is the totalnumber of persons in a dwelling (excluding kitchen, bathroom and verandah). Age is the numberof years a person is alive up to his/her last birthday (in years). Contraceptive method comes fromthe question “Are you and your partner currently using a method of contraception? …”, and ifthe answer is yes “Which method of contraception do you use?” Age at which began usingcontraception was taken from “How old were you when you first used contraception? Area of 7
  • residence is measured from “In which area do you reside?” The options were rural, semi-urbanand urban (1 = rural, 0 = otherwise; 1 = semi-urban, 0 = otherwise, and urban is the referencegroup). Currently having sex is measured from “Have you had sexual intercourse in the last 30days?” (1=yes, 0 = otherwise). Education is measured from the question “How many years didyou attend school?” Marital status is measured from the following question “Are you legallymarried now?”, “Are you living with a common-law partner now? (that is, are you living as manand wife now with a partner to whom you are not legally married?)”, “Do you have a visitingpartner, that is, a more or less steady partner with whom you have sexual relations?”, and “Areyou currently single?” Age at menarche is measured from “How old were you when your firstperiod started (first started menstruation)?” Gynaecological examination is taken from “Haveyou ever had a gynaecological examination?” (1 = yes, 0 = no). Pregnancy was assessed by “Areyou 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 onceper 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 socialclass is measured from “In which class do you belong?” The options are lower, middle or uppersocial hierarchy (1 = middle class, 0 = otherwise; 1 = upper class, 0 = otherwise; reference groupis lower class). Forced to have sexual relations was assessed from the question “Were you forcedto have sex at your first intercourse?” and the options were yes, no, don’t know and refused toanswer (1= yes, 0 = otherwise). Age at first sexual debut, age at menarche, age at firstcontraceptive use, and years of schooling were used as continuous variables. Early sexual debutis having sexual intercourse before the statutory legal age to do so (in Jamaica, this is 16 yearsold). 8
  • ResultTable 1.1 presents the demographic characteristics of the sample, which comprises 7,168respondents (women who are ages 15-49 years at their last birthday). Most of the women in thesurvey have been pregnant (84.3%) prior to this study and (4.4%) were pregnant at the time ofthe study. Only 40.6% of the sample indicated that they had wanted to become pregnant, whenthey realized they were. The mean age of menarche was 13.5 years (SD = 4.4 years), with themedian age of first sexual relations being 16.0 years (Range = 36 years). The mean age at whichthe sample began using a contraceptive method was 19.8 years (SD = 4.3 years). Twenty-fivepercentages 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 sexeducation at 13.0 years (Range: 10, 29 years). The mean age for those who had their first sexualintercourse was 15.2 years (SD = 5.9). One-half of the sample stated that they were dating theirpartners 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 permonth 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 withtheir husbands at the time of this study, five percent (5%) of those who have been pregnant hadstill births, 12.1% had miscarriages, and 11.4% have been forced to have sexual relations withanother person. Fifty-six percentages of the respondents are currently using a contraceptive to preventpregnancy. 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%). 9
  • Figure 1.1 provides information on the relations between the respondents and the personswith whom they (respondents) had her first sexual encounter. Majority of the sample indicatedthat they used a contraceptive method on their first sexual relations (64.1%). These methodsinclude the condom (95.1%); rhythm or knaus-ogino method (2.3%); pill (1.9%); injection andintra-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 abortionwere 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 ofa partner (2.0%) and other issues (22.5%). Thirty-five percentage of the respondents indicatedthat they became pregnant while attending school, of which 28.3% continued their educationafter 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 usedpublic/government facilities (public hospitals, 8.9%; government clinics, 22.2%). Frequent attendees to church begin having sexual relations on average (mean) at 17.4years (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 ofparticular geographical areas (F-statistic = 32.4, P < 0.0001). On average rural women beganhaving sexual intercourse at 16.5 years (SD = 2.6 years) compared to 1.7 years (should this be 10
  • 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 thestudied population (F statistic = 47.3, P < 0.0001). Table 1.3 examines factors that are associated with the age of first sexual relations ofwomen ages 15 to 49 years in Jamaica. Using multiple regressions analyses, of the 17 variablesthat were tested in the model, 11 variables emerged as statistically significant predictors of age offirst sexual relations (F-statistic [11, 5720] = 176.2, P-value < 0.0001). The factors explained27.8% of the variability in age of first sexual relations.Discussion The sociodemographic related evidence of early sexual initiation has been put forward inthis study and shows consonance with the literature. It is realized that sexual intercourse at anearly age is usually by someone older and who is outside of a union. The risk associated with thisfactor is that “older male partner presents a greater HIV transmission risk because they are morelikely than adolescent men to have had multiple partners; to have had varied sexual and drug useexperience and to be infected with HIV.”5 Sometimes the young female is persuaded by the theirolder male perpetrators or partner, from using condom because of varying personal ideologiesand are therefore, less likely to use condom at first sexual intercourse (82%),5 unlike the findingsof this study (64.1%). This not only result in STIs but also unwanted pregnancy (which affects 28more than 80 million people worldwide ), thus the high possibility of school drop-out, mosttimes after receiving up to approximately 12 years of formal education (similar to the findings of 11
  • this study). Where females are persuaded from using condom at first sexual intercourse, this maybe explained by the fact that males tend to be more casual about sexual relations and are morewilling to emphasize sexual aspects than their female counterparts, who are more likely toromanticize sexual relationships. This view point bears consistency with the findings of this study, whereby drop-outs weremore prevalent among those who became pregnant while attending school (35%) whencompared to those who continued their education after the pregnancy (28.3%). Other schools ofthought postulated that sexual activity and pregnancy among adolescents or teenagers inJamaica, 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 onaverage began having sex 8 months earlier than other women (at 16.5 years) that is the age inwhich they would be in grades 10 and/or 11. Those grades are pivotal for the completion ofsecondary level education, which means that lower level education will be greater among ruralwomen than those in other geographic areas. It is this lowered age of sexual debut and ignoranceof 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 ifinformation was available.2 Therefore, “the lack of knowledge and available optionsundermines the right of couples and individuals to exercise control over their fertility and to havechildren in health and by choice”.2 Knowledge about contraception and the various servicesavailable regarding its access is considered an obligation of national governments, especiallyfrom a human rights perspective.31 In Jamaica, many youths lack accurate sexual healthinformation, especially with regard to the possibility of pregnancy at first intercourse; protectionagainst STIs via the correct use of the correct contraceptives; the effectiveness of oral 12
  • contraceptives against pregnancy; fallacies relating to contraceptive methods.32 Such asymmetricinformation result in unintended pregnancies, STIs, and abortion. Where abortion is illegal andaccess to contraception is limited, more than half of the pregnancies end in abortion.28 Take forinstance, in the cases of Chile, Hungary, Russia, Turkey, Czech Republic, abortion rates declinedsignificantly owing to access to modern forms of contraception.28 Similarly, in Canada, access touser-friendly reproductive health services, high quality sex education and the increase use of oralcontraception has resulted in a decline in teen pregnancy rate.33 In Jamaica, a research by McNeilconcurs with the aforementioned studies that teenage pregnancy fell by 14.6% (from 1997 to2000) because of sex education programmes, training, counseling, skills training and increasedcontraceptive use.34 Many scholars view early pregnancies as a potential population problem as this increasesthe chance of larger family size. This has contributed to 30% birth in islands such as St. Kitts andNevis, Dominica, St. Lucia and 32% for Jamaica.35 In an effort to avoid poor education or schooldrop-outs, pregnancies are sometimes interrupted (induced abortion), which is about 60% amongthe average teenager.14 In South Africa, a study found that 32% of pregnant teenagers completehigh school,36 suggesting and agreeing that medical or surgical abortions reduce the probabilityof poor educational attainment. Another study shows that “adolescent girls contribute 55% of allclandestine abortions” in Nigeria.37 While abortion still remains a public policy and public health 31debate, in some countries it is considered a human right (Sweden), legal (Guyana and Haitiand illegal (Jamaica, Nicaragua and Chile). The reality is “Over 19 million women globallyresort to unsafe abortion each year, largely among the world’s poorest and most vulnerablewomen, especially young women”,38 indicating that the illegality of abortion does not abate itspractices, but it becomes a public health concern. In Jamaica, abortion is considered a serious 13
  • offence under the Offences Against the Person Act 1973, Section 73, 39 and this goes to reducingtheir reproductive health choice and open avenues of them seeking the service in unsafeconditions. The reality is, with poverty being greater in rural areas and among females inJamaica,40 unwanted pregnancies which are arising from ignorance of contraception and earliersexual initiation means that educational disparity and income inequality if not abated will see ahigher fertility, adoption and unsafe abortions among those women. Worldwide, “more than half a million women die every year from pregnancy-relatedcauses”.2 Many deaths resulted from approximately 20 million unsafe abortions that occuryearly, especially among adolescent girls and young women in developing countries.2 In manydeveloping 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 anobstacle to their enjoyment of human rights”.31 The goal of the World Summit on SocialDevelopment (WSSD) Declaration and Programme of Action 1995, the ICPD 1994 and theWorld 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 fromunsafe 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. Onein six women in other Caribbean nations between the ages of 15 and 24 became sexually active 14,15before the age of 15 years, and 1 in 4 women in Jamaica begin at 15 years, and this is evenlower among non-frequent religious women (14.7 years). The current research shows a marginaldifference in the Crawford, McGrowder and Crawford’s16 which had that the mean age of sexualdebut for female was 15.8 years in Jamaica. Disaggregating the age at which women aged 15-49 14
  • years had their first sexual intercourse, we found that the mean age at sexual debut was lowestfor 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 wasout of violence, this research disagrees as we found that only 11.4% of those who have hadearlier sexual intercourse were raped,16 which indicates that the majority of first sexual debutwas a consensual act although by statutes all sexual relations below 16 years is a rape.41 A study 42in New Zealand found that 7% of first sexual intercourse was forced, which is marginallylower than that of Jamaica. The time difference may account for this dissimilarity as Dickson et 42al.’s work was in 1993-1994, while the current study used data for 2004. Moreover, “Firstsexual intercourse almost always took place outside of a formal union”3 and with older men (forthe females).4 We found that the majority of first sexual relations took place with a boy friend ina visiting relationship with the respondent. Based on the foregoing, “The timing of sexual debut among adolescents is influenced bya wide range of factors including: age, gender, poverty, family structure, educational level,pubertal timing, socio-economic status, self-efficacy, peer influences, religiosity, knowledge andperceived risk of sexually transmitted infections, parenting practices and parental supervision,community, media and health inequalities”.43 Outside of those factors which explain early firstcoitus in the developing nations, particularly the Caribbean is the masculine orientation andculture.44 Research demonstrates that the role of culture in the socialization of children is criticalto fashioning the adult, and as soon as females begin to grow breast and to menstruate there is aperception of womanhood. During this growth and development process, the female adolescents’physiology of reproduction sometimes begins in order to establish womanhood. 15
  • The validity of recall of age of first sexual intercourse has been established by a group ofresearchers in 1997. They found that the test-retest correlations for the recall of age at first sexualrelations was 0.85 for females and 0.91 for males,45 which indicates the validity of usage ofrecall data to measure the phenomenon. Hence, there is legitimacy in the use of cross-sectionalsurvey data to examine age at first sexual intercourse in Jamaica, and the findings thereforeprovide invaluable insight into the attitude, behaviour and practices of women in Jamaica andthose 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 socioeconomicconditions are associated with age at first sexual intercourse.46-48 It also concurs with otherstudies that sexual activity is no longer strongly predicted by marriage49-52 as the majority ofwomen who had their first sexual experience, engaged in such activity with a boy friend, strangeror mere acquaintance (87 out of every 100 women). With the low condom usage on first sexualintercourse found in this research, young women are open to the risk of STI, pregnancy andpsychological challenges of early sexual relations, and therefore this justifies the rationale forwanting to modify sexual practices of adolescents.53,54 While the current reality of age at first sexual intercourse in Jamaica appears low, this isequally the case in other nations as we found that 80% of a recent cohort of youths who had sexdid so become 20 years.55 The image that is embodied in these figures is the sexual complaintswhich are likely to result from the adult sexual decision that will be taken by adolescents, 56, 57and 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 areasin the world are not reaching adolescents as they are have committed (under the ICPD 1994), and 16
  • by extension have failed to reduce the lowering of age of first sexual intercourse. With thefactors which emerged from the current study as accounting for age at first sexual intercourse, as 58-60 61well as those from other studies, like McGrath and colleagues, we believe that amultisectoral 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 inthe reviewed studies, 62-64 as well as the evidentiary support of Jamaica. Within the context oflowered age at first sexual intercourse of Jamaican women as well as the association betweenforced sexual relations and early age of sexual debut, 65 this would be contributing to the currentpublic health problems of teenage pregnancies, high fertility, STIs, increased maternal and childmortality, and psychologically challenged young people as they undergo the difficulty of theexperience.66-68 Clearly, this study highlighted the finding that the average age at first sexual debut forJamaican women (median age was 16.0 years) was lower than that of women in rural SouthAfrican (median age was 18.5 years)69 and eastern Zimbabwe (median age was 18.5 years).70 Astudy, using European women ages 16-44, found that the average age of first sexual debut wasless than 16 years, and offers little solace for public health practitioners in Jamaica.23 AlthoughSouth Africa had the highest HIV infection rate in the world69 and an age at first sexual debutlower than that of Jamaican women, public health specialists need to use the current findings toensure 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 shownthe association between age at first sexual intercourse and having an STI.70 The rationale for thisprescriptive recommendation for public health specialists is embedded in the association betweenearly sexual debut and sexually transmitted infections as well as evidence which shows that STIs 17
  • are a gateway to complications such as pelvic inflammatory infections, infertility, ectopicpregnancy, fetal abnormality and HIV/AIDS.70-72 Those are not the only issues of concerns at ageat 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 thisphenomenon.19,20,22,25,69,70,73 This study concurs with the literature and added more variables suchas age at contraceptive use, forced sexual relations, employment status, shared sanitaryconvenience, area of residence, and marital status, indicating that multi-variables are associatedwith age at first sexual initiation of Jamaican women.ConclusionPublic health policies have failed to effectively increase the age at first sexual intercourse forwomen in Jamaica. This study shows that a multisectorial philosophy to the intervention isneeded in order to address the multidimensional nature of the factors which are associated withage at first sexual debut. Sexual intercourse is commonly initiated in the adolescence years, andwith the increased risk of sexually transmitted infections, teenage pregnancy and adoption withearly sexual initiation, the public health consequences will be dire if they are felt unabated or theage at sexual debut allowed to fall lower than current value.DisclosuresThe author report no conflict of interest with this work. 18
  • DisclaimerThe researcher would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researcher.AcknowledgementThe 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 ReproductiveHealth Survey, RHS) available for use in this study, and the National Family Planning Board forcommissioning the survey. 19
  • References[1] Jamaica, National Family Planning Board (NFPB). Reproductive Health Survey, 2002.Kingston: NFPB; 2005[2] Family Care International. Commitments to Sexual and Reproductive Health and Rights forAll. Framework for Action. New York, NY: Family Care International; 1995[3] US Department of Health and Services (2006). Gender Differences in Reproductive Health.Department of Health and Human Services, Centre for Disease Control, USAID and JamaicaNational Family Planning Board.[4] Sexual Initiation. American Sexual Behaviour.http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010).[5] Miller KS, Clarke LF, Moore JS. Sexual initiation with older male partners and subsequentHIV risk behavior among female adolescents. Family Planning Perspectives; 29, 1997:212-214.[6] Drayton VLC. Contraceptive use among Jamaican teenage mothers. Pan Am H Public Health2002; 11(3):150-157.[7] Jagdeo T. The dynamics of adolescents fertility in the Caribbean. St. John’s, Antigua:Caribbean Family Planning Affiliation; 1992.[8] Williamson LM, Parkes A, Wight D, Petticrew M, Hart GJ. Limits to modern contraceptiveuse among young women in developing countries: A systematic review of qualitative research.Reproductive Health 2009; 6:3[9] Warren CW, Powell D, Morris L, Jackson J, Hamilton P. Fertility and family planning amongyoung adults in Jamaica. Int Family Planning Perspectives 1988; 14(4):137-141.[10] Eggleston E, Jackson J and Hardee K. Sexual attitudes and behavior among youngadolescents in Jamaica. Guttmacher. International Family Planning Perspectives; 25(2), 1999.[11] Henry-Lee A. Women’s reasons for discontinuing contraceptive use within 12 months:Jamaica. Reproductive Health Matters 2001;9(17):213-220.[12] World Health Organization (WHO). Reproductive health research at WHO: A newbeginning. Biennial report 1998-1999. Geneva: WHO; 2000.[13] World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009.[14] Rawlins J. Teenage Pregnancy: A study in three communities in Trinidad and Tobago.Paper presented at the Caribbean Health Research Conference 2007, Jamaica.[15] Jamaica Observer. Study shows Jamaican Girls Encounter Violent Sexual Relationships.Jamaica Observer (15 April 2009).[16] Crawford TV, McGrowder DA, Crawford A. Access to contraception by minors in Jamaica:a public concern. North Am J of Med Sci 2009; 1(5):247-255.[17] Fatusi AO, and Blum, RW. Predictors of early sexual initiation among a nationallyrepresentative sample of Nigerian adolescents. BMC Public Health; 8, 2008.[18] Santelli JS, Kaiser J, Hirsch L, Radosh A, Simkin L, Middlestadt S: Initiation of sexualintercourse among middle school adolescents: the influence of psychosocial factors.J Adolesc Health 2004, 34:200-208.[19] Penfold SC, Teijlingen ERV, Tucker JS. Factors associated with self-reported first sexualintercourse in Scottish adolescents. BMC Research Notes 2009; 2:42.[20] Rosenthal DA, Smith AMA, De Visser R. Personal and social factors influencing age at firstsexual intercourse. Archives of Social Behavior 1999; 28(4):319-333. 20
  • [21] Statistical Institute of Jamaica (STATIN). Demographic statistics, 2007. Kingston:STATIN; 2008.[22] Louie KS, de Sanjose S, Diaz M, et al. Early age at first sexual intercourse and earlypregnancy are risk factors for cervical cancer in developing countries. Br J Cancer 2009;100(7):119-7.[23] Population Reference Bureau. Preventing cervical cancer worldwide. Washington, D.C:Population Reference Bureau; 2004.[24] Pan American Health Organization (PAHO). A situational analysis of cervical cancer inLatin American and the Caribbean. Washington, D.C: PAHO; 2004.[25] Kahn JA et al., Mediators of the association between age of first sexual intercourse andsubsequent human papillomavirus infection, Pediatrics, 2002, 109(01).[26] Mardh PA, Creatsas G, Guaschino S, et al. Correlation between early sexual debut, andreproductive health and behavioral factors: a multinational European study. Eur J ContraceptReprod Health Care 2000; 5:177-82.[27] Polit DF. Data analysis and statistics from nursing research. Stamford: Appleton & LangePublisher; 1996.[28] Population Action International. Contraceptive use helps reduce the incidence of abortion.Fact Sheet. Washington DC., Population Action International.[29] Alan Gunmacher Institute. Women and reproductive health in Latin America and theCaribbean. Women, families and the future. NY: The Institute, 1994.[30] Castro MT. Guatemala: Encuesta Nacional de Salud Materno Infantil, 1995. Demographicand Health Survey. MD: Macro International, 1996.[31] Ministry of Foreign Affairs. Sweden’s International Policy on Sexual and ReproductiveHealth and Rights. Stockholm: Ministry of Foreign Affairs, Sweden; 2006.[32] Ward M The reproductive and sexual health of Jamaican youth. Advocates for Youth.Washington DC., Advocates for Youth; 2001.[33] McKay A. Adolescent sexual and reproductive health in Canada: A report card in 2004.The Canadian Journal of Human Sexuality; 13(2), 2004:67-81.[34] McNeil P. Coping with teenage pregnancy. In: Morgan O. ed. Health issues in theCaribbean 2005; pp. 51- 57.[35] Rawlins J. Parent-Child interaction and teenage pregnancy. Master of Science DegreeThesis. University of the West Indies, Jamaica; 1981.[36] Cooper D, Dickson K, Blanchard K, et al. Medical abortion: The possibilities forintroduction in the public sector in South Africa. Reproductive Health Matters 2005;13:35-43.[37] Bankole A, Oye-Adeniran BA, Singh S, et al. Unwanted pregnancy and induced abortion inNigeria: causes and consequences. New York: Guttmacher Institute; 2006[38] Reproductive Health Matters. Consensus statement. Medical abortion: Expanding access tosafe abortion and saving women’s lives. Reproductive Health Matters 2005;13(26):11-12.[39] Jamaica Laws. Offences Against the Person Act, 1973. Kingston: Jamaica GovernmentPrintery;1973.[40] Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). JamaicaSurvey of Living Conditions, 2007. Kingston: PIOJ, STATIN: 2008.[41] Jamaica Laws. Child Care and Protect Act, 2004. Kingston: Jamaica Government Printery;2004. 21
  • [42] Dickson N, Paul C, Herbison P, Silva P. First sexual intercourse: age, coercion, and laterregrets reported by a birth cohort. BMJ 1998;316:39-30.[43] Lammers C, Ireland M, Resnick M, Blum R: Influences on adolescents’ decision topostpone sexual intercourse: a survival analysis of virginity among youths aged 13 to 18 years. JAdolesc Health 2000, 26:42-48[44] Chevannes B. Learning to be a man: Culture, socialization and gender identity in fiveCaribbean communities. Kingston, Jamaica: The Univer. of the West Indies Press; 2001. [45] Dunne MP, Martin NG, Statham DJ, Pangan T, Madden PA, Heath AC. The consistency ofrecall age at first sexual intercourse. J of Biosocial Science 1997;29:1-7.[46] Upchurch DM, Levey-Storms, Sucoff CA, Aneshensel CS. Gender and ethnic differences inthe timing of first sexual intercourse. Family Planning Perspectives, 1998, 30(3):121–127.[47] DeLamater J. The social control of sexuality. Annual Review of Sociology, 1981; 7: 263–290.[48] Udry JR and Campbell BC, Getting started on sexual behavior, in: Rossi AS, ed., SexualityAcross the Life Course, Chicago: University of Chicago Press; 1994.[49] D’Emilio J and Freedman ES, Intimate Matters: A Historyof Sexuality in America, NewYork: Harper and Row, 1988.[50] Nathanson CA, Dangerous Passage: The SocialControl of Sexuality in Women’sAdolescence, Philadelphia:Temple University Press, 1991.[51] Hogan DP and Astone NM, The transition to adulthood, Annual Review of Sociology, 1986,No. 12, pp.109–130.[52] Miller BC and Heaton TB, Age at first sexual intercourse and the timing of marriage andchildbirth, Journal of Marriage and the Family, 1991, 53(3):719–732.[53] Brindis CD et al., Complex Terrain: Charting a Course of Action to Prevent AdolescentPregnancy, San Francisco: Center for Reproductive Health Policy Research, Institute forHealth Policy Studies, University of California, 1997.[54] Moore KA et al., Adolescent Sex, Contraception, and Childbearing:A Review of RecentEvidence, Washington, DC: Child Trends, 1995.[55] Henshaw SK, U.S. teenage pregnancy statistics, NewYork: The Alan Guttmacher Institute,1994.[56] Woo JST, Brotto LA. Age of first sexual intercourse and acculturation: Effects on adultsexual responding. The J of Sexual Medicine 2008;5:571-582.[57] Slaymaker, E, Bwanika, J B, Kasamba, I, Lutalo, T, Maher, D, Todd, J. Trends in age atfirst sex in Uganda: evidence from Demographic and Health Survey data and longitudinalcohorts in Masaka and Rakai. Sex. Transm. Infect. 2009; 85: i12-i19.[58] Gupta N, Mahy M. Sexual initiation among adolescent girls and boys: trends anddifferentials in sub-Saharan Africa. Arch Sex Behav 2003; 32:41–53.[59] Hallett TB, Lewis JJ, Lopman BA, et al. Age at first sex and HIV infection in ruralZimbabwe. Stud Fam Plann 2007; 38:1–10.[60] Fatusi AO, Blum RW. Predictors of early sexual initiation among a nationally representativesample of Nigerian adolescents. BMC Public Health 2008; 8.[61] McGrath N, Nyirenda M, Hosegood V, Newell M-L. Age at first sex in rural South Africa.Sex Transm Infect 2009 85: i49-i55[62] Hargreaves J, Boler T. Girl power: the impact of girls’ education on HIV and sexualbehaviour. Johannesburg: ActionAid International, 2006. 22
  • [63] Birdthistle IJ, Floyd S, Machingura A, et al. From affected to infected? Orphanhood andHIV risk among female adolescents in urban Zimbabwe. AIDS 2008; 22:759–66.[64] Gregson S, Nyamukapa CA, Garnett GP, et al. HIV infection and reproductive health inteenage women orphaned and made vulnerable by AIDS in Zimbabwe. AIDS Care 2005;17:785–94.[65] Baumgartner JN, Geary CW, Tucker H, Wedderburn M. The influence of early sexual debutand sexual violence on adolescent pregnancy: A matched case-control study in Jamaica.Guttmacher Institute; 35(1), 2009.[66] Bachanas PJ, Morris MK, Lewis-Gess JK, Sarett-Cuasay, EJ, Sirl, K, Ries, JK, SawyerMK. Predictors of Risky Sexual Behavior in African American Adolescent Girls: Implicationsfor Prevention Interventions. JOURNAL OF PEDIATRIC PSYCHOLOGY; 27(6), 2002: 519-530.[67] Caminis A, Henrich C, Ruchkin V, et al. Psychosocial predictors of sexual initiation andhigh-risk sexual behaviors in early adolescence. Child and Adolescent Psychiatry and MentalHealth 2007; 1:14.[68] Majaraj RG, Nunes P, Renwick S. Health risk behaviours among adolescents in the English-speaking Caribbean: a review. Child and Adolescent Psychiatry and Mental Health 2009; 3:10.[69] McGrath N, Nyirenda M, Hosegood V, Newell M-L. Age at first sex in rural South Africa.Sex Tansm Infect 2009; 85(suppl 1):49-55.[70] Kaestle CE, Halpern CT, Miller WC, Ford CA. Young age at first sexual intercourse andsexual transmitted infections in adolescents and young adults. Am J Epidemiol 2005; 161:774-780.[71] Moodley P, Sturm AW. Sexually transmitted infections, adverse pregnancy outcome andneonatal infection. Semin Neonatol 2000; 5:255-69.[72] Sorvillo F, Smith L, Kerndt P, et al. Trichomonas vaginalis, HIV, and African-AmericansEmerg Infect Dis 2001;7:927-32.[73] Cremin I, Mushati P, Hallett T, et al. Measuring trends in age at first sex and age atmarriage in Manicaland, Zimbabwe. Sex Transm Infect 2009; 85(Suppl 1):34-40. 23
  • Table 1.1. Demographic characteristic of studied population, n = 7, 168Characteristic n %Shared sanitary convenience with other household No 5907 82.9 Yes 1219 17.1Employment status Employed 3025 42.2 Unemployed (including students) 4143 57.8Main source of financial support Partner 4129 57.6 Other 3039 42.4Marital status Legally married 1542 21.5 Common-law 1733 24.2 Visiting 1959 27.3 Not currently in union 1934 27.0Currently pregnant Yes 288 4.4 No 6219 94.6Ever been pregnant Yes 5301 84.3 No 985 15.7Forced to have sex Yes 747 11.4 No 5707 86.8Health 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 0.3Area of residence Urban 1144 16.0 Semi-urban 2079 29.0 Rural 3945 55.0Socioeconomic class Lower 1705 23.8 Middle 3079 43.0 Upper 2384 33.2No. 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) 24
  • Figure 1.1 Person with whom respondents had their first sexual relations 25
  • Table 1.2. Age cohort of respondents by age at sexual debut Age at sexual debut (in years)Age cohort of respondents (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 deviationF statistic = 47.3, P < 0.0001 26
  • 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 0.511 0.364 - 0.659 0.006 week) 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 0.001NA – Not applicable 27
  • Chapter 2 Young males whose first coitus began at most 15 years old Paul A. BourneIntroductionFor decades, public health practitioners have been designing intervention programmes gearedtowards addressing (1) teenage pregnancy, (2) high fertility, (3) HIV/AIDS epidemic, and (4) ageat first coitus in developing nations, particularly in Jamaica. Inspite of their efforts to makebehavioural changes in those societies, the aforementioned issues continue to linger and are stillpublic health problems [1-5], for policy makers. Thousands of dollars have been spent onintervention 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 lastdecade in Jamaica [8-12]. In 2002 statistics showed that the mean age at first coitus among females Jamaicans was15.8 years and 13.5 years for males [8]. With 1 in every 50 people in the Caribbean beinginfected 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 yearsold in Jamaica; coupled with the promiscuous lifestyle of Caribbean males [13], in Jamaica, 3out of every 4 males aged 15-24 years old had sexual intercourse at least once per week and that11 out of every 50 young males aged 15-24 years old had have coitus in their lifetime [4], thenunsafe 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 ofrisk factors which account for increased mortality and morbidity in the world [14]. Clearly fromthe aforementioned issues, the continuously lowering of the age of coitus and its association with 28
  • unsafe sexual behaviour, it is a cause for concern in public health. Many studies haveinvestigated age at sexual debut and factors associated with it in order to provide acomprehensive framework for addressing those issues [9-12]. Coitus continues to commenceduring the adolescence years in many developing nations as well as the United States [15], whileresearchers understandably so continue to examine age at first sexual intercourse and multiplesexual relationships among these individuals, no study has explored the reproductive healthpractices 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 toprovide information on unsafe sexual practices that can be used to guide public health policyframework, understanding the aged ≤ 15 years may produce somewhat of different informationthat other aged cohorts would have give. Thus, the current study seeks to elucidate informationon the reproductive health practices of males aged ≤ 15 years as this is the aged in which manyof them commenced sexual relations. The rationale of this paper is provide policy makers withresearch evidence that can be used to structure framework for intervention programmes for thosemales aged ≤ 15 years who are have sexual intercourse.MethodsSampleThis descriptive cross-sectional study used a secondary dataset, 2002 Reproductive HealthSurvey. Since 1997, the National Family Planning Board (NFPB) has been collectinginformation from Jamaican men (ages 15-24 years) and women (ages 15-49 years) regardingcontraception usage and/or reproductive health for the purpose of aiding government policies. In2002, the Reproductive Health Survey (RHS) collected data on Jamaican men ages 15-24 years 29
  • and women 15-49 years. For this research, there are two sets of inclusion criteria. These are maleand age of first coital activity by at most 15 years. The current study extracted a sample of 1,083males who had their first sexual coital activity by at most 15 years old from the initial sample of2,437 men aged 15-24 years old. Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomasand St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica comparedto 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 eachPSU constituted an ED, which in turn was comprised of 80 households. The previous samplingframe was in need of updating, and so this was performed between January and May 2002. Oncompletion of the exercise, the total number of households visited was 15,950 of which 17.5% ofthe inhabitants dwelled in urban areas, 27.7% resided in semi-urban zones and 54.8% lived inrural areas. Almost 18% of the households had eligible men (ages 15-24 years old, n = 2,795men). Sixteen percent of the eligible men resided in urban areas, 27.7% lived in semi-urban areasand 56.4% dwelled in rural areas. The new sampling frame formed the basis upon which thesampling size was computed for the interviewers to use. The sample represents a response rate of 30
  • 87.2%: 88.3% of eligible urban men, 88.0% of semi-urban and 86.7% of eligible ruralrespondents. Stage 3 was the final selection of one eligible male from each sampled household and thiswas 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 instrumentadministered was a 35-page questionnaire [10]. The data collection began on Saturday, October26, 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 175instruments were pre-tested, of which 40.6% were given to eligible men. Modifications weremade 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 thenation.Statistical methodsFor this paper, the Statistical Packages for the Social Sciences (SPSS) for Windows, Version16.0 (SPSS Inc; Chicago, IL, USA) was used to examine the data. Frequencies and means werecomputed on the sociodemographic characteristics. Chi-square (χ2) tests and independentsample-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 thelast sexual encounter. 31
  • Odds ratios were determined from the use of a binary logistic regression model, andWald 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 beretained during the final construction of the model. To derive accurate tests of statisticalsignificance, we used SUDDAN statistical software (Research Triangle Institute, ResearchTriangle 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.MeasureCrowding is the total number of persons in a dwelling (excluding kitchen, bathroom andverandah). 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. Thesemethods include tubal ligation, vasectomy, implant (norplant), injection, emergencycontraceptive protection, pill, condom, foaming tablets, creams, jellies, diaphragm, abstinence,withdrawal, the rhythm method, calendar or Billings (1= yes, 0 = otherwise). Non-steady sexualpartner denotes casual sexual relations with someone with whom the individual is not having acommon-law sexual relationship, visiting relationship or to whom the individual is legallymarried (1 = yes, 0 = otherwise). Education is taken from the question, ‘How many years did youattend school?’ Shared facility is taken from ‘Are these [sanitary conveniences] shared withanother 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 womenpregnant for you?” (1= yes, 0 = otherwise). Had sex is taken from the question “Have you hadsexual intercourse in the last 30 days?” (1= yes, 0 = otherwise). Frequent church attendance isderived from, “With what frequency do you attend religious services? The options are at least 32
  • 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 perweek, 0 = otherwise).ModelUsing 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 sexualencounter among Jamaican males whose first sexual coitus was ≤ 15 years. Different socialfactors influence men’s choices, and their decision to (1) have sexual relations, (2) frequentlychurch 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 andreproductive factors and contraceptive use among young males aged 15-25s. Econometricanalysis was used to establish multifactorial determinants. The current research will use thetheoretical framework of Bourne and Charles’ econometric analysis to examine factors that areassociated with (1) had sex, (2) frequency of church attendance, (3) in sexual union and (4) useda condom on the last sexual encounter among males whose first sexual coital activity occurred atmost 15 years old in Jamaica. The variables used in this econometric model are based on theliterature 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 acondom 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-householdmembers; age of first sexual relations; currently had sexual intercourse in the last 30 days; 33
  • number of sexual partners; religiosity; currently in a sexual union; hearing family planningmessage; extracurricular activities; crowding in household; condom usage; in sexual union,frequency in church attendance, involvement in family planning programme and having hadsexual intercourse in the last 30 days with a non-steady partner.ResultsDemographic characteristic of studied population Table 2.1 presents information on the demographic characteristics of the studiedpopulation 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 planningeducation by had sex (in the last 30 days). The findings revealed a significant statisticalassociation 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 inextracurricular 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 concurrentrelationships (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 = 34
  • 0.274 (Table 2.3). The data correctly classified 71.3% of those who had sexual relations in thelast 30 days. Using logistic regression analyses, four variables emerged as statistically correlated withfrequency 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. Threevariables 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 beingpregnant for emerged as factors accounting for having used a condom on the last sexualencounter (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).DiscussionSexual promiscuity is a feature of many developing nations, particularly in the English-speakingCaribbean countries [13]. It is well documented in the literature that age at first sexualintercourse is occurring during the adolescence years in many societies [9-12], and this is evenlower among males than females [8]. Chevannes opined that sexuality and sexual behaviouramong 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 areexpected to be promiscuous, but this is not equally defined for females. The culture and socialstructure 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 35
  • population being less than 15 years old [14] and about one half being males, the present study iscritical 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 areengaged in more by younger than older males, but that “… sexual awareness begins quite earlyin life.” [13, p.192]. According to Chevannes, “By the time small children reach the age of sevenor 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, 843Jamaicans aged 15-74 years old, Wilks et al. [4] found that 96.2% of males had sex comparedwith 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 multiplepartners 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 alsoengaged in multiple relationships, particularly more males than females, 12.8% of females hadmultiple partners compared with 26.2% of males. Polygamy seems to be a male phenomenon across the world, which is supported by theculture that men’s sexual drives indicate prowess and women’s sexual drive should be passiveand 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 currentstudy 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 36
  • male adults who had their first sexual encounter did so ≤ 15 years old. This paper willcomprehensively examined the aforementioned aged cohort in order to provide public healthpolicy makers with useful research evidence that can be utilize to frame interventionprogrammes. Many factors have been identified in the literature as explaining age at first sexualintercourse [9, 18-20], but no study specifically examined a sample of those at the mean age atsexual debut and particular reproductive health matters. In this research, it was revealed thatfrequency in church attendance, involvement in extracurricular activities, non-partner sexualrelations, in sexual union, employment status and age influence males who had sex in the last 30days. The findings highlighted that those who are frequent church attendees were 47% less likelyto have reported having had sex, and involvement in extracurricular activities reduced sexualrelations by 32%. The cultural values of the churches continue to lower sexual relationships. Thisfinding 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 theCatholics (within their 17th year) and those of other religion (18th year) [21]. While the differencein 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 areinfrequent church attendees than frequent church attendees (sexual relations by frequent churchattendees, 13.5%). Among the factors which reduce sexual relations is extracurricular involvement. Thispaper found that those who are engaged in extracurricular activities were 32% less likely to havehad sex in the last 30 days compared with those who were no involved in extracurricularmeasures. Clearly the church is not only a place for biblical teaching as in this research it was 37
  • discovered that extracurricular activities was 1.9 times more engaged in by frequent churchattendees and those who had sex were 41% less likely to be frequent attendees. The church isacting as social agency against sexual involvement through its teaching and responsibilities thatit thrust on young males. The church is also imparting self-esteem which is allowing youngmales 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 (parentalmonitoring), school life (enjoyment), gender, self-esteem, religion, and informal sexual healthintervention were associated with self-reported first sexual intercourse. Another group ofscholars found that the perception of greater physical maturity, expectations of earlier autonomyamong gender, and the use of illicit drugs to be statistically associated with age at first sexualdebut among high schoolers [19]. The churches seem to embodying in young males who arefrequent attendees, greater self autonomy as well as self-esteem that they use to delay age atsexual intercourse which is not the case among non-frequent attendees. Embedded in the findings of this research is that frequent church attendees’ as well astheir families are less likely to share sanitary convenience, suggesting that the socioeconomicstatus of this cohort is better than non-frequent attendees. The church is therefore an institutionwhich is frequent by the middle and upper class families of young males, indicating that it apartof 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 thechurch as extracurricular activities that become engaging for the young males, and so reduce thelikeliness of sexual involvement. Then, with increased probability of sharing sanitary 38
  • convenience for poor family, sexual activities are increased as they are introduced by otherindividuals. With the engagement in social activities, children are introduced to others who have beensocialized within a different sub-culture. It is the other agents of socialization, that when themale children are exposed, he is likely to change from the teaching and values of the church orthe family. It emerged in this study that as males get older he is more likely to be involved insexual union and this is also foster by more years of schooling. While education provides greaterknowledge of issues including reproductive health matters, self-esteem, and an opportunity forsocioeconomic advancement, it increases sexual unions, sexual activities and risky sexualpractices. Those who engaged in sexual relations in the last 30 days were 3.9 times more likelyto be in a sexual union, which is a side effect of exposure to other agents of socialization such asthe peer groups and schools. It was revealed here that increased schooling is providing more thaneducation, 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 reportmore sex partners. Peer influences are important, and students whose friends live with boyfriendsand who work at places of entertainment (where alcohol and sex are likely present) are 2 timesmore 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 50of the studied population reported having used a condom the last time a sexual activity wasperformed, 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 acondom and this even greater among non-steady sexual partners (2.3 times). Wilks et al. found 39
  • that among males aged 15-24 years old, condom usage was 65.8% [4], which means that youngmales 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 itcontravenes the law of Jamaica, it opens young males to adult activities and responsibilitiesbefore time such as the pregnancy of female partner(s). Condom usage is high among the studiedpopulation, but with little information about consistent usage, it is difficult to rightfullydetermine unsafe sexual practices. Using statistics from PAHO [6, pp. 452-453], HIV is thefourth dealing cause of mortality among Jamaicans aged 10-19 years. Extrapolating from thePAHO’s data, clearly ignorance about sexual practices, proper condom usage, and unfittedcondoms are accounts for the high prevalence of HIV virus and that there is high risk sexualbehaviour among the present study population. Multiple sexual relationships, therefore, areaccount for the high prevalence of HIV among young male adolescents in Jamaica. Byextrapolation, this study is in agreement with researchers in Africa who argued that multiplesexual 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 findingswhich showed that 41 out of every 50 had sex with a non-steady partner, and 11 out of every 25had multiple concurrent relationships, which is reinforcing Chevannes’ work that Caribbeanmales are socialized to be sexually adventurous [13]. Chevannes captured this adequately whenhe stated that we loose the bull and tie the heifer, meaning that we allow the males to be sexuallyfree and expects this not to be the case from the females. The promiscuity of males in theCaribbean, particularly in Jamaica, appears to have some African antecedents [23-26] as we thesame 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 40
  • 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 adolescentfemales 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 andpolicy framework.ConclusionPublic health intervention programmes need to have a new thrust of extracurricular activities foryoung males as a medium of increasing age at first coitus. The gains of extracurricular activitiesfor young males include (1) social engagement, (2) time consumption, (3) reduced sexualinvolvement, (4) built self-esteem, and (5) social capital. The church, which is an agent ofsocialization, provides young males with the aforementioned positives as well as ethics andmorals that justify the delay of coitus. The issues of ethics and moral coupled withextracurricular 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 sideto the social engagement which is accommodated by schooling, as peer groups are encouragingsexual unions. These sexual unions are fostering sexual unions, sexual activities and the loweringof age at coitus which must be taken into the intervention programmes and educational system tolower the probability of sexual engagement. Furthermore, any new intervention programme mustinclude economic survivability of family, extracurricular activities, building self-esteem, socialcapital, values and morals in order to effectively change the current state of first coitus among 41
  • young males. Because people are prisoners to the beliefs, practices, values and customs (vices orotherwise), merely providing young males with knowledge about reproductive health mattersand/or abstinence will continue to be ineffective as this research showed those factors which arelikely to cause increased age at first coitus must take a multisectoral approach as the factors aredifferent and not focused on a single theme. Merely bombarding the airwave with middle classvalues when young people have not absorbed these aspiring values, as is the case used bytraditional and contemporary public health practitioners, will be useless to direct healtheducational programmes at these individuals. In summary, the best public health intervention programmes to address the presentyoung male population away from first coitus before 16 years must include values from an earlyage, games and other extracurricular activities and not the traditional outer-directed approach tohealth education. While education, undoubtedly provide many positives for young males,programmes must be geared towards peer pressure, social engagement, and sexual relationshipswhich are likely to occur in educational institutions. The research findings are in, and should beuse to frame health promotion that will aggressively address the current challenges whichemerged from this study. Using fear to sell sexual behaviour modifications may be dangerousand counterproductive as positive ideas, messages and imagery are more effective than negativeones. Using this study’s results, young males need opportunities, values, self-esteem and outletsof releasing sexual urges which are likely during adolescents. Then, while health promotion isgood it must incorporate those issues within it policy framework. Otherwise, public health willcontinue to ineffective and useless in address the lowering of age at first coitus among youngpeople, particularly males.Disclosures 42
  • The authors report not conflict of interest with this work.DisclaimerThe researchers would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researchers.AcknowledgementThe 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 ReproductiveHealth Survey, RHS) available for use in this study, and the National Family Planning Board forcommissioning 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. 43
  • 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. 44
  • Table 2.1: Demographic characteristics of studied population, n = 1, 083Characteristic n %Had sex (in last 30 days) No 529 48.2 Yes 554 51.2In sexual union No 501 46.3 Yes 582 53.7Non-partner sexual relation No 175 17.4 Yes 831 82.6Frequent church attendance No 877 81.0 Yes 206 19.0Involvement in extra-curricular activities No 796 73.8 Yes 283 26.2Involvement in family planning education programme No 995 91.9 Yes 88 8.1Educational levels Primary or below 82 7.6 Secondary 469 43.3 Tertiary 522 48.2Female pregnant for No 1040 97.0 Yes 32 3.0Shared sanitary convenience No 891 83.3 Yes 178 16.7Employment status Employed 448 41.6 Not working but have a job 2 0.2 Unemployed 276 25.6 Student 351 32.6Used condom last time had sex No 199 18.4 Yes 884 81.6Area of residence Urban 188 17.4 Semiurban 294 27.1 Rural 601 55.5No. of child/ren want to have, median(range) 3 (0 – 10)Crowding, median (range) 2 persons (1 – 2) 45
  • Table 2.2: Particular demographic and reproductive health variables by had sex (in last 30 days) Had sex (in last 30 days)Characteristic No Yes χ2, P value 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 = 0.195SD denotes standard deviation 46
  • Table 2.3: Logistic regression analyses: Explanatory variable of had sex (in last 30 days), n =981 Std Wald Odds Dependent: Had sex β coefficient error statistic 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 0.02Model chi-square = 225.28, P < 0.0001-2 Log likelihood = 1130.62Nagelkerke r-squared = 0.274Hosmer and Lemeshow test, χ2 = 7.44, P = 0.49Overall correct classification = 71.3%Correct classification of cases that had sex = 75.9%Correct classification of cases that did not have sex = 66.0% 47
  • Table 2.4: Logistic regression analyses: Explanatory variable of frequent church attendance, n =946 Std Wald Odds Dependent: Frequent church attendance β coefficient error statistic 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 2.03Model chi-square = 75.13, P < 0.0001-2 Log likelihood = 1792.84Nagelkerke r-squared = 0.06Hosmer and Lemeshow test, χ2 = 6.44, P = 0.60Overall correct classification = 81.0%Correct classification of cases, frequent church attendance = 60.0%Correct classification of cases, infrequent church attendance = 100.0% 48
  • Table 2.5: Logistic regression analyses: Explanatory variable of in sexual union, n = 990 Dependent variable: In sexual Std Wald Odds union β coefficient error statistic 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 0.01Model chi-square = 176.45, P < 0.0001-2 Log likelihood = 1180.41Nagelkerke r-squared = 0.219Hosmer and Lemeshow test, χ2 = 4.58, P = 0.801Overall correct classification = 68.7%Correct classification of cases in sexual union = 74.1%Correct classification of cases not in sexual union = 61.7% 49
  • Table 2.6: Logistic regression analyses: Explanatory variable of used condom on last sexualencounter, n = 946 Dependent variable: Used condom on last sexual encounter Std Wald Odds β coefficient error statistic 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 3.16Model chi-square = 63.72, P < 0.0001-2 Log likelihood = 686.18Nagelkerke r-squared = 0.119Hosmer and Lemeshow test, χ2 = 0.62, P = 0.734Overall 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% 50
  • 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. BourneIntroductionFor decades, the developing countries like the developed nations have been experiencinglowered age at first coital activity, which commences during the adolescence years. Youngpeople (ie. adolescents) continue to be engaged in sexual activities outside of marriage and eventhe statutes. The continuity of early sexual debut means that there are some health and socialmatters that will face the society because of early sexual relationships. It is well documented thatearly sexual initiation is associated with increased HIV, human papillomavirus (HPV), cervicalcancers, teenage pregnancy, unwanted pregnancies, abortion (safe and unsafe), and loweredlevels of education and financial opportunities [1-6]. While the developing nations have beenplagued by the HIV/AIDS epidemic and lowered age at sexual debut, the developed world ismore so experiencing lowered age at first sexual debut than the prevalence and incidence ofHIV/AIDS epidemic faced by the developing societies. A previous study established that thelowering 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 longitudinalstudy of a cohort born in Dunedin in 1972-3, found that there were young people who wereengaged in sexual activities before 13 years old. This concurs with a five communityethnographic study carried out by Chevannes in the Caribbean [8], which found that sex amongadolescents’ starts as early as 14 years. The aforementioned early sexual debut in the Caribbean 51
  • and New Zealand is also obtained in the United States [9], and a group of researchers found thatalmost 12 out of every 25 individuals aged 15-19 years in the United States reported having hadsexual intercourse at least once [10]. In United States, the median age at first sexual debut was 17 years, which is higher thanthat in Jamaica (15.0 years) [11, 12]. Like United States, New Zealand and Jamaica, someAfrican nations (such as Uganda, Kenya, Ghana, Tanzania, Zambia and Zimbabwe) had amedian age which is statistical the same, suggesting that premarital sexual behaviour is similar inmany 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 that22 out of every 25 people aged 15-24 years have had sexual intercourse - 21 out of every 25males aged 15-24 years and 19 out of every 25 females of the same age [13]. The sexualexpression and practices of young Jamaicans (aged 15-24 years) is embedded in the fact that 11out of every 25 have sex at least once per week - 11 out of every 25 males and 10 out of every 25females [13]. Statistics also showed that 2.6% of Jamaicans aged 15-24 years had a STI in thelast 12 months compared with 2.4% of Jamaicans aged 15-74 years old. Comparatively betweenthe United States and Jamaica, less Americans aged 14-22 years were sexually active comparedto Jamaicans aged 15-24 years [9, 13]. However, there were similarities between Jamaica and theUnited 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 atfirst coitus was 14.7 years (SD = 3.1, median age at first intercourse = 15.0, range = 13 – 16years) [14], and the median age of first coitus among females aged 16-49 years was 16.0 years in2001, this fell from 17.3 years in 1997 [12]. The rationales for using < 16 years and 16+ are (1) 52
  • the age of individual sexual consent is 16 years, and (2) the median age of first coitus amongfemales aged 15-49 years was 16 years. Inspite of public health campaigns to address (1) the lowering of age of sexualintercourse, (2) HIV/AIDS among the population, particularly among adolescents and youngadults, (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 continuouserosion of values because the aforementioned matters continue unabated and there seems to beno end in sight. Many developed nations such as New Zealand and the United States isexperiencing the early age of sexual debut epidemic like Jamaica. Apart of the justification ofthis public health challenge is that lifestyle practices, cultural values and expectation as well asorientations which are changing in the 21st century. Although females in world have been living longer than males (life expectancy or healthylife expectancy), which is the case in Jamaica, statistics revealed that the incidence of STIsamong 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 responsibilityand the rise of HIV/AIDS in the nation. Embedded in the incidence of STIs are the culturalvalues, lifestyle, norms, beliefs and sexual practices of females, which will not easily changebecause 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 thatdetermine contraceptive use of female [2-7, 15, 16], but no research existed that examineddifferentials in factors of contraceptive use between females whose first coital activity was < 16years and 16+ years old. Bourne et al. [16] eight factors were statistical associated withcontraceptive use among females aged 15-49 years. The factors were age (OR = 0.95, 95%CI = 53
  • 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 sexin 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), andcrowding (OR = 1.4, 95%CI = 1.21 – 1.60). If research provides an understanding of issues inour physical and social milieu, then, a study on the aforementioned is critical and timely as itwould provide insights into their behaviour, thereby allowing health practitioners and educator tobetter understand how to address the increasing HIV/AIDS virus and other public healthproblems such as unwanted pregnancies and unsafe abortions. With previous studies havingdemonstrated that early sexual activities are associated with increased HIV/AIDS infections,cervical cancers and other health problems [1-6, 15], understanding early sexual activity (beforethe statutory age 16 years in Jamaica) and post the statutory age will provide invaluable insightsinto practices and measure that can be formulated to address the lifestyle of these individuals. This current study, recognizing limitations of previous research on the aforementionedissue within the context of the increased HIV/AIDS virus, unwanted pregnancy, abortions andhigh fertility [17-19] coupled with the continuous lowering of age of sexual debut over thedecades, can add value to public health by studying factor differentials in contraceptive usebetween females whose first coital activity was < 16 years and those 16+ years old as well astheir demographic profile. Such a research is timely and will guide policy formulation andintervention programmes. The rationales for the study are primarily based on (1) femalesvulnerability in contracting HIV/AIDS and other STI, (2) females being less economicindependent than their male counterparts, (3) the vetoing power of males over females’reproductive health choices in developing nations, (4) income inequalities between the genders, 54
  • and (5) the issue of survivability. This research aims to elucidate information on the differentialsin factors of contraceptive use between females whose first coital activity was < 16 years and16+ years old and to provide a socio-demographic and reproductive health profile of theseindividuals.MethodsSample (participants) and proceduresA 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 femalesand ages. The eligibility criterion for age was 15 to 49 years at last birthday. In 2002, RHScollected data on Jamaican men ages 15-24 years as well as women 15-49 years old. The currentstudy 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 thereproductive ages, with a response rate of 77.6%. Of those who responded (n=5, 565), 32.5% hadfirst coitus before 16 years old compared with 67.5% who began at 16+ years old. Thus, theentire 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 thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais 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 2comprises Portland, St. Mary and St. Ann; Region 3 is made up of Trelawny, St. James, Hanoverand Westmoreland, with Region 4 being St. Elizabeth, Manchester and Clarendon. The 2001 55
  • 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% [12]. In stage 2, the households were clustered into primary sampling units (PSUs), and eachPSU constituted an ED, which in turn was comprised of 80 households. The previous samplingframe was in need of updating, and so this was performed between January and May 2002. Theprevious sampling frame was in need of updating, and so this was carried out between January2002 and May 2002. The new sampling frame formed the basis upon which the sampling sizewas computed for the interviewers to use. Again, the sample was selected based on probabilityproportion to size of the four regions, and interviewers were given particular ED(s) which theyexhausted in a clockwise manner. Stage 3 was the final selection of one eligible female from each sampled household andthis was done by the interviewer on visiting the household [12]. The Statistical Institute of Jamaica (STATIN) provided the interviewers and supervisors,who were trained by McFarlane Consultancy, to carry out the survey. The instrumentadministered 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-testingof the instrument was conducted between March 16 and 20, 2002. Modifications were made tothe pre-tested instrument (questionnaire), after which the final exercise was carried out. Validityand reliability of the data were conducted by many statisticians, statistical agency, and universityscholars before the data was used as the data are for national policy planning [12]. After which itwas released to the University of the West Indies, Mona, Data Bank for use by scholars. The datawas weighted in order to represent the population of female aged 15 to 49 years in the nation[12]. 56
  • MeasuresAge at first sexual debut (or initiation or intercourse) was measured based on a respondent’sanswer to the question “At what age did you have your first intercourse? Crowding is the totalnumber of persons in a dwelling (excluding kitchen, bathroom and verandah). Age is the numberof years a person is alive up to his/her last birthday (in years). Contraceptive method comes fromthe question “Are you and your partner currently using a method of contraception? …”, and ifthe answer is yes “Which method of contraception do you use?” Age at which began usingcontraception was taken from “How old were you when you first used contraception? Area ofresidence is measured from “In which area do you reside?” The options were rural, semi-urbanand urban (1 = rural, 0 = otherwise; 1 = semi-urban, 0 = otherwise, and urban is the referencegroup). Currently having sex is measured from “Have you had sexual intercourse in the last 30days?” (1=yes, 0 = otherwise). Education is measured from the question “How many years didyou attend school?” Marital status is measured from the following question “Are you legallymarried now?”, “Are you living with a common-law partner now? (that is, are you living as manand wife now with a partner to whom you are not legally married?)”, “Do you have a visitingpartner, that is, a more or less steady partner with whom you have sexual relations?”, and “Areyou currently single?” Age at menarche is measured from “How old were you when your firstperiod started (first started menstruation)?” Gynaecological examination is taken from “Haveyou ever had a gynaecological examination?” (1 = yes, 0 = no). Pregnancy was assessed by “Areyou 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 onceper 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 57
  • class is measured from “In which class do you belong?” The options are lower, middle or uppersocial hierarchy (1 = middle class, 0 = otherwise; 1 = upper class, 0 = otherwise; reference groupis lower class). Forced to have sexual relations was assessed from the question “Were you forcedto have sex at your first intercourse?” and the options were yes, no, don’t know and refused toanswer (1= yes, 0 = otherwise). Age at first sexual debut, age at menarche, age at firstcontraceptive use, and years of schooling were used as continuous variables. Early sexual debutis having sexual intercourse before the statutory legal age to do so (in Jamaica, this is 16 yearsold).Statistical analysesData were entered, stored and retrieved using SPSS for Window, Version 16.0 SPSS Inc;Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographiccharacteristics of the sample (frequency, mean, standard deviation (SD), and range). All metricvariables were tested for normality (age at first sexual debut, crowding, age, and years ofschooling). Where skewness was found to be less than 0.5, the variable was used in its currentform and a value more than 0.5 was normalized by natural log. Independent sample t-test wasused to examine differences in age at sexual debut between those who frequently attend churchesand those who infrequently visit churches and F-statistic was employed for age of sexual debutand subjective social class (Table 3.4). Chi-square analyses were used to examine two non-metric variables (Table 3.4). Pearson Product Moment correlation was used to evaluate statisticalassociation between age of first sexual intercourse and number of sexual partners for the sample.Stepwise logistic regression analyses were used to fit the one outcome measure (contraceptiveuse) by different sociodemographic as well as reproductive health variables. Thus, onlyexplanatory variables (i.e. statistically significant variables) are shown in Table 3.5. Where 58
  • collinearity existed (r > 0.7), variables were entered independently into the model to determinethose that should be retained during the final model construction [19]. To derive accurate tests ofstatistical 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.ResultsDemographic characteristic of sampleTable 3.1 presents information on the demographic characteristic of the studied population byage at first coital activity (< 16 years or 16+ years old). Of the studied respondents, 7.3% hadtheir first sexual intercourse at most 13 years old, 16.7% at most 14 years old, 32.5% at most 15years old, 51.4% by at most 16 years, 92.6% by at most 20 years old and 99% by at most 26years old. Twenty one percentages of the respondents had no sexual partner, 75.6% had onesexual partner compared with 3.4% who had 2+ sexual partners. Table 3.2 highlights particular reproductive health characteristic of studied population byage at first coital activity (< 16 years or 16+ years old). Table 3.3 displays information on methods of contraception Method of contraception andwhen began using by age at first coital activity (i.e. < 16 or 16+ years old). Table 3.4 forwards information on particular demographic variables by subjective socialclass of respondents controlled for by age at first coital activity (i.e. < 16 or 16+ years old). On examination of age at first sexual intercourse and number of sexual partners for thepast month and the former 3 months, a significant statistical correlation was found between (1)age at first sexual intercourse and number of sexual partners in the last 4 weeks (rxy = - 0.034, P= 0.011), and (2) age at first sexual intercourse and number of sexual partner in the last 12 weeks(rxy = - 0.037, P = 0.006). 59
  • A significant statistical difference was found among the subjective social classes and ageat first sexual intercourse (F = 187.4, P<0.0001). Females in the lower socioeconomic stratumbegan having sex at 16.0 years (SD = 2.3) compared with 16.5 years (SD = 2.4) for those in themiddle class and 17.8 years (SD = 3.2) for those in the wealthy socioeconomic stratum.However, no statistical difference emerged among the subjective social classes and number ofsexual partners (F = 2.23, P = 0.107). On average, crowding was 1.9 persons (SD = 0.30) among females who were in the lowersocioeconomic stratum compared with 1.8 persons (SD = 0.43) for those in the middle stratumand 1.3 persons for those in the wealthy socioeconomic stratum – F-statistic = 252.03, P<0.0001. Females who frequently attend church begins having sex at 17.4 years (SD = 3.5)compared with 16.4 years for those infrequent female church attendees (t-test = - 12.56,P<0.0001).Multivariate analyses Table 3.5 shows explanatory factors which account for contraceptive use among femalesin Jamaica aged 15-49 years based on age at first sexual activity that the individual is classifiedin (i.e. < 16 or 16+ years old).DiscussionA previous study had that “Experiences at sexual debut may be linked to reproductive healthlater in life” [21, p. 1] and that the age of first sexual debut is associated with future reproductivehealth outcomes [1-6]. The current works concurs with the literature, and provide detailedinformation on the differences on demographic profile and factor differentials in contraceptiveuse between the two cohorts (females aged 15-49 years who began having sexual intercourse <16 years and those who started at 16+ years). This research found that females whose first sexual 60
  • intercourse happened before 16 years old were less likely to use a condom with a steady partner,do Pap smear and gynaecological examination as well as utilize the pill as a method ofcontraception, but they were more likely to be in the lower socioeconomic stratum, live in ruralareas, have a lower educational level, first sexual intercourse was forced, use injection as amethod of contraception, shared sanitary convenience, currently in a sexual relationship, sexualpartnerships in last 3 months and unemployed. Factor differentials on contraceptive use emergedbetween the two cohorts. These were social class (upper class: OR = 0.72, 9%% CI = 0.55 –0.94) for those who begin < 16 years old but not for those 16+ and area of residence (Rural area:OR = 1.26, 95% CI = 1.07 – 1.47) for the latter but not the former. Embedded in those findings isthe fact that females who are in the upper socioeconomic stratum that commenced sexualintercourse before 16 years are engaged in riskier sexual practices than those in the lower class. In Jamaica, statistics revealed that females are poorer and less employed compared withmales [22, 23]. This reality means that there is high economic dependence of females on malesfor financial survivability, making young females within the lower socioeconomic stratumhaving different reproductive health outcome than those in the wealthy socioeconomic stratabecause of their socio-economic marginalized situation. Many of these females commenced sexat an early age because of economic vulnerability, and so they are likely to be engaged high-riskbehaviours [21]. On the other hand, in order to provide for themselves many females who are within thelower socioeconomic stratum become involved with older men who expose them to the same riskof pregnancy, STIs, and HPV. With females in the lower socioeconomic stratum having morepeople in a dwelling area compared with those in the other socioeconomic strata, they will turnoutside the household for financial assistance and oftentimes this is provided in visiting sexual 61
  • unions in which the males are older. In such unions, because females are in a socioeconomicvulnerable position and by extension poorer and marginalized, males are able to dictate manythings including reproductive health choices. Females, therefore, in those income class will bearchildren as an economic flows and/or some will have unsafe abortions, but those in the upperclass are able to carry out safe abortions compared with those in the lower class because ofaccess to financial resources, and where they consider their lives. Thus, the aforementionedarguments justify female who began sexual intercourse at most 15 years who are more likely tobe in the lower class, dwell in rural areas, unemployed, have multiple sexual partners and lesseducated were more likely to be engaged in sexual relationships, and forced into sexualactivities. Their economic vulnerabilities account for the rationale of using fewer condoms as amethod of contraception because this is vetoed by the male. Money is important to women, but the risky sexual behaviour of upper class femaleswhose first sexual activity begins before 16 years old is not for the money as those in the lowersocioeconomic strata. The high risk sexual behaviour among upper class females whose firstsexual intercourse was before 16 years, suggests that many of them would have abortions, STIsand even HPV because of their lifestyle practices. The work also showed a negative correlationbetween number of sexual partners and age at first coitus, indicating that younger females aremore promiscuous and that this changes with age at they move into stable sexual unions. Simplyput the adolescence years are about fun, frolic, sexual freedom, sexual expression, inconsistentcondom usage and sexual carelessness, which seems to continue even in the adult years amongwealthy females. Even though money is important to particular reproductive health outcomes (such as safeabortions), early sexual intercourse comes with less likeliness of a method of contraception, 62
  • which is because of ignorance. It was revealed from the findings that those females whocommenced sexual intercourse at older ages were more likely to use a particular method ofcontraception (pill) than condoms that expose them to STIs, HPV, HIV/AIDS and pregnancies,which is in keeping with the literature from other nations [2, 21, 24,25]. Embedded in thisfinding is the influence of knowledge of contraceptive with age, and not money. While money isassociated with employment and other socioeconomic benefits, it is not responsible for lowermethod of contraception among Jamaicans females. Rural poverty in Jamaica is about twice urban poverty, with more people residing in ruralareas and a sex ratio that is greater for females than males [22, 26], if money matters, then ruralfemales who begins having sexual intercourse at 16+ years would not be 1.3 times more likely touse a method of contraception compared with those in urban areas. Or, those in those whosefamilies are in the wealthy strata would be more likely to use a method of contraceptioncompared with those in the lower socioeconomic stratum, but the reverse is true in Jamaica.Embedded in these findings are inexperience and the euphoria surrounding first sexual activity aswell as the age of the initiating partner that account for lower contraceptive use based on age atfirst sexual coital activity than money. According to Gomez et al. [21], “Sixty-five percent ofwomen reported sexual initiation with a partner younger or less than 5 years older, 28% with apartner 5 to 10 years older, and 7% with a partner 10 or more years older”, and in Jamaica astudy revealed that many young women began their sexually initiation with men at least 5 yearsolder than them [12]. Embodied here is an understanding of the lifestyle of adolescents inregarding to sex, and how older men can expose them to sexually transmitted infections. Themedia continues to glamorize sex and sexuality, which are capturing the attention and practicesof young people. The young females are culturized in sex, and this they see to explore as they 63
  • become cognizant of sex during the adolescent years when there is growth and development ofthe body. Even with age, knowledge, exposure and high accessibility to method of contraceptionand low cost of contraceptives, inconsistent condom use and condom use is low among Jamaicanwomen aged 15-49 years. The current work revealed that 42.5% of those who began having sexbefore 16 years old currently use a condom consistently with their steady partner and the figurewas 2.5% more among those who started at 16+ years old. This finding provides evidence of thedifficulty to change lifestyle practices as although the majority of people in Jamaica have beenexposed to public health education and intervention programmes [12], this has not significantlychange their sexual behaviour as the age of sexual initiation continues to fall as well as anincrease prevalence of HIV/AIDS among the populace. Abel-Smith is correct, therefore, when heclaimed that people are prisoners of their lifestyle [27], suggesting that values, customs, normsand early socialization are difficulty to change, but that it is still possible over time. Apart of theCaribbean culture is that a woman is not a woman without bearing children, like the man [8, 28].Such an orientation and culture, implies and dictates a diet of sex, inconsistent contraceptive useand risky sexual practices. School is an agent of socialization, in which people are provided the tools ofsocioeconomic survivability, has become a place of indirectly promoting sex through sexualeducation and peers of different socioeconomic situations and background. The current findingsrevealed that 43% those whose first sexual activity started before 16 years old began using amethod of contraception during school compared with 7% who started at 16+ years. With therebeing an inverse association between age and contraceptive use [4-7, 10, 16], it can be deducedthat high contraceptive use is associated with sexual activities. Like Gomez [21], this study 64
  • recognizing the importance of age and gender-based power differentials between the sexesregarding sex note that delaying sexual debut must understand those differences as well as theeducational system. Dickson [7] opined that adolescent sexual behaviour is influenced by social factors. It canbe deduced from Dickson’s work that educational system is able to change sexual practices andparticular reproductive health outcome. From the current research, the educational system hasmodified the use of contraception, but not increasing the age at sexual debut. During school,children are not only exposed to health and reproductive health education and subjects’ trainings,they are interfacing with other children of different socialization, lifestyle, values andorientations. With the glamorization of sex in the media, on cable television, many children areexposed to a diet of sex, and some will seek to practice this while attending school. This isreinforcing sex, sexuality and orientation of sex that is even covertly reinforced withreproductive health education in schools. Based on Bourne et al.’s work [29] that “Health education and health promotion aredriven based on understanding lifestyle practices of a population” [29], the current findingsprovide some critical information that can be used for a new thrust into public health interventionprogrammes in the future that can be used to modify current practices. As formal educational isnot able to change the sexual practices and/or reproductive health behaviour of females becausemore than 55% of the sample have tertiary level education (or have attained this level) comparedto only 9.6% who have at most primary level education. The social and cultural values,orientation, beliefs, and expectations of the society are such that formal education is notmodifying the lifestyle practices that public health specialists and behaviouralists would want tochange. 65
  • Clearly, a public health problem that emerged from the current paper is that 1.5 timesmore females who had sex before 16 years were sexually assaulted compared to those who beganat 16 years and older. Outside of the obvious that many early sexual encounters among femalesat most 16 years is as a result of rape, the perpetrators are normally friends, family membersand/or acquaintances who carry out these acts against the physical vulnerable adolescents andchildren [30, 31]. Such abase leave an indelible psychological scar for the adolescent and Loweet al. [32] posited that this leaves immense psychological trauma which are sometimes aresuicidal. Another psychological matter which is a consequence of sexual assault of is aggressionon the path of the victim [33], suggesting that the sexual appetite of Jamaican males is exposingfemale adolescent and children to future psychological traumas as well as reproductive healthproblems. This matter becomes even more complex when the adolescent is found to be pregnant,family is poor, lowly educated, unemployed and religious. One researcher found positivestatistical correlations between poverty and not seeking medical care (R = 0.576), and povertyand unemployment (R = 0.48) [34], indicating that economic vulnerable adolescents and theirfamilies are likely to see the young female doing unsafe abortion, carrying the pregnancy to termand going into depression and/or other psychological traumas because of socioeconomicdeprivation. No or little access to money means less choices including abortion for females whobecome pregnant as a result of rape and the economic power of the perpetrator is also able tochange the outcome of criminal conviction. Thus public health practitioners need to recognizemoney and power as influencing reproductive health, and how these may retard self autonomy ofthe females, particularly those young females who are from low socioeconomic background. Thesocio-economic consequences of poverty, low educational attainment, self-esteem and social 66
  • isolation can, therefore, influence public health intervention programmes [36], making it difficultfor public health practitioners to be effective in meeting their objectives without addressing thoseinadequacies and the social structure in the society. Religiosity is associated with better sexual practice as it increased the age of first sexualintercourse, which concurs with the literature [20, 37, 38]. The church which is a part of thesocial structure is delaying sexual intercourse among Jamaican females aged 15-49 years by oneyear, which speaks to the embedded sex culture and the difficulty in changing this practicewithout structural and cultural changes, over time. Again this reinforces the fact that delayingearly sexual behaviour is also a future good as people will continue bad practices if they startearly in life. Research evidence demonstrates that the religiosity network in which the adolescentinvolved as well as the friends’ religious positively lowers age at first coital activity [39]. Withthe number of churches in Jamaica, particularly in the lower socioeconomic areas, it isparadoxical that age at first sexual intercourse continues to fall. Some of those issues can beexplained by the economic deprivation in inner-city communities and the culture values, beliefsand customs within the society as well as the sub-cultures and countercultures on sex andsexuality. Clearly, the culture in inner-city communities coupled with crowding are fostering earlysexual intercourse because those in the lower socioeconomic stratum commenced sexualintercourse on average at 16 years compared with 16.5 years for those in the middle class and17.8 years among those in the wealthy stratum. It can be deduced and extrapolated from thosefigures that men are using the economic vulnerability of young females against them, and this isresulting in those females becoming engaged in transactional sex. They are exchanging sex forgood, commodities and other support things for sex from older men. Although the same is not 67
  • the case for females in the wealthy socioeconomic stratum, those who starting having sex before16 years old are currently engaged in risky sexual behaviour. This speaks to the early lifestylepractices, values which were garnered during that period and its bearing on current practices.Thus, old habits are difficult to change. This is the difficulty that public health practice need totackle, those who began having sexual intercourse at most 15 years old as they are high sex risktakers even in the adults years. One study demonstrates this aptly as the researchers found that“…children are significantly more likely to become sexually active before age 14 if their motherhad sex at an early age and if she has worked extensively” [40] Previous studies have demonstrated that many of the cases of sexual assault and rapes areperpetrated by acquaintances. With the crowding being an issue in inner-city communities (orlower socioeconomic areas), a number of the sexual initiations occur as a result of this fact. Theadolescents are sometimes gullibly encourages to become involvement in sexual activities withfamily members, household members and friends. With the crowding in inner-city communitiesmeans that many of the rapes are perpetrated by non-household members by acquaintances in thearea. The next issue is the associations of the adolescents, and whether those networks are amongreligious members or non-religious individuals. Hardy and Raffaelli [38] provide an explanationfor the previously mentioned situation. They opined that religiosity delay the transition ofadolescents venturing into sexual activity, suggesting that religion is a social control. It follows,therefore, that adolescents who are friends of non-religious individual would not have this levelof control and will initiate sexual intercourse early. The peer group influences the reproductivehealth outcome of people, particularly children and/or adolescents as well as adults [41] andincreases early sexual practices which in this case justify future sexual behaviour of adults. It isthis explanation why public health practitioners need to address social institutions in thwarting a 68
  • campaign that will foster better sexual practices of adults as early as childhood and during theiradolescence years. The traditional approach to health behaviour modification was to give people knowledgeabout a particular issue, practice or happenings within their sociophysical milieu and instructthem into a new path [42]. According to one group of researchers, in 2009, “Knowledge aboutthe prevalence of sexual risk behaviour (SRB) in adolescence is needed to prevent unwantedhealth consequences” [43], and this justifies the continuation of poor sexual practices in thefuture. Such an argument implies that lifestyle behaviour is easily changeable, which is thefartherest from the reality. This is captured in the current work which showed that educationalattainment is not associated with usage of contraceptives. On the contrary, those in the wealthyincome stratum had the greatest prevalence of tertiary level education, yet those who startedhaving sexual intercourse before 16 years were less likely to use a method of contraception.Thus, education cannot easily change peoples’ behaviour and so it is about knowledge on aparticular issue. This is capture in the Wilks et al.’s work [13] which found that in 2002 78.3% ofJamaicans aged 15-74 years used a condom with their main partner and this fell to 43.1% in 2008although the percentage of Jamaicans with secondary-to-tertiary level education had increased,with 11.3% having had tertiary level training. They also found that more people were engaged invisiting and/or single unions compared with married and common law, and the more people had2+ sexual partner in 2008 (24.4%) compared to 2000 (23.0%). The current work that showed that adult women who began having sex at 16+ years weremore likely to use a method of contraception than those who started before 16 years, thissuggests that risky sexual behaviour which commenced early in life is likely to continue intoadulthood. Again, people are prisoners to their culture, social structure, values, beliefs, and 69
  • socialization. Cohen, Scribner and Farley [44] developed a model for behaviour change usingstructural modeling which addresses physical structures, social structures, cultural and mediamessages. Like Cohen et al. [44], Bourne et al. opined that health promotion for Jamaicans mustinclude social, economic, and lifestyle choices [29]. In the previous works, the authorsrecognizing the complexity of humans have coalesced a multidimensional apparatus to addressbehaviour change and not simply imparting knowledge or by formal education. Although a groupof scholars found that the women’s level of education and that of her spouse and age determinecontraceptive use, this concurs and disagrees with those findings [45, 46]. For the current work, age is a factor in contraceptive use, which is supported by theliterature [16, 45], but the same cannot be said about education. Education is not changing sexualpractice as it relates to contraceptive use among Jamaica females, despite its provision inimparting knowledge and behaviour medications. People are not barrels in which they are fed adiet of information from external sources such as health educators to want them to carry out aparticular action or cease one because the social and environmental factors influence behaviour,particularly contraceptive use [47]. Hogan et al. [47], provided some clarifications to the socialand other factors which are associated with contraceptive use, when they postulated that, “Socialand environmental variables were found to affect contraceptive preparedness at 1st intercourseonly, and not subsequent initiation of contraceptive practice” [47]. Outside of this clarification, itis evident that the culture, physical milieu, values, and beliefs impact on people behaviour andthis include education, but that this is not the case among female Jamaicans aged 15-49 years oldwhether sexual initiation was < 16 years or 16+ years old. There is cultural conflict amongfemale Jamaicans, the health care system and the health care educators because the symbols ofthe culture and ways of life are not supported by the health care educators, particularly related 70
  • with sexual practices, sex and reproductive health matters. Embedded in the current findings isthe value of the social environment in which these females live and grow, which fashion theircultural development, identification and belief system. Those are the reasons why “Morallyunacceptable policies designed to pressure or compel people to limit their fertility have beenshown to be unnecessary and thus have been abandoned, except in China” [48] as well as beingineffective in behaviour medication, and any such similar public health intervention programmesthat used force, moral suasion or dictatorial stance.ConclusionEarly sexual initiation is influencing future health and reproductive health outcomes amongJamaican women aged 15-49 years old. Those outcomes include more coital activity,involvement in sexual unions, and less contraceptive use. Despite reproductive health educationprogrammes in Jamaica, the culture is clearly retarding good reproductive health practices andsexual lifestyle. In Jamaica, although fertility is lower and educational advancement is greater inurban than in rural areas, rural females whose first coitus began at 16+ years were more likely touse a method contraception compared with their urban counterparts. Clearly, there is a lifestylechange occurring among females in rural areas which needs examination, and equally so is therisky sexual practices of affluent females who started having sex before 16 years old. With the global economic downturn, sexual autonomy of female Jamaicans will befurther reduced, particularly those in the lower socioeconomic stratum, unemployed, uneducated,and young because males will now have greater vetoing powers over sex, sexuality andreproductive health matters. Public health practitioners have not begun to address those realitiesin the communities and human rights of women will be thwarting because money is important insurvivability. Sexual rights of women cannot be supported by merely ascribing it to them or 71
  • penning social constructions in this regards in must be supported by economic independency.While legislation and policies that promote sexual autonomy are good, the reality is money ispower, and with the economic downturn in the Jamaican economy there will be greaterpromiscuity as women seek more assistance in sexual relationships, which is embedded in Wilkset al.’s work which showed an increase in visiting unions and number of sexual concurrentpartners between 2000 and 2008. Because money is associated with better education, physical milieu, social opportunities,good nutrition and sexual autonomy; to asked the question “If women are so keen to avoidpregnancy, why do they not use a method of contraception?” [49] is to deny people of theirsocial environment and the role of money in it. There will be in social justice in society that doesnot understand the factors which are associated with sexuality, rights and sexual justice; and therole of money in influencing health and reproductive health matters. It means that apart of thesexual lifestyle of females is justified by the economic situation in the communities [50, 51],nation and the world. Such social and financial environments means that public health mustbegin to address the new reality as all the gains that have been accomplished in past decades willbe erodes because of the increased economic vulnerability of peoples and economicmarginalization of the poor, particularly among young, uneducated, and unemployed females. In summary, delaying age at first sexual intercourse influences contraceptive use, byincrease methods of contraception. It also fosters good sexual practices in the future. Clearly, thereproductive health problems in Jamaica are structurally driven which care embedded in thecultural values that make it difficult for public health practitioners to address without includingthose issues in health education, communication and intervention programmes. Because peopleare sexual being, sex will always be a part of their social existence and an issue that cannot be 72
  • left unaddressed by public health policies makers within the current findings and the globaleconomic downturn. There is a need for structural changes in developing as well as developednations to address many reproductive health matters. The factors of method of contraception arenot the same across the age cohort at which a female began having sexual intercourse, and theyare also some different to those of women in the reproductive ages 15-49 years old. The findingswhich emerged from the current results are far reaching and can be used to guide new publichealth intervention programmes.DisclosuresThe authors report no conflict of interest with this work.DisclaimerThe researchers would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researchers.AcknowledgementThe 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 ReproductiveHealth Survey, RHS) available for use in this study, and the National Family Planning Board forcommissioning the survey.References 1. World Health Organization (WHO). Comprehensive cervical cancer control: A guide to essential practice. Geneva: WHO; 2006. 2. Pettifor AE, van der Stratan A, Dunbar MS, Shiboski SC, Padian NS. Early age of first sex: A risk factors for HIV infection among women in Zimbabwe. Epidemiology and Social 2004; 18(10):1435-1442. 3. Andersson-Ellstrom A, Forssman L, Milsom I. Age of sexual debut related to life-style and reproductive health factors in a group of Swedish teenage girls. Acta Obstet Gynecol Scand 1996; 75:484–9. 4. Coker AL, Richter DL, Valois RF, et al. Correlates and consequences of early initiation of sexual intercourse. J Sch Health 1994; 64:372–7. 5. Zaba b, Pisani E, Slaymaker E, et al. Age at first sex: Understanding recent trends in African demographic surveys. Sex Transm Infect 2004; 80 (Suppl II):ii28-ii35. 73
  • 6. Kaestle CE, Halpern CT, Miller WC, Ford CA. Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J of Epidemiology 2005; 161(8):774-780.7. Dickson N, Paul C, Herbison P, Silva P. First sexual intercourse: Age, coercion, and later regrets reported by a birth cohort. BMJ 1998; 316:29-33.8. 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; 2001.9. Santelli JS, Brener ND, Lowry R, Bhatt A, Zabin LS. Multiple sexual partners among U.S. adolescents and young adults. Family Planning Perspectives 1998; 30:271-275.10. Abma JC et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002, Vital and Health Statistics, 2004, Series 23, No. 24.11. The Alan Guttmacher Institute (AGI), In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men, New York: AGI, 2002.12. Jamaica National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston: NFPB; 2005.13. 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; 2008.14. National Family Planning Board, 2002 [Computer file]. Kingston, Jamaica: National Family Planning Board [producer], 2002. Kingston, Jamaica: Derek Gordon Databank, University of the West Indies [distributors], 2003.15. Ma Q, Ono-Kihara M, Cong L, et al. Early initiation of sexual activity: a risk factor for sexually transmitted disease, HIV infection, and unwanted pregnancy among university students in China. BMC Public Health 2009; 9: 111.16. Bourne PA, Charles CAD, Crawford TV, Kerr-Campbell MD, Francis CG, South-Bourne N. Current use of contraceptive method among women in a middle-income developing country. Open Access J of Contraception 2010; 1:39-49.17. Pan American Health Organization (PAHO). Health in the Americas, 2007, volume II – Countries. Washington, D.C.; 2007: pp.448-464.18. 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. 62-76.19. World Health Organization (WHO). World Health Statistics, 2009. Geneva: WHO; 2009.20. Bourne PA, Charles CAD. Contraception usage among young adult men in a developing country. Open Access J of Contraception 2010; 1:51-59.21. Gomez AM, Speizer IS, Reynolds H, Murray N, Beauvais H. Age differences at sexual debut and subsequent reproductive health: Is there a link? Reproductive Health 2008; 5:8.22. Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica. Jamaica Survey of Living Conditions, 1988-2007. Kingston: PIOJ, STATIN; 1989-2008.23. Planning Institute of Jamaica (PIOJ). Economic and social survey, Jamaica, 1970-2008. Kingston; PIOJ; 1971-2009.24. Mardh PA, Creatsas G, Guaschino S, Hellberg D, Henry-Suchet J: Correlation between an early sexual debut, and reproductive health and behavioral factors: a multinational European study. Eur J Contracept Reprod Health Care 2000, 5:177-182. 74
  • 25. Mnyika KS, Klepp KI, Kvale G, Ole-Kingori N: Determinants of high-risk sexual behaviour and condom use among adults in the Arusha region, Tanzania. Int J STD AIDS 1997, 8:176-183.26. Statistical Institute of Jamaica (STATIN). Demographic statistics, 1989-2007. Kingston; STATIN; 1990-2008.27. Abel-Smith B. An introduction to health: Policy, planning and financing. London: Pearson Education; 1994.28. Barrow C. Caribbean Gender Ideologies: Introduction and Overview. In: Barrow C. ed. Caribbean Portraits: essays on Gender Ideologies and Identities. Kingston, Jamaica: Ian Randle Publishers; 1989: pp.xi-xxxviii29. Bourne PA, McGrowder DA, Holder-Nevins D. Public Health Behaviour-Change Intervention Model for Jamaicans: Charting the Way Forward in Public Health. Asian Journal of Medical Sciences 2010; 2(2):56-61.30. United Nations Children’s Fund (UNICEF). Child Protection. 2008. Retrieved on August 26, 2010 from: http://www.unicef.org/jamaica/violence.html.31. Walker et al. Nutritional and health determinants of school failure and dropout in adolescent girls in Kingston, Jamaica. International Centre for Research on Women: Washington DC; 1994.32. Lowe GA, Gibson RC, Christie CD. HIV infection, sexual abuse and social support in Jamaican adolescents referred to a psychiatric service. West Indian Med J 2008; 57(3):307-311.33. Le Franc E, Samms-Vaughan M, Hambleton I, Fox K, Brown D. Interpersonal violence in three Caribbean countries: Barbados, Jamaica, and Trinidad and Tobago. Rev Panama Salud Public 2008; 24(6):409-421.34. Bourne PA. Impact of poverty, not seeking medical care, unemployment, inflation, self- reported illness, health insurance on mortality in Jamaica. North American Journal of Medical Sciences 2009; 1(3):99-109.35. Berer M. Power, money and autonomy in National Policies and Programmes. Reproductive Health Matters 2003; 12(23):6-13.36. Buston K, Williamson L, Hart G. Young women under 16 years with experience of sexual intercourse: who becomes pregnant? J Epidemiol Community Health 2007; 61(3):221-225.37. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010).38. Hardy SA, Raffaelli M. Adolescent religiosity and sexuality: an investigation of reciprocal influences. Journal of Adolescence 2003; 26:731-739.39. Adamczyk A, Felson J. Friends’ religiosity and first sex. Social Science Research 2006; 34(4):924-947.40. Mott FL, Fondell MM, Hu PN, Kowaleski-Jones L, Menaghan EG. The determinants of first sex by age 14 in a high adolescent population. Family Planning Perspectives 1996; 28(1):13-18.41. Sieving RE, Eisenberg ME, Pettingell S, Skay C. Friends’ influence on adolescents’ first sexual intercourse. Perspectives on Sexual and Reproductive Health 2006; 38(1):13-39.42. Glanz K, Rimer BK, Lewis FM. Health Behavior and Health Education: Theory, 75
  • Research, and Practice, 3rd. CA: John Wiley and Sons; 2002.43. Kalina O, Geckova AM, Jarcuska P, Orosova O, van Dijk JP, Reijneveld SA. Psychological and behavioural factors associated with sexual risk behaviour among Slovak students. BMC Public Health 2009, 9:15.44. Cohen D, Scribner R, and Farley T. A structural model of health behavior: A pragmatic approach to explain and influence health behaviors at the population level. Preventive Medicine, 2000; 30, 146-154.45. Tehrani FR, Farahani FKA and Hashemi MS. Factors influencing contraceptive use in Tehran. Family Practice 2001; 18(2): 204–208.46. Ekabua JE, Ebabua KJ, Odusolu P, Iklaki U, Agan TU, Etokidem AJ. Factors associated with contraceptive use and initiation of coital activity after childbirth. Open Access J Contraception 2010; 1:85-91.47. Hogan DP, Astone NM, Kitagawa EM. Social and environmental factors influencing contraceptive use among black adolescents. Fam Plann Prospect 1985; 17(4):165-169.48. Bongaarts J, Sinding SW. A response to critics of family planning programs. Int Perspec on Sexual and Reproductive Health 2009 35(1):39-44.49. Ravindran TKS, Balasubramanian P. “Yes” to abortion but “No” to sexual rights: The paradoxical reality of married women in rural Tamil Nadu, India. Reproductive Health Matters 2004; 12(23):88-99.50. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. International Journal of Collaborative Research on Internal Medicine & Public Health, 2009;1(5):132-155.51. Bourne PA. Health status and Medical Care-Seeking Behaviour of the poorest 20% in Jamaica. International Journal of Collaborative Research on Internal Medicine & Public Health, 2009;1(6&7):167-185. 76
  • Table 3.1: Demographic characteristics of studied population Age at first coital activity < 16 years old 16+ years old χ2, PvalueCharacteristic n = 1811 n = 3754 n (%) n (%)Area of residence 19.48, < 0.0001 Urban 265 (14.6) 668 (17.8) Semiurban 470 (26.0) 1156 (30.8) Rural 1076 (59.4) 1930 (51.4)Educational level 195.95, < 0.0001 Primary and below 225 (12.4) 306 (8.1) Secondary 832 (45.9) 1096 (29.2) Tertiary 739 (40.8) 2352 (62.7)Shared sanitary convenience 40.36, < 0.0001 No 1380 (76.9) 3101 (83.0) Yes 414 (23.1) 636 (17.0)Social class 182.61, < 0.0001 Lower 603 (33.3) 771 (20.5) Middle 839 (46.3) 1560 (41.6) Upper 369 (20.4) 1423 (37.9)Employed 71.05, < 0.0001 No 1158 (63.9) 1938 (51.6) Yes 653 (36.1) 1816 (48.4)Frequent church attendance 47.40, < 0.0001 No 1289(71.2) 2799 (62.0) Yes 522 (28.8) 1714 (38.0)Partner main source of financial 0.001, 0.979support No 89 (42.6) 93 (42.3) Yes 120 (57.4) 127 (57.7)Age at first coital activity mean (SD) 14.1 yrs (1.1) 29.8 yrs (26.3) t=-40.01, <0.0001Current age of respondents, mean (SD) 30. 5 years (9.2 yrs) 33.1 yrs (8.4) t=10.27, <0.0001Crowding, mean (SD) 1.8 persons (0.42) 1.7 persons (0.5) t=9.02,<0.0001SD denotes standard deviation 77
  • Table 3.2: Particular reproductive health characteristic of studied population Age at first coital activity < 16 years old 16+ years old χ2, PvalueCharacteristic n = 1811 n = 3754 n (%) n (%)Want to be pregnant 0.005, 0.943 No 228 (12.6) 486 (12.9) Yes 83 (4.6) 172 (4.6) Missing 1500 (82.8) 3096 (82.6)Had sex (in last 30 days) 9.71, 0.002 No 573 (31.6) 1318 (35.1) Yes 1238 (68.4) 2436 (64.9)Forced to have sex (ever) 64.19, <0.0001 No 1321 (73.1) 3072 (82.0) Yes 485 (26.9) 675 (18.0)Forced to have sex (first time had coital activity) 82.18, < 0.0001 No 1491 (82.9) 3367 (90.5) Yes 309 (17.1) 356 (9.5)Currently pregnant 0.481, 0.488 No 1725 (95.3) 3592 (95.7) Yes 85 (4.7) 161 (4.3)In sexual union 16.22, < 0.0001 No 310 (17.1) 789 (21.0) Yes 1501 (82.9) 2965 (79.0)Currently used method of contraception 2.98, 0.084 No 601 (34.3) 1302 (36.0) Yes 1151 (65.7) 2312 (64.0)Frequency of condom usage With steady partner 8.58, 0.073 Always 221 (42.5) 463 (45.0) Most times 259 (49.8) 493 (47.9) Seldom 29 (5.6) 66 (6.4) Never 2 (0.4) 1 (0.1) Never had a steady partner 9 (1.7) 7 (0.7) Missing 1291 (71.3) 2724 (72.6) With non-steady partner 22.23, < 0.0001 Always 93 (18.1) 111 (10.8) Most times 41 (8.0) 60 (5.9) Seldom 0 (0.0) 2 (0.2) Never 30 (5.8) 59 (5.8) Never a non-steady partner 351 (68.2) 7923 (77.3) Missing 1296 (71.6) 2730 (72.7)Number of sexual partners in last month – mean (SD) 0.7 person (0.7) 0.7 person (0.8) t=1.78, 0.076Number of sexual partners in last 3 months - mean (SD) 1.1 person (1.4) 0.9 person (1.2) t=3.02, 0.003 78
  • Table 3.3: Method of contraception, when began using, gynaecological and Pap Smearexamination by age at first coital activity (ie. < 16 or 16+ years old) Age at first coital activity < 16 years 16+ years old χ2, PvalueCharacteristic old n = 1811 n = 3754 n (%) n (%)Contraceptive method used (or using) 25.22, 0.009Female sterilization (tubal ligation) 216 (11.9) 388 (10.3)Implant (Norplant) 5 (0.3) 6 (0.2)Injection 251 (13.9) 380 (10.1)Pill 274 (15.1) 706 (42.9)Morning after pill (ECP) 1 (0.1) 2 (0.1)IUD/coil 20 (1.1) 42 (1.1)Withdrawal 35 (1.9) 100 (2.6)Rhythm, calendar 5 (0.3) 19 (0.5)Condom 447 (24.7) 969 (25.8)Foaming tablets/cream/jelly 1 (0.1) 0 (0.0)Other 0 (0.0) 5(Were you in or out of school, when you began usingmethod of contraception In 33 (41.8) 4 (6.8) Out 32 (40.5) 46 (78.0) Both 14 (0.8) 9 (15.3)Gynaecological examination 4.57, 0.033 No 420 (61.9) 1272 (57.3) Yes 258 (38.1) 947 (42.7)Pap Smear 22.73, < 0.0001 No 1474 (81.4) 3423 (75.8) Yes 337 (18.6) 1090 (24.2) 79
  • Table 3.4: Particular demographic variables by subjective social class of respondents controlled for by age at first coital activity (< 16or 16+ years old) Subjective social class Subjective social class 2 Lower Middle Upper χ , Pvalue Lower Middle UpperCharacteristic n = 603 n = 839 n = 369 χ2, Pvalue % % % % % %Area of residence 71.72, 0.0001 234.20, 0.0001 Urban 9.3 15.6 21.1 8.6 19.0 21.4 Semiurban 20.9 25.1 36.0 18.6 28.7 39.6 Rural 69.8 59.2 42.8 72.6 52.3 38.9Educational level 78.72, 0.0001 248.36, 0.0001 Primary or below 20.0 11.5 9.5 15.0 8.0 4.6 Secondary 52.7 45.4 36.0 39.3 32.9 19.7 Tertiary 29.2 43.1 54.5 45.7 59.1 75.8Partner main source of 0.559, 0.756 0.006, 0.997financial support No 39.5 44.6 45.2 42.6 42.2 42.0 Yes 60.5 55.4 54.8 57.4 57.8 58.0Employed 20.39, 0.0001 228.21, 0.0001 No 69.8 63.4 55.6 70.0 55.4 37.5 Yes 30.2 36.6 44.4 30.0 44.6 62.5In sexual union 1.81, 0.405 0.647, 0.723 No 18.7 16.6 15.7 21.4 20.4 21.5 Yes 81.3 83.4 84.3 78.6 79.6 78.5Currently pregnant 1.18, 0.555 4.36, 0.113 No 94.7 95.3 96.2 94.4 96.3 95.8 Yes 5.3 4.7 3.8 5.6 3.7 4.2Forced to have sex (in life) 1.20, 0.549 11.58, 0.003 No 72.6 72.6 75.4 77.9 82.5 83.7 Yes 27.4 27.4 24.6 22.1 17.5 16.3Crowding mean (SD) 1.9 1.8 1.4 < 0.00011 1.9 1.8 1.4 < 0.00012 80
  • 1 2 F-statistic = 209.22, P<0.0001; F-statistic = 537.28, P<0.0001 81
  • Table 3.5: Logistic regression analyses: Explanatory variables of use of contraception by age at first coital activity (ie. < 16 or 16+years old) 1 2 Age at first coital activity ( < 16 years old) Age at first coital activity ( ≥ 16 years old) β coefficient Dependent variable: Method of Std Wald Odds Wald Odds contraception β coefficient error Lower ratio CI (95%) Std error Lower ratio CI (95%) Age of respondents -0.02 0.01 7.90 0.98 0.97 -1.00 -0.03 0.01 32.07 0.97 0.96 - 0.98 Upper class -0.33 0.14 6.05 0.72 0.55 – 0.94 - - - - - Lower class (reference group) 1.0 - - - - - In sexual union (1=yes) 1.63 0.14 135.10 5.09 3.87 – 6.69 2.24 0.10 533.33 9.37 7.75 - 11.38 Currently pregnant (1=yes) -4.72 0.46 105.74 0.03 0.00 - 0.02 -5.51 1.01 29.82 0.01 0.00 – 0.03 Rural - - - - - 0.23 0.08 7.93 1.26 1.07 - 1.47 Urban (references) - - - - - 1.00 0.08 0.22 0.11 1.08 - -0.20 0.18 1.44 0.80 - Constant1 Model chi-square = 320.74, P<0.0001-2 Log likelihood = 1909.11Nagelkerke r-squared = 0.234n = 1728Hosmer and Lemeshow test, χ2 = 8.22, P = 0.412Overall correct classification = 74.1%Correct classification of cases in sexual union = 90.7%Correct classification of cases not in sexual union = 42.4%2 Model chi-square = 951.90, P<0.0001-2 Log likelihood = 3737.40Nagelkerke r-squared = 0.319n = 3588Hosmer and Lemeshow test, χ2 = 7.95, P = 0.439Overall correct classification = 77.3%Correct classification of cases in sexual union = 91.4%Correct classification of cases not in sexual union = 52.2% 82
  • Chapter 4Young males who delay first coitus for the statutory age and beyond in Jamaica Paul A. BourneIntroductionPrevious studies have long established the association between early first sexual encounter andsexually transmitted infections (STIs), unitary tract infection, human papillomavirus (HPV),cervical cancers and general health status. [1] With more than 1 in every 2 person who is affectedby the HIV/AIDS virus being less than 25 years old and the Caribbean having the second highestHIV infections in the world (1 in every 50 peoples in the region) [2] coupled with the fact thatsexuality and sex begins at an early age in the region [3, 4], this is all the more reason for anexamination of those who delay sex for at least the statutory age of 16+ years in Jamaica. Using statistics from the 2002 Reproductive Health Survey in Jamaica, the mean age atfirst coitus among males was 15.8 years. From a sample of 2,468 Jamaicans aged 15-74 yearsold, Wilks et al. [5] found that 87.6% of males aged 15-24 years have had sexual intercourse,with 42.4% having sexual relations at least once per week, and only 23.6% do not have a sexualpartner. Sexual intercourse is detached from the legal rights to have sex or a sexual license whichis provided by a formal marriage relationship. There is evidence that showed that young peopleare not waiting for a sexual license and/or statutory rights before engagement in sexualrelationships. This ranges from Jamaica [3-6], Scotland [7], South Africa [8], Zimbabwe [9],Uganda [10], China [11], United States [12] to other nations [13]. 83
  • The right to have sexual relations is detached from formal marriage and statutory rights tohave sex, but these are not adhered to by young people across the globe. In many of thosesocieties, promiscuity is more practices by males because culturally they have the freedom to doso. According to one anthropologist, “Problems will invariably arise among East Indians if awoman is not a virgin at the time of marriage, a phenomenon that does not hold for the African-Caribbean population where virginity is unrelated to formal marriage” [4]. This extends beyondthe Caribbean to the United States [12], China [11], and many African societies [8-10]. Despitethe high prevalence of HIV/AIDS in Southern Africa (8.6%) and the Caribbean (2.1%) [14],sexual promiscuity continues in those nations, without any abating in the near future. Many studies have examined and/or explored age at first sexual relations and factorsaffecting age at sexual debut, but none emerged in the literature that has evaluated thereproductive health matters of males who delay sexual relations for the legal age, which is 16years in Jamaica. With contraceptive prevalence being 69% in Jamaica [15] and the rate of STIinfection among males was 2.3 times more than that for females [16], promoting healthy lifestyleand sexual responsibility is a must so is understanding the reproductive health of those whodelay sex to the legal age in order to comprehend how to address the public health challenge ofthose who partake for this legal age. In an ethnographic study on three Caribbean nations (Jamaica, Guyana and Dominica),Chevannes found that in Jamaica, sex among adolescents begin as early as fourteen years [3,p.55], which is concurred by a national representative survey in 2002, which found that the meanage at first coitus was 14.7 years (SD = 3.1, median age at first intercourse = 15.0, range = 13 –16 years) [17]. The issue is even lower than Chevannes mentioned as the data from the nationallyrepresentative probability survey of males aged 15-24 years reproductive health matters revealed 84
  • that age first sexual relations begins before fourteen years (in Jamaica, 30.5% males aged 15-24years had sex before 14 years old, using 2002 data). However, Chevannes opined that theacceptable social age of sexual activity was seventeen or eighteen years old. In 2005, the age ofindividual sexual was legally set at 16 years, which is reduction from eighteen years in previousdecades. Is it that the law is catching up the social values of the society, or is legislators and/orpolicy makers recognizing the traditional legal age of consent must be in keeping with thecontemporary cultural values? Irrespective of the answers to those questions, sexual freedom thatis given to males in the world is creating health and other socio-economic problems, whichpublic health seems not to understanding as it has not effectively address the lowering of the ageof first coitus over the years. With Frederick et al. stating that “Adolescent risks are associatedwith early initiation of sexual careers without protection against pregnancy and disease – aperiod recognized as the most vulnerable of one’s life, because of the often devastatingconsequences” [2, p.44], this speaks to the primacy of early sexual relationship in public healthdiscourse. Another issue which highlights the importance of researching early sexual initiation inthe Caribbean, particularly in Jamaica, is embedded in what McNeil described as “The fact thatJamaica’s population is very young has serious implications for reproductive health and familyplanning services” [18, p.51], suggesting that value of research on the reproductive healthmatters of those who begin sexual activities at legally stipulate age. In world, the reality is such that sexual intercourse will continue to be an adolescentphenomenon. But, legislators in Jamaica cannot reduce the age of sexual consent in order toaddress the social realities and the culture of early sexual relations. It is a failure of the society toeffectively address the lowering of the age of sexual consent, and this cannot be remedied by 85
  • legislating a reduced age because we have not found the reasons to revert this practice. WithHIV/AIDS virus being in an epidemic status in the Caribbean, among the five leading cause ofmortality in adolescents aged 10-19 years [16], research on the reproductive health practices ofthose who delay sexual intercourse to the statutory age can provide some insights into prolifethese individuals. Because this can be used to formulate policies to change the sexual behaviourof those who does not delay sex before 16 years old. The current study will examine (1) theprofile, (2) factors which account for having sexual relations, (3) factors which influencecontraceptive use, (4) factors which determine having sex with a non-steady partner.MethodsSampleThis descriptive cross-sectional study used a secondary dataset, 2002 Reproductive HealthSurvey. Since 1997, the National Family Planning Board (NFPB) has been collectinginformation from Jamaican men (ages 15-24 years) and women (ages 15-49 years) regardingcontraception usage and/or reproductive health for the purpose of aiding government policies. In2002, the Reproductive Health Survey (RHS) collected data on Jamaican men ages 15-24 yearsand women 15-49 years. For this research, there are two sets of inclusion criteria. These are maleand age of first coital activity by at most 15 years. The current study extracted a sample of 571males who had their first sexual coital activity by at least 16 years old from the initial sample of2,437 men aged 15-24 years old (ie 23.4%). Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaica 86
  • is classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomasand St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica comparedto Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8% [6] In stage 2 the households were clustered into primary sampling units (PSUs), and eachPSU constituted an ED, which in turn was comprised of 80 households. The previous samplingframe was in need of updating, and so this was performed between January and May 2002. Oncompletion of the exercise, the total number of households visited was 15,950 of which 17.5% ofthe inhabitants dwelled in urban areas, 27.7% resided in semi-urban zones and 54.8% lived inrural areas. Almost 18% of the households had eligible men (ages 15-24 years old, n = 2,795men). Sixteen percent of the eligible men resided in urban areas, 27.7% lived in semi-urban areasand 56.4% dwelled in rural areas. The new sampling frame formed the basis upon which thesampling size was computed for the interviewers to use. The sample represents a response rate of87.2%: 88.3% of eligible urban men, 88.0% of semi-urban and 86.7% of eligible ruralrespondents. Stage 3 was the final selection of one eligible male from each sampled household and thiswas 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 instrumentadministered was a 35-page questionnaire [6]. The data collection began on Saturday, October26, 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 87
  • instruments were pre-tested, of which 40.6% were given to eligible men. Modifications weremade 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 thenation.Statistical methodsFor this paper, the Statistical Packages for the Social Sciences (SPSS) for Windows, Version16.0 (SPSS Inc; Chicago, IL, USA) was used to examine the data. Frequencies and means werecomputed on the sociodemographic characteristics. Chi-square (χ2) tests and independentsample-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) had sexual intercourse with a non-steady sexual partner, (3) in sexual union and (4)used a condom on the last sexual encounter. Odds ratios were determined from the use of a binary logistic regression model, andWald 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 beretained during the final construction of the model [19]. To derive accurate tests of statisticalsignificance, we used SUDDAN statistical software (Research Triangle Institute, ResearchTriangle 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.MeasureCrowding is the total number of persons in a dwelling (excluding kitchen, bathroom andverandah). 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 88
  • methods include tubal ligation, vasectomy, implant (Norplant), injection, emergencycontraceptive protection, pill, condom, foaming tablets, creams, jellies, diaphragm, abstinence,withdrawal, the rhythm method, calendar or Billings (1= yes, 0 = otherwise). Non-steady sexualpartner denotes casual sexual relations with someone with whom the individual is not having acommon-law sexual relationship, visiting relationship or to whom the individual is legallymarried (1 = yes, 0 = otherwise). Education is taken from the question, ‘How many years did youattend school?’ Shared facility is taken from ‘Are these [sanitary conveniences] shared withanother 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 womenpregnant for you?” (1= yes, 0 = otherwise). Had sex is taken from the question “Have you hadsexual intercourse in the last 30 days?” (1= yes, 0 = otherwise). Frequent church attendance isderived from, “With what frequency do you attend religious services? The options are at leastonce 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 perweek, 0 = otherwise).ModelUsing 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 sexualencounter among Jamaican males whose first sexual coitus was ≤ 15 years. Different socialfactors influence men’s choices, and their decision to (1) have sexual relations, (2) frequentlychurch attendance, (3) in sexual union and (4) used a condom on the last sexual encounter.Bourne and Charles [20] have established a connection between particular social andreproductive factors and contraceptive use among young males aged 15-25s. Econometric 89
  • analysis was used to establish multifactorial determinants. The current research will use thetheoretical framework of Bourne and Charles’ econometric analysis to examine factors that areassociated with (1) had sex, (2) frequency of church attendance, (3) in sexual union and (4) useda condom on the last sexual encounter among males whose first sexual coital activity occurred atmost 15 years old in Jamaica. The variables used in this econometric model are based on theliterature 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 acondom 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-householdmembers; age of first sexual relations; currently had sexual intercourse in the last 30 days;number of sexual partners; religiosity; currently in a sexual union; hearing family planningmessage; extracurricular activities; crowding in household; condom usage; in sexual union,frequency in church attendance, involvement in family planning programme and having hadsexual intercourse in the last 30 days with a non-steady partner. Wilks et al. noted that 22 out ofevery young males aged 15-24 years had reported having sexual intercourse, but we are notcognizant of the percentage of them who delay sexual relations to the statutory age of individualsexual consent, and their reproductive health matters in order to guide policies for those whobegan before this stipulation.ResultsDemographic characteristic of studied population 90
  • Table 4.1 presents information on the demographic characteristic of studied population as well asparticular reproductive health matters. Those who delay sexual intercourse for 16+ years were(1) tertiary level graduands (55%); (2) unemployed (53.2%); (3) in sexual union (56%); (4) hadsex in the last 30 days (56.4); (5) had sex with non-steady partner (76.1%); (6) used a condom onthe last sexual activity (88.1%); (7) lived in rural areas (53.2%), and (5) median age of firstsexual intercourse was 17 years. Furthermore, 25% of the sample had sexual relation at 16 yearsold, 50% at 17 years old and 75% at 18 years old.Bivariate analysesAlmost 53% of those who had sex with a non-steady partner were in concurrent multiple sexualrelationships compared to 66% who were not (χ2 = 7.68, P = 0.006). A statistical differenceexisted between the age of respondents and who in or not in a sexual union (mean = 20.5 years(SD = 2.4 years) and 19.7 years (SD = 2.4 years), t-test = - 4.35, P < 0.0001 respectively).Likewise a statistical difference was found between the age at first coitus and those in or not in asexual union (mean = 19.8 years, SD = 3.1 years; 17.3 years, SD = 2.2 years, t –test = - 2.39, P =0.017, respectively). 91
  • Multivariate analysesTable 4.2 shows explanatory variables which account for had sex (in last 30 days). Using logisticregression analyses, four variables emerged as statistically significant variables of had sex(Model chi-square = 98.33, P < 0.0001; -2 Log likelihood = 623.67; Hosmer and Lemeshow test,χ2 = 5.76, P = 0.674). Overall, 69.4% of the data were correctly classified. Using logistic regression analyses, four variables emerged as statistically significantfactors of having sex with a non-steady partner (Model chi-square = 31.85, P < 0.0001; -2 Loglikelihood = 551.83; Nagelkerke r-squared = 0.09; Hosmer and Lemeshow test, χ2 = 1.38, P =0.97), and 76.6% of the overall data were correctly classified. Area of residence, employment status, age of respondents, having sex with non-steadypartner, had sex (in the last 30 days) and used a method of contraception (ie. condom) the lasthad sexual intercourse as factors explaining in sexual union (Table 4.4, Model chi-square =105.20, P < 0.0001; -2 Log likelihood = 594.02; Nagelkerke r-squared = 0.250; Hosmer andLemeshow test, χ2 = 6.61, P = 0.58). Almost 70% of the data were correctly classified. Table 4.5 presents information on factors which account for currently using a method ofcontraception (ie. Condom) - Model chi-square = 16.53, P < 0.0001; -2 Log likelihood = 341.05;Nagelkerke r-squared = 0.06. Overall, 89% of the data were correctly classified.DiscussionWithin the social and cultural setting of Caribbean nations, particularly Jamaica, sex and age atfirst sexual intercourse is not tied to statutory stipulations and/or formal marriage. Sex, sexualityand promiscuity are synonymous to personal values more than the statutes in developing nations,justify the reality of 14 year old or young have sexual relations despite the decree of the society. 92
  • Jamaica is experience a moral crisis as it has changed old legislation in keeping with culturalreality of the lowering of age at first coitus. For decades public health policy makers have beeneffortless formulating programmes that are geared towards modified sexual behaviour, risksexual practices and particular reproductive health matters among its people, in particular theyoung adults. It appears that governments in not want it to be construed that public healthprogrammes have failed under their stewardship, have sought to rectify the challenge bylowering the age of sexual consent to 16 years in Jamaica, because the reality is age at firstsexual intercourse continue to decline with each passing years inspite of the public healthspending on those initiatives. Young males who delay first coitus to 16+ years in Jamaica are few, as the current studyfound that only 23.4% of males aged 15-24 years have done so, using 2002 Reproductive HealthSurvey data. This public health problem appears to be in dire need of intervention as Wilks et al.found that 22 out of every 25 male aged 15-24 years have had sexual intercourse with about 11out of every 25 reporting having had sex at least once per week, and 12 out of every 25 having atleast 2 sexual partners. The current work revealed that 13 out of every 25 males aged 16+ yearsold who commenced their first sexual relations at this age were in multiple concurrent sexualrelationships, reinforcing the sexual freedom with the culture that is afford to males [3,4]. Sexappears to be high on the agenda of the young Jamaican males because finding previously statedand the fact that 12 out of every 25 of the current sample had sex in the last 30 days, which wasthe same percentage for those in sexual unions. While ethnographic studies of Chevannes [4], Durant-Gonzalez [21], and Gayle [23]provide invaluable insights into the cultural setting of sex and sexuality in Jamaica, this study,using a national probability sample, provides even more understanding of choices and 93
  • reproductive health matters of those who delay sex to the statutory age of 16 years. Clearly asyoung males become older (16 years old), sex becomes even a greater issue on the social agendaas they seek entry into sexual unions to establish their coming into manhood. This is not limitedto Jamaica as the same was found in Guyana, and Dominica. According to Chevannes, inGuyana “By arranging marriages early, East Indians in effect give an early start to sexualactivity” [4, p. 215]. In Dominica, Chevannes found that “The strict control over the girl child,matched by the loose reins over the boy child, has implications for both female and malesexuality” [4, p. 112]. It is undeniable that early sexual activities, whether this is by arrangedmarriage or individual choice, is critical in Caribbean societies. On the other hand, frequentchurch attendance and extracurricular are precursor to reduction in sexual culture in thosenations. This work revealed that among the studied population, those who frequent attend church(mosque, synagogue, and temple) were 48% less likely to have had sex in the last 30 days andthose in extracurricular activities were 43% less likely to be engaged in sexual intercourse. Thusthe cultures of the church and extracurricular activities have some influence over sexual activity,but the dichotomy between the church and the social setting must be difficult for the youngbecause as Chevaness said, “A man is not a real man unless he is sexually active” [4, p.217]. The orientation of the church and its teachings are curtailing sexual activities andpromiscuity. This paper showed that those who are frequent church attendees were 48% lesslikely to be engaged in sexual relations with a non-steady partner, suggesting that the churches’teachings and values are against the cultural and social values of sexual freedom and promiscuityamong males. This work is agreeing with previous studies which found that religious andparticular denominations are aiding in the fight against sexual promiscuity and early sexualintercourse. From a sample of 4,379 Scottish adolescents, Penfold et al. [7] found that family 94
  • (parental monitoring), school life (enjoyment), gender, self-esteem, religion, and informal sexualhealth intervention were associated with self-reported first sexual intercourse. A research thatexamined sexual initiation of persons within the age range of 15-44 years, found that protestants(similar to those of non-religion) were more likely to have their first sexual initiation within their16th year, compared to the Catholics (within their 17th year) and those of other religion (18th year)[23]. Even though this work was not able to verify the findings of the previous work, we concurwith the finding that church attendance influences sexual activities and sexual promiscuityamong young males aged 16+ years had sex for the first time. The current work shows that religiosity is not only a future good, but it is providingpresent benefits for young males in Jamaica as it relates to sexual behaviour. The churchescontinues to temper sexual promiscuity and early sexual activities among young males, becauseits orientations, teaching and programmes extend beyond sexual activity to social programmesand extracurricular activities that are retard the cultural values and expectations on sex andsexuality. Clearly embedded in the current findings is the fact that church loses its influence overthe young males as he matures and develops into manhood. The expectations of the society ofsex, sexuality, heterosexuality, children and family opens the young males to relinquishing someof the values of the church in order to mean the greater setting of his social role in society. This work provides invaluable information as it found that sexual promiscuity is greateramong semiurban young males compared with urban males of the same age. Furthermore, theseyoung males (semiurban) are less likely to be engaged in stable sexual unions, suggesting ariskier sexual lifestyle. The results also shows that those in sexual unions were 45% less likely toinvolved in having sexual relations with a non-steady partner, and that those in sexual unionswere 58% less likely to use a condom on the last sexual activity, indicating the high risk of 95
  • young adults who are engaged in stable sexual relationships. Those issues highlight not only therisk of exposure to sexually transmitted infections, HPV, and other health matters, but the realitythat the culture dictates for adults, parenthood and family. Thus, the young male in seeking toestablish his coming of age into manhood he needs to start a family, yet there is thesocioeconomic demands to take of a family within the context of sex driven society. Thestructure is such that the young males becomes engaged into sexual unions, sex and particularactivities just to prove his manhood, yet he wants to abstain from sexual involvement. Thisparadox is only relieved if he adheres to the social pressures, and signals his manhood in aculture that sex begins at an early age and heterosexual relationships. Chevannes’ workemphases this well when he opined that “A male heterosexual identity is not only a matter ofpersonal choice, but is also an issue of concern of the wider community. Many parents aretherefore quite anxious to confirm their sons heterosexual orientation, and as we have seen, evento encourage it” [4, pp. 217-218]. The pressure of the culture is such that man fear to engage in rectal examination becauseof the sexuality. This is captured in Wilks et al.’s work which found that 79 out of every 100males aged 15-74 years had never done a rectal examination, and this was as high as 94 out ofevery 100 males aged 15-24 years old [5]. With adolescents aged 10-19 years experiencing goodhealth, this results in more risky sexual behaviour because of the social structure of the societyon sex, sexual roles and sexuality. The consequence of the risky sexual behaviour among theseindividual explains the consequence of high prevalence of HIV, and it being among the 5 leadingcause of mortality among Jamaicans aged 10-19 years old [16]. Thus, changing sexual behaviouramong young males will be futile without some structural changes, which is supported byChevannes. He opined that structure of the society accounts for sexual promiscuity and males 96
  • having children outside of marriage [4], which is adopted by young males as a part of thesocialization. Public health intervention continues to operate within an old structure which supportssex, promiscuity, and sexual freedom of males. Lowering the age at first coitus is a structurechange but this is not what Chevannes implies or this study. The structural changes which werecommend are (1) the casual nature in which families start, (2) the prosecution of males whohave sexual intercourse before 16 years old, (3) rebuilding the economic base of families, (4)restructure the values, attitudes and moral in the society, (5) increase social amenities incommunities such as sporting complexes for extracurricular activities, (6) increase age ofdeparting from secondary schooling to 20 years, (7) reduce child labour and (8) increase accessto tertiary level education. The new thrust in public health must be a multisectoral approach,including structural changes and economic spending on social programmes because the old wayof business has failed in reducing age at first sexual initiation and reproductive health problems.The old public health intervention programmes have the genesis in knowledge and fear aboutparticular lifestyle that needs to be change, but knowledge is not enough to change risky sexualbehaviour because the culture is embedded in the structure of the society and individual.According to Abel-Smith, “To a large extent people are prisoners of their values and the valuesof the society they live in, and are limited by their economic and social environment quite apartfrom any health knowledge they may possess” [24, p.33]. Clearly the fear approach that is the used by public health policy makers in developingnations is not working because the statistics are there on (1) HIV/AIDS prevalence, (2) teenagepregnancies, (3) unwanted pregnancies, (4) lowered age at first coitus, and (5) other healthproblems [1,2,615] which continue unabated. Whitehead postulated that behavioural changes 97
  • which are induced by fear are short lived [25], and that the knowledge driven approach is equallyineffective as the fear mechanism. Peoples’ values, beliefs, and ideology can change over time,but simply understanding those issues are important in order to structure a way forward.Conclusion In Jamaica is a dichotomy among values, beliefs, social and economic pressures andpractices. Young people are socialized in a society where the aforementioned are not coinciding,which creates challenges for public health intervention programmes. Because these issues arediverse, the churches are only able to make a temporary change in general societal values and theculture. The lifestyle of young males is an imitation of those of older males and the generaldictates of the society. Thus, to a large extent the practice of young males mirror theexpectations, culture and social setting because people are socialized within a particularorientation and becomes prisoners of the values, customs and belief as well as the socioeconomicpressures. Early sexual intercourse, promiscuity and other reproductive health issues emerged fromthe current study provide insights into measures that can be implemented to address early sexualdebut of males before 16 years old. The new thrust of public health must include structuralchanges in the society as well as economic investment in the population, particularly thosefamilies in the lower socioeconomic stratum. There is sexual pollution in the developing nations,particularly in the Caribbean as well as Jamaica, and this cannot be reverted without societalstructural changes because young males are products of their socialization which promotes sex,gender roles and sexuality more than values, and extracurricular activities. As these offer someexplanation for the failure of public health intervention programmes in the past. Public healthprogrammes have omitted those fundamental issues which emerged in the current work without 98
  • which no change is likely to produce any positive result in sexual behaviour among young malesthat are long lasting.DisclosuresThe authors report not conflict of interest with this work.DisclaimerThe researchers would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researchers.AcknowledgementThe 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 ReproductiveHealth Survey, RHS) available for use in this study, and the National Family Planning Board forcommissioning the survey.References 1. World Health Organization (WHO). Comprehensive cervical cancer control: A guide to essential practice. Geneva: WHO; 2006. 2. Frederick J, Hamilton P, Jackson J, et al. Issues affecting reproductive health in the Caribbean. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. 41-50. 3. 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. 4. Chevannes B. Parenting – the male contribution. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. 58-61. 5. 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. 6. Jamaica National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston: NFPB; 2005. 7. Penfold SC, Teijlingen ERV, Tucker JS. Factors associated with self-reported first sexual intercourse in Scottish adolescents. BMC Research Notes 2009; 2:42. 8. McGrath N, Nyirenda M, Hosegood V, et al. Age at first sex in rural South Africa. Sex Transm Infect 2009; 85:i49-i55. 9. Cremin I, Mushati P, Hallett T, et al. Measuring trends in age at first sex and age at marriage in Manicaland, Zimbabwe. Sex Transm Infect 2009; 85(Suppl 1):i34-i40. 10. 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 99
  • 11. 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; 9:305.12. Santelli JS, Brener ND, Lowry R, Bhatt A, Zabin LS. Multiple sexual partners among U.S. adolescents and young adults. Family Planning Perspectives 1998; 30:271-275.13. Kaestle CE, Halpern CT, Miller WC, et al. Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J Epidemiol 2005; 161:774-780.14. 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. 62-76.15. World Health Organization (WHO). World Health Statistics, 2009. Geneva: WHO; 2009.16. Pan American Health Organization (PAHO). Health in the Americas, 2007, volume II – Countries. Washington, D.C.; 2007: pp.448-464.17. National Family Planning Board, 2002 [Computer file]. Kingston, Jamaica: National Family Planning Board [producer], 2002. Kingston, Jamaica: Derek Gordon Databank, University of the West Indies [distributors], 2003.18. McNeil P. Coping with teenage pregnancy. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. 51-57.19. Bourne PA, Eldemire-Shearer D. Differences in social determinants of health between men in the poor and the wealthy social strata in a Caribbean nation. North Am J of Med Sci 2010;2(6):267-275.20. Bourne PA, Charles CAD. Contraception usage among young adult men in a developing country. Open Access J of Contraception 2010;1:51-59.21. Durant-Gonzalez V. Role and status of rural Jamaican women: Higglering and mothering. PhD diss., University of California, Berkley; 1976.22. Gayle H. Adolescent Male Survivability in Jamaica. Kingston: The Jamaica Adolescent Reproductive Health Project (Youth. now); 2002.23. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010).24. Abel-Smith B. An introduction to health: Policy, planning and financing. London: Pearson Education; 1994.25. Whitehead M. Swimming upstream. King’s Fund Institute. London; 1989. 100
  • Table 4.1: Demographic characteristic of studied populationCharacteristic n %In sexual union No 254 44.5 Yes 317 55.5Educational level Primary or below 51 9.0 Secondary 208 36.4 Tertiary 312 54.6Employed No 304 53.2 Yes 267 46.8Shared sanitary convenience No 491 87.1 Yes 73 12.9Involvement in extracurricular activities No 429 75.3 Yes 141 24.7Involvement in Family Planning Education Programme No 527 92.3 Yes 44 7.7Some pregnant for No 551 97.9 Yes 12 2.1Currently used a condom (last sexual activity) No 68 11.9 Yes 503 88.1Age group 16 – 19 years 239 41.9 20 – 24 years 332 58.1Had sex (in last 30 days) No 249 43.6 Yes 322 56.4Frequent church attendance No 477 83.5 Yes 94 16.5Having sexual relations with non-steady partner No 131 23.9 Yes 418 76.1Area of residence Urban 93 16.3 Semiurban 174 30.5 Rural 304 53.2Age at first coitus, median (range) 17 years (16 – 24 years) 101
  • Table 4.2: Logistic regression analysis: Explanatory variables of had sex (in last 30 days), n =530 Std Wald Odds Dependent variable: Had sex β coefficient error statistic ratio CI (95%) Involved in extracurricular activity (1=yes) -0.57 0.23 6.25 0.57 0.36 - 0.89 Frequent church attendance (1=yes) -0.65 0.26 6.20 0.52 0.31 - 0.87 In sexual union (1=yes) 1.46 0.20 55.10 4.28 2.92 - 6.29 Age 0.14 0.04 12.11 1.16 1.07 - 1.25 Constant -3.11 0.83 14.01 0.05 Model chi-square = 98.33, P < 0.0001-2 Log likelihood = 623.67Nagelkerke r-squared = 0.228Hosmer and Lemeshow test, χ2 = 5.76, P = 0.674Overall correct classification = 69.4%Correct classification of cases had sex in last 30 days = 76.1%Correct classification of cases did not have sex in last 30 days = 60.3% 102
  • Table 4.3: Logistic regression analysis: Explanatory variables of had sex with non-steady partner(in last 30 days), n = 530 Dependent variable: Had sex with non- steady partner Std Wald Odds β coefficient error statistic ratio CI (95%) Involved in extracurricular activity (1=yes) -0.66 0.23 8.07 0.52 0.33 - 0.82 Semiurban area 0.52 0.21 5.84 1.67 1.10 - 2.54 Urban (reference group) 1.00 Frequent church attendance (1=yes) -0.66 0.26 6.23 0.52 0.31 - 0.87 In sexual union (1=yes) -0.60 0.22 7.30 0.55 0.36 - 0.85 Constant 1.56 0.23 45.82 4.78Model chi-square = 31.85, P < 0.0001-2 Log likelihood = 551.83Nagelkerke r-squared = 0.09Hosmer and Lemeshow test, χ2 = 1.38, P = 0.97Overall correct classification = 76.6%Correct classification of cases had sex with non-steady partner in last 30 days = 99.0%Correct classification of cases did not have sex with a non-steady partner in last 30 days = 5.5% 103
  • Table 4.4: Logistic regression analysis: Explanatory variables of in a sexual union, n = 509 Std Wald Odds Dependent variable: in sexual union β coefficient error statistic ratio CI (95%) Semiurban area -0.50 0.20 6.26 0.60 0.41 - 0.90 Urban 1.00 Employed (1=yes) 0.44 0.21 4.53 1.55 1.04 - 2.33 Age 0.09 0.04 3.97 1.09 1.00 - 1.19 Having sex with non-steady partner -0.59 0.24 5.97 0.55 0.35 - 0.89 Had sex (1-yes) 1.53 0.20 55.91 4.61 3.09 - 6.89 Used condom (1=yes) -1.02 0.36 8.01 0.36 0.18 - 0.73 Constant -0.96 0.96 1.01 0.38Model chi-square = 105.20, P < 0.0001-2 Log likelihood = 594.02Nagelkerke r-squared = 0.250Hosmer and Lemeshow test, χ2 = 6.61, P = 0.58Overall correct classification = 69.9%Correct classification of cases in a sexual union = 78.4%Correct classification of cases did not in a sexual union = 59.3% 104
  • Table 4.5: Logistic regression analysis: Explanatory variables of currently used method ofcontraception (condom), n = 530 Dependent variable: Used method of β Std Wald Odds contraception (condom) coefficient error statistic ratio CI (95%) Woman pregnant for (1=yes) -1.72 0.63 7.41 0.10 0.05 - 0.62 In sexual union -0.86 0.33 6.92 0.42 0.22 - 0.80 Constant 2.76 0.28 100.23 15.79Model chi-square = 16.53, P < 0.0001-2 Log likelihood = 341.05Nagelkerke r-squared = 0.06Hosmer and Lemeshow test, χ2 = 0.0, P = 1.0Overall correct classification = 89.4%Correct classification of cases in a sexual union = 100.0%Correct classification of cases did not in a sexual union = 15.4% 105
  • Chapter 5Reproductive health matters: Women whose first sexual intercourse occurred at 20+ years old Paul A. BourneIntroductionHealth and reproductive health literature is filled with studies that have examined age at firstsexual intercourse (or sexual relations, coitus, sexual debut or sexual initiation) [1-5], andrightfully so because of its association in explaining HIV/AIDS infection, unwanted pregnancies,teenage pregnancy, sexual promiscuity, sexual and reproductive health matters, and generalhealth status [6-8]. In Jamaica, statistics showed that the median age of first coitus amongfemales was 16.0 years in 2001, which fell from 17.3 years in 1997 [9]. Early sexual relation isan adolescent phenomenon, and it is falling more during the adolescence years in Jamaica. Firstsexual intercourse during the adolescence years is not atypical to Jamaica as this is equally thecase in Antigua and Barbuda, Haiti, Guyana, Trinidad and Tobago, Dominica Republic [10],America [11], China [12] and many other developing countries, particularly in Africa [13,14] aswell as in the United States of America [3,15]. The prevalence of sexually transmitted infections (STIs) has been on the rise over thedecades in Jamaica [16], China [12, 17] and the wider developing nations [18]. Given that mostof these occur in individuals aged 15-44 years, particularly 50 percent among people less than 25years old [19], this is undoubtedly a public health concerns in many respects. In 2007, 1 in 4Jamaicans were under 25 years old [20]; of those females aged 15-24 years old, only 24.6%reporting never having sex and 67.8% had at least one sexual partner. 106
  • Previous studies have examined reproductive health matters of adolescents and age atsexual debut [1-5, 10, 19], but there is none which investigated the reproductive health matters ofthose who commenced sexual intercourse at least 20 years old. For decades, the developingnations have been suffering from increased HIV/AIDS infections, teenage pregnancies,unwanted pregnancies, and lowering of the age at sexual intercourse, yet plethora of studieswhich have been conducted have not resulted in a fundamental change in the public healthproblems previously identified. The answers to changing those issues are not beyond us, it is justthat a new avenue should be taken in understanding the phenomena. Clearly, the evidence is in that public health interventions have failed to effectivelyaddress HIV/AIDS infections and lowering the age at first sexual intercourse in the developingnations, particularly in Jamaica despite the amount received and spent on interventionprogrammes. This study emerged out of the wanting to provide answers to public healthpractitioners to change the old approach in viewing a problem that continues to reoccur in thedeveloping nations. The current work will elucidate information on the reproductive healthmatters of women who delay their first sexual encounter until 20+ years old as this will offersome explanation that can be used to curb the reproductive health practices of those whocommenced sexual intercourse during the adolescence years. The present study is therefore a part of larger initiative to change the old approach inexamining reproductive health matters of adolescents in wanting to modify (1) age at first sexualintercourse, (2) gynaecological examination; (3) currently used a method of contraception; and(4) the role of church attendance influence sexual behaviour. The new way of addressing theissues identified earlier is examine those issues from the perspectives of those who wait until 20+years old. 107
  • Methods and materialSampleThis descriptive cross-sectional study used a secondary dataset from the National FamilyPlanning 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 onwomen (ages 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 15-24years as well as women 15-49 years old. The current study extracted 649 females who beganhaving sexual intercourse at 20+ years old. The study population from which the current sampleis drawn was 7,168 women of the reproductive ages [9]. Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomasand St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica comparedto Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8% [9]. In stage 2, the households were clustered into primary sampling units (PSUs), and eachPSU constituted an ED, which in turn was comprised of 80 households. The previous samplingframe was in need of updating, and so this was performed between January and May 2002. The 108
  • previous sampling frame was in need of updating, and so this was carried out between January2002 and May 2002. The new sampling frame formed the basis upon which the sampling sizewas computed for the interviewers to use. Stage 3 was the final selection of one eligible female from each sampled household andthis 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 instrumentadministered 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-testingof the instrument was conducted between March 16 and 20, 2002. A total of 175 instrumentswere 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. Validity andreliability of the data were conducted by many statisticians, statistical agency, and universityscholars before the data was used as the data are for national policy planning. After which it wasreleased to the University of the West Indies, Mona, Data Bank for use by scholars. The data wasweighted in order to represent the population of female aged 15 to 49 years in the nation [9].Statistical analysesData were entered, stored and retrieved using SPSS for Window, Version 16.0 SPSS Inc;Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographiccharacteristics of the sample (frequency, mean, standard deviation (SD), and range). All metricvariables were tested for normality (age at first sexual debut, crowding, age, and years ofschooling). Where skewness was found to be less than 0.5, the variable was used in its currentform and a value more than 0.5 was normalized by natural log, or another method. Independent 109
  • sample t-test was used to examine differences in age at sexual debut between those whofrequently attend churches and those who infrequently visit churches and F-statistic for age ofrespondents by age at sexual debut. Finally, ordinary least square (OLS) regression was used tofit the data because the dependent variable (age at sexual debut) was a continuous one. Stepwisemultiple linear regression was used to fit the one outcome measure (age at first sexual debut) bydifferent sociodemographic variables. Thus, only explanatory variables (i.e. statisticallysignificant variables) are shown in Table 5.3. Where collinearity existed (r > 0.7), variables wereentered independently into the model to determine those that should be retained during the finalmodel construction. To derive accurate tests of statistical significance, we used SUDDANstatistical software (Research Triangle Institute, Research Triangle Park, NC), and this adjustedfor the survey’s complex sampling design. A p-value < 0.05 (two-tailed) was used to establishstatistical significance.MeasuresAge at first sexual debut (or initiation or intercourse) was measured based on a respondent’sanswer to the question “At what age did you have your first intercourse? Crowding is the totalnumber of persons in a dwelling (excluding kitchen, bathroom and verandah). Age is the numberof years a person is alive up to his/her last birthday (in years). Contraceptive method comes fromthe question “Are you and your partner currently using a method of contraception? …”, and ifthe answer is yes “Which method of contraception do you use?” Age at which began usingcontraception was taken from “How old were you when you first used contraception? Area ofresidence is measured from “In which area do you reside?” The options were rural, semi-urbanand urban (1 = rural, 0 = otherwise; 1 = semiurban, 0 = otherwise, and urban is the referencegroup). Currently having sex is measured from “Have you had sexual intercourse in the last 30 110
  • days?” (1=yes, 0 = otherwise). Education is measured from the question “How many years didyou attend school?” Marital status is measured from the following question “Are you legallymarried now?”, “Are you living with a common-law partner now? (that is, are you living as manand wife now with a partner to whom you are not legally married?)”, “Do you have a visitingpartner, that is, a more or less steady partner with whom you have sexual relations?”, and “Areyou currently single?” Age at menarche is measured from “How old were you when your firstperiod started (first started menstruation)?” Gynaecological examination is taken from “Haveyou ever had a gynaecological examination?” (1 = yes, 0 = no). Pregnancy was assessed by “Areyou 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 onceper 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 socialclass is measured from “In which class do you belong?” The options are lower, middle or uppersocial hierarchy (1 = middle class, 0 = otherwise; 1 = upper class, 0 = otherwise; reference groupis lower class). Forced to have sexual relations was assessed from the question “Were you forcedto have sex at your first intercourse?” and the options were yes, no, don’t know and refused toanswer (1= yes, 0 = otherwise). Age at first sexual debut, age at menarche, age at firstcontraceptive use, and years of schooling were used as continuous variables. In stable unionmeasured (1) being legally married or (2) in a common-law union (are you living with acommon-law partner now that is, are you living as man and wife now with partner to whom youare not legally married).Results Demographic characteristics of study population 111
  • Table 5.1 summarizes the demographic characteristics of the studied population.Furthermore, 59.4% of the population currently use a method of contraception, and the mean ageat sexual debut was 22.1 years (SD = 2.8 years). Almost 89% of the sample had their first sexualencounter before 26 years old, 57.3% at least 21 years and 2.3% at least 30 years old. None ofthe sample had their first sexual experience after 36 years old. Marginally more of the sample indicated currently using a method of contraception(59.4%). The methods were pill (29.9%); condom (29.3%); female sterilization (22.2%);injection (9.0%); and other. Of those who used a condom, with a steady partner, 42.7% remarkedalways, 51.7% mentioned most times and 5.6% said seldom (Table 5.2). Bivariate analyses Of the sample, on average women in the lower social class had 2.9 children (SD = 2.3)compared to 2.1 children for those in the middle class (SD = 1.8) and 1.5 children for those in theupper class (SD = 1.4) (F statistic = 319.4, P < 0.0001). Those with primary or below educationhad 3.3 children (SD = 2.9) compared to 2.4 children (SD = 2.1) among those with secondarylevel education and 1.7 children (1.6) among those with tertiary level education (F statistic =185.9, P < 0.0001). There exists a statistical association between educational levels and subjective socialclass (χ2 = 507.48, P < 0.0001). Seventy percentages of those in the upper class had tertiary leveleducation compared to 52.6% of those in the middle class and 37.2% of those in the lower class. Table 5.3 presents information on marital status, employment status, raped, currentlyusing a method of contraception, shared sanitary convenience, subjective social class, area of 112
  • residence, age at sexual debut, age of respondent, years of schooling, age of menarche, age beganusing method of contraception, crowding and age at marriage by frequency of church attendance. Multivariate analyses Age at sexual debut can be explained by 6 explanatory variables (F statistic = 38.05, P <0.0001, R2 = 0.376, Table 5.4). These are age, frequent church attendance, number of live births,gynaecological examination done in the last 12 months, education and in a stable union. Age at marriage can be explained by age of respondent, area of residence, age at sexualdebut and crowding (F statistic = 6.422, P < 0.0001, R2 = 0.075, Table 5.5). Three explanatory variables account for 29.1% of the variance in currently using amethod of contraception: In a stable union; subjective social class and age at sexual debut(Model chi-square = 98.48, P < 0.021; -2 log likelihood = 447.86). Almost 75% of the data werecorrectly classified (Table 5.6). Six variables emerged as statistically significant correlates of a women having had agynaecological examination in the past 12 months (Model chi-square = 160.28, P < 0.0001, -2Log likelihood = 611.18). The factors (area of residence; subjective social class; employmentstatus; age of respondent, education and Pap smears in the last 12 months) account for 32.3% ofthe variance in gynaecological examination in the last 12 months. Seventy-three percentage ofthe data were correctly classified (Table 5.7).DiscussionThe current study found that 9 in every 100 women aged 15-49 years commenced having sexualintercourse at least 20 years. Of those whose sexual relations begin at 20+ years old, 2 out ofevery 5 are married; 13 out of every 25 years are frequent church attendee (at least once perweek); 4 out of every 5 have never had a non-steady sexual partner; 14 out of every 25 were in 113
  • the upper class; 1 out of every 10 shared sanitary convenience; and they began usingcontraceptives on average at 24 years. Among the factors that positively influences age at firstsexual intercourse are frequency in church attendance, age, educational attainment and in a stableunion. According to Bourne and Charles [21], church attendance is among the factors whichaccount for young men’s (aged 15-24 years) lowered age at first sexual intercourse. Thisresearch concurs with Bourne and Charles’ study that frequent church attendance is responsiblefor increased age at sexual debut among those who began having sexual intercourse at least 20years. In this work, it was revealed that 13 out of every 25 women who delay sexual intercoursefor 20+ years attend church on a regular basis. It was also found that among the studiedpopulation, those who are frequent church attendees on average commenced their sexualencounter age 22.7 years which is 1.2 years later than those who are infrequent attendees. Onestudy which explored sexual initiation of persons within the age range of 15-44 years, found thatprotestants (similar to those of non-religion) were more likely to have their first sexual initiationwithin their 16th year, compared to the Catholics (within their 17th year) and those of otherreligion (18th year) [22]. It can be concluded that the cultural values and orientation of thechurches that occasional attendance do not change women delaying sexual debut, but thatfrequent attendance is one of the media that increase delaying age at sexual relations. Another justification which account for delaying age at sexual debut among women is astable sexual union. Embedded in this finding is fact that women who starts in stable unions suchas marriage or common-law sexual unions are least likely to search for such a union as in thecase of women who are in visiting relationship. Furthermore, the cultural values of the church issuch that frequent membership is more fostered in marriage and therefore accounts for why 29 114
  • out of every 50 women who frequently attend church are married compared to 10 out of every 50of those who infrequently visit churches. This is also embedded in the current finding whichshowed that 4 out of every 5 women who delay having sexual intercourse at 20+ years oldindicated that they have never had a non-steady partner, suggesting that visiting union are moreabout sex than stable union. Thus, when Wilks et al. [16] found that 8 out every 25 women aged15-24 years had never had a sexual partner (or in the last 12 months), it follows that thesefemales are seeking for stable than transitional sexual union that are likely to result in anothersexual relationship. Another issue which emerged from current work about the studied population issubjective social class. It was found that 14 out of every 25 women who begin having sexualrelationship at 20+ years old are in the upper class, and that 3out of every 25 are in the lowerclass. One scholar postulated that money is positively associated with health [23], but is appearsthat economic disparity accounts for the delaying of sexual intercourse, advanced educationalattainment and number of live births. The current research found that women who delay sexualintercourse for 20+ years old is money, which fosters accessing higher level of education, lesschildren, and have a greater sexual autonomy of their live than those in the lower class. LikeMarmot, money matters for women health as well as their reproductive health and the age atwhich they begin having sexual intercourse. Poverty, economic deprivation and the socialsettings among those who are poor is account for the early sexual relation. Those in the sample have higher educational attainment are among the upper class. Thiswork shows that educational level is positively associated with increased age at first sexualintercourse, suggesting that poverty increases people search for social relationship as a source ofmaterial goods. Those individuals have less sexual autonomy, and sexual intercourse is left up to 115
  • the male who wants this earlier than later and not for the purpose of desiring a stable union.Because those sexual unions are mainly visiting and/or transitional partnerships, knowing thevulnerability of some females, males will dictate condom usage as a price for economic support.The results of inconsistent condom usage are STIs, unwanted pregnancies, and females beingcaught in the cycle of more such relationship for financial support because the last one offeredless and they desire continuous assistance owing to their economic deprived status. Thus, thisexplains the negative association between number of live births and age at sexual debut, meaningthat as more economic independency or family with economic resources have more sexual andreproductive rights which justifies them delaying sexual intercourse for a later time (20+ years). If Yan et al’s postulations holds true in developing nations outside of China that “Safesexual behaviors include having a single sex partner and using condoms in every sexualencounter, and these behaviors also reduce risk of HIV/STDs.” [12, p. 2], then women in instableunions will continue to inconsistently use condoms as they are economically dependent on amale partner for some level of survivability. In addition to the aforementioned, thus, thissupports the finding that stable unions influence age at sexual intercourse and that money mattersin reproductive health matters as well as sexual autonomy. This is supported by the a WorldHealth Organization’s (WHO) postulation that stated, “In high-income countries, communicablediseases account for only 8% of years of life lost, compared with 68% in low-income countries”[24, p. 47], suggesting economic deprivation is retarding the real accomplishments which couldhave materialized in public health interventions if there were income equality among people andwithin countries. The Pan American Health Organization (PAHO) offered another angle to thediscussion that culturally there is greater tolerance for premarital sexual relationships amongthose in the lower socioeconomic strata [25], which provides yet another argument for money in 116
  • addressing health, reproductive health matters and sexual behaviour. PAHO [25] noted thatchronic poverty ‘enforced promiscuity’ because of overcrowding, sharing sanitary convenienceand living accommodations with other households, and less marriage occurred in this cohortcompared with those in the middle socioeconomic strata and wealthy socioeconomic class. This paper revealed a positive statistical association between age at marriage and age atsexual debut, suggesting that women who delay sexual intercourse to 20+ years old are oldermeaning that they are more economic independent, career oriented, and are able to way for stableunion in which they have an equal state in the union. The economic dependency of females isaccounting for early marriage among rural women as they seek the assistance for the malepartner. Clearly the age at which a female commenced sexual intercourse may hold someexplanation for her choice in currently using a method of contraception. It was found that womenwho begin sexual relations at 20+ years old are 8% less likely to currently use a method ofcontraception as they seek family because of the stability of their unions. This is reinforced byYan et al [12] who stated that “Adolescents typically engage in short-lived relationships thatmake them more likely than adults to have sex with multiple partners, thereby placing them atgreater risk for contracting HIV/STDs” [12, p. 2] and that “…attitudes to sex have an enormousinfluence on sexual behavior” [12, p. 9]. However, embedded in Yan et al.’s work is the fact thatearly sexual partnerships are more likely to be visiting, less knowledgeable and/or educatedfemales, more economically dependent young people, and so their males’ partners are more ableto veto their reproductive rights and/or choices. The reality here coupled with the currentfindings is that young females in economically vulnerable homes will not delay sexual 117
  • intercourse as this provides survivability that cannot be found by the family unlike those inwealthy households. Money is not only influence risky sexual behaviour; it is also guiding healthchoices such as Papanicolaou (Pap) smear examination. Wilks et al. [16] found that 18% of women aged 15-74 years old in Jamaica had done aPap smear in the last 12 months, but in this study it was 32%. The high cervical screening amongthe studied population has something to do with their educational awareness, income, andunderstanding of their bodies more so than the general female population. This is reinforced in aWorld Health Organization’s publication [26] which stated that “All women who have hadsexual intercourse are potentially at risk because they might have been infected with HPV[human papillomavirus].” It should be noted here that all the women are currently sexuallyactive, and because of their awareness of cervical issues and their sexual practices account forthe substantially greater percentage having done a Pap smear or gynaecological examination inthe last 12 months. It was found that women in the upper class were almost 2 times more likelyto had a gynaecological examination, those with tertiary level education were 1.2 times morelikely to have this test, and being employed was another critical factors that fosters having thetest done.ConclusionFemales delaying their first sexual intercourse to 20+ years in Jamaica can provide acomprehensive insight into increasing age at sexual debut and a guide to public healthpractitioners in the way forwarding for intervention programmes. The current study highlightsthat education, income (or social class – ie. upper class), stable union, are frequent churchattendance critical for increasing age at first sexual intercourse. Money does matter in delaying 118
  • the time at which women become engaged in sexual relations, and this cannot be ignored in anyintervention programme. Money increases women economic independency and it also doeseducational advancement, which must be included in public health intervention programmes thatmust be a part of the solutions in the way forward. In summary, public health programmes which are not geared towards economicindependency and educational advancement will be futile. The way forward should not be aboutabstinence (or ‘say no to sex’) or consistency condom usage as the current study should a roadmap on issues that account for why some women delay sexual intercourse. The thrust of any newintervention programme that is geared towards changing sexual behaviour of Jamaican womenshould be on education and economic independency as those are the key tenants and not thecurrent approach. The new paradigm is on education and creating economic independence andnot first on safe sex, abstinence and/or on consistency condom usage or increasing knowledgeabout a reproductive or HIV/AIDS among young women.DisclosuresThe author report not conflict of interest with this work.DisclaimerThe researcher would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researcher.AcknowledgementThe author thanks 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 ReproductiveHealth Survey, RHS) available for use in this study, and the National Family Planning Board forcommissioning the survey. 119
  • References 1. 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 2. Fatusi AO, and Blum, RW. Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC Public Health; 8, 2008. 3. 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. 4. Penfold SC, Teijlingen ERV, Tucker JS. Factors associated with self-reported first sexual intercourse in Scottish adolescents. BMC Research Notes 2009; 2:42. 5. 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. 6. Miller KS, Clarke LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents. Family Planning Perspectives; 29, 1997:212-214. 7. 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. 8. 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. 9. Jamaica National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston: NFPB; 2005. 10. Rawlins J. Teenage Pregnancy: A study in three communities in Trinidad and Tobago. Paper presented at the Caribbean Health Research Conference 2007, Jamaica. 11. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010). 12. 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. 13. McGrath N, Nyirenda M, Hosegood V, et al. Age at first sex in rural South Africa. Sex Transm Infect 2009; 85:i49-i55. 14. Cremin I, Mushati P, Hallett T, et al. Measuring trends in age at first sex and age at marriage in Manicaland, Zimbabwe. Sex Transm Infect 2009; 85(Suppl 1):i34-i40. 15. Rotermann M. Sex, condoms and STDs among young people. Health Reports 2005;16:339-42. 16. 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. 17. State Council AIDS Working Committee Office and UN Theme Group on HIV/AIDS in China: A joint assessment of HIV/AIDS prevention, treatment and care in China (2005). Beijing 2005. 120
  • 18. 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.19. Frederick J, Hamilton P, Jackson J, et al. Issues affecting reproductive health in the Caribbean. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp. 41-50.20. Statistical Institute of Jamaica (STATIN). Demographic statistics, 2007. Kingston: STATIN; 2008.21. Bourne PA, Charles CAD. Contraception usage among young adult men in a developing country. Open Access J of Contraception 2010; 1:51-59.22. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010).23. Marmot M: The influence of Income on Health: Views of an Epidemiologist. Does money really matter? Or is it a marker for something else? Health Affairs. 2002; 21: 31- 46.24. World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009.25. Pan American Health Organization (PAHO). Health of women in the Americas. Washington D.C.: PAHO; 1985.26. World Health Organization (WHO). Comprehensive cervical cancer control: A guide to essential practice. Geneva: WHO; 2006 121
  • Table 5.1: Demographic characteristic of study population, n= 649Characteristic n %Shared sanitary convenience No 578 89.2 Yes 70 10.8Want to be pregnant No 611 94.1 Yes 38 5.9Employment status Unemployed (including sick, students, etc.) 244 37.6 Employed 405 62.4Pap smear (in last 12 months) No 437 67.3 Yes 212 32.7Raped No 561 86.7 Yes 86 13.3Had sex (in last 30 days) No 0 0.0 Yes 649 100.0Marital status Married 261 40.2 Common-law 83 12.8 Visiting 140 21.6 Previously in union (divorced, separated, widowed) 153 23.6 Single 12 1.8Social class Lower 82 12.6 Middle 201 31.0 Upper 366 56.4Age cohort (in years) 20-24 41 6.3 25-29 109 16.8 30-34 149 23.0 35-39 149 23.0 40-44 124 19.1 45-49 77 11.9Educational level Primary or below 32 4.9 Secondary 127 19.6 Tertiary 482 74.3Area of residence Urban 145 22.3 Semiurban 223 34.4 Rural 281 43.3Frequent church attendance No 307 47.3 Yes 342 52.3 122
  • Table 5.2: Particular reproductive health mattersCharacteristic n %Currently using a method of contraception No 249 40.6 Yes 365 59.4First method of contraception Condom 22 3.4 Other (modern methods) 4 0.6 Withdrawal, Rhythm or calendar 2 0.3 Did not respond 621 95.7Current method of contraception Female sterilization 81 22.2 Implant 1 0.3 Injection 33 9.0 Pill 109 29.9 Emergency contraception 1 0.3 IUD/Coil 10 2.7 Diaphragm 2 0.5 Withdrawal 14 3.8 Rhythm, calendar 7 1.9 Condom 107 29.3Frequent condom usage (with steady partner) Always 61 42.7 Most times 74 51.7 Seldom 8 5.6 Never 0 0.0Frequent condom usage (with non-steady partner) Always 14 9.9 Most times 6 4.3 Seldom 0 0.0 Never 7 5.0 Never had a non-steady partner 114 80.9Age began using method of contraception, mean 23.9 years (4.0 yrs)(SD) 123
  • Table 5.3: Particular demographic characteristics of sample by church attendance, n = 649 Frequent church attendance χ2, PvalueCharacteristic Infrequent Frequent n (%) n (%)Marital status 141.0, < 0.0001 Married 63 (20.5) 198 (57.8) Common-law 69 (22.5) 14 (4.1) Visiting 104 (33.9) 36 (10.5) Separated, widowed, divorced 66 (21.5) 87 (25.4) Single 5 (1.6) 7 (2.0)Employment status 0.053, 0.818 Unemployed (including student, sick, etc) 114 (37.1) 130 (38.0) Employed 193 (62.9) 212 (62.0)Raped 3.168, 0.075 No 273 (89.2) 288 (84.5) Yes 33 (10.8) 53 (15.5)Currently using method of contraception 1.26, 0.262 No 112 (38.2) 137 (42.7) Yes 181 (61.8) 184 (57.4)Shared sanitary convenience 12.496, < 0.0001 No 259 (84.6) 319 (93.3) Yes 47 (15.4) 23 (6.7)Subjective social class 1.617, 0.445 Lower 44 (4.3) 38 (11.1) Middle 95 (30.9) 106 (31.0) Upper 168 (54.7) 198 (57.9)Area of residence 17.487, <0.0001 Urban 90 (29.3) 55 (16.1) Semiurban 102 (33.2) 121 (35.4) Rural 115 (37.5) 166 (48.5) t-test, PvalueAge at sexual debut 21.5 yrs (2.3) 22.7y yrs (3.2) -5.582, < 0.0001Age 34.8 yrs (7.0) 36.0 yrs (7.1) -2.184, 0.029Years of schooling 14.4 yrs (3.2) 14.5 yrs (3.6) -0.140, 0.889Age of menarche 13.6 yrs (4.1) 13.6 yrs (3.8) -0.214, 0.831Age began using method of contraception 23.6 yrs (4.0) 24.2 yrs (4.1) -1.777. 0.076Crowding 1.5 persons (0.5) 1.5 persons (0.5) -0.165, 0.869Age at marriage 32.9 yrs (26.1) 33.4 yrs (24.9) -0.239, 0.812Number of live births mean (SD) 2.1 children (1.9) 2.0 children (2.0) 0.912, 0.362 124
  • Table 5.4: Ordinary least square regression: Explanatory variables of age at sexual debut Unstandardized Std. CI (95%)Dependent variable: Age at sexual debut coefficient error BetaConstant 12.94 0.87 11.24 - 14.64Age 0.35 0.03 0.52 0.30 - 0.41Frequent church attendance (1=yes) 0.90 0.23 0.17 0.45 - 1.35Number of Live Births -0.44 0.09 -0.20 -0.61 - -0.26Gynaecological exam (1=yes) -0.72 0.23 -0.13 -1.17 - -0.28Education (in years) 0.07 0.03 0.10 0.01 - 0.13In a stable union (1=yes) 0.54 0.23 0.10 0.08 - 1.00F statistic = 38.05, P < 0.0001R2 = 0.376, adjusted R2 = 0.366N = 612 125
  • Table 5.5: Ordinary least square regression: Explanatory variables of age at marriage Unstandardized StdDependent variable: Age at marriage coefficient error Beta CI (95%)Constant -14.92 11.85 -38.21 - 8.38 Age 0.64 0.18 0.18 0.30 - 0.99In stable union (1=yes) -7.56 2.42 -0.15 -12.32 - -2.80Rural -6.10 2.52 -0.12 -11.05 - -1.16Urban (reference group)Age at sexual debut 1.05 0.42 0.12 0.22 - 1.88Crowding 4.82 2.39 0.10 0.11 - 9.52F statistic = 6.422, P < 0.0001R2 = 0.075, adjusted R2 = 0.063N = 612 126
  • Table 5.6: Logistic regression analyses: Explanatory variables of currently using a method ofcontraception Dependent variable: Currently using a β Std. Odds method of contraception coefficient error ratio CI (95%) In a stable union (1=yes) 2.48 0.30 11.95 6.68 - 21.37 Middle class -0.64 0.26 0.53 0.32 - 0.87 Lower class (reference group) 1.00 Age at sexual debut -0.09 0.04 0.92 0.85 - 0.99 Constant 0.61 0.90 1.84Model chi-square = 98.48, P < 0.021-2 Log likelihood = 447.86Nagelkerke r-squared = 0.291Hosmer and Lemeshow test, χ2 = 1.734, P = 0.973Overall correct classification = 74.5%Correct classification of cases of currently using a method of contraception = 92.3%Correct classification of cases of not currently using a method of contraception = 47.8% 127
  • Table 5.7: Logistic regression analyses: Explanatory variables of those who had done agynaecological examination in the last 12 months, n=603 Dependent variable: Gynaecological Std. Odds exam β coefficient error ratio CI (95%) Rural -0.76 0.21 0.48 0.31 - 0.70 Urban 1.00 Upper class 0.68 0.21 1.99 1.31 - 3.00 Lower class (reference group) 1.00 Employment (1= employed) 0.45 0.21 1.56 1.04 - 2.36 Age of respondent 0.06 0.02 1.06 1.03 - 1.10 Years of schooling 0.15 0.04 1.16 1.07 - 1.26 Pap smear in last 12 months 1.363 0.25 3.91 2.38 – 6.42 Constant -4.20 0.87 0.02Model chi-square = 160.28, P < 0.0001-2 Log likelihood = 611.18Nagelkerke r-squared = 0.323Hosmer and Lemeshow test, χ2 = 5.95, P = 0.653Overall correct classification = 74.3%Correct classification of cases of currently using a method of contraception = 85.1%Correct classification of cases of not currently using a method of contraception = 52.5% Kaestle CE, Halpern CT, Miller WC, et al. Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J Epidemiol 2005; 161:774-780. 128
  • Chapter 6 On sexual and non-intimate unions among the general reproductive population of women in Jamaica: A cross-sectional survey Paul A. BourneIntroductionSome people are inclined to assume that reproductive health matters are overly studied. But thesematters affect many areas of the individual’s life and/or that of a nation such as life expectancy,quality of life, health status, population compositions, mortality patterns, production,productivity, economic growth and economic development, and therefore speak to theirimportance. Furthermore, reproductive health issues persist on a yearly basis and as such justifythe continuation of reproductive health research in an attempt to provide incessant answers onissues that affect people as well as the nation. In Caribbean nations, HIV/AIDS, other sexuallytransmitted infections and unwanted pregnancies are continuously rising as well as the loweringof the age of sexual debut; despite the designed sexual education intervention programmes,developing nations have not effectively address those challenges which persist on a yearly basisand so they cannot be set-aside to other sociomedical problems that may appear atop of the socialand medical hierarchy of challenges. For years, Jamaican policy makers have been using different designed sexual educationprogrammes to address various reproductive health matters. Inspite of their efforts, in 1997, theJamaican National Family Planning Board found that the median age at first sexual intercoursefor women was 17.3 years and this fell to 16.0 years in 2002.1 Two in every 5 Jamaican womenhave been pregnant prior to reaching the age of 20 years, and most of the pregnancies wereunplanned, especially during the adolescent years (80%).1 Continuing, in 2002, the mean age of 129
  • sexual debut in Jamaica was 15.8 for females and 13.5 for males,1 much of which were forcedand is seen as a direct link with violence, as well as one of the roots of sexual and reproductivehealth problems in the international community.2 These matters go against the principles of theICPD 1994, which stipulates that when it comes to matters of sexual relations, full respect for theintegrity of the individuals involved should be of the utmost.2 Empirical evidence showed that the “First sexual intercourse almost always take placeoutside of a formal union”3 and with older men (for the females). 4 Those occurrences are likelyto result in health situations relating to STIs and HIV, as well as drug abuse.5 Warren et al.,6 thehigh fertility population in Jamaica was women ages 14-24 years, indicating a high degree ofpremarital sexual activities and inconsistent condom use within the context of reduced age at firstsexual intercourse.7 A study of some sub-Saharan African and South-East Asian nations showsimilar sexual behaviour and attitude of young people8 whereas one by Henry-Lee9 found that66% of Jamaican women used method of contraception, but only 34% of pregnancies wereplanned for. This indicates that inconsistent contraceptive use is accounting for increasedHIV/AIDS and STIs in Jamaica that is typical in the wider developing countries, as young adultsare engaged in risky sexual practices.10,11 Within the context of the lowered age of sexual debut in the world11-16 and theaforementioned identified reproductive health matters, it follows that reproductive health issuesmust be continuously studies as they affect many areas in the life of the individual and the nationthat do not cease but progress and become problematic for nation building. With researchshowing the “First sexual intercourse almost always take place outside of a formal union,”3 STIson the rise17-19 and that 22 out of every 25 Jamaicans aged 15-24 years have had sexualintercourse as well as 24.1% of Jamaicans aged 15-74 years indicated having at least 2 sexual 130
  • partners (females, 8.4%; males, 41.0%),20 it follows that an investigation on the reproductivehealth matters of those in a sexual union versus those who do not is timely. And this wouldprovide invaluable insights into both cohorts, and how policies can be better implemented toaddress the identified challenges which emerged. Poverty is associated with illness, material deprivation, low educational attainment andother issues. In Jamaica, with rural poverty being at least twice that of urban poverty and povertybeing greater among females than males,21 then females who reside in rural areas are morevulnerable to reduced sexual autonomy than their urban counterparts as they rely more on malesfor financial assistance than their urban or periurban counterparts because of low educationalstatus, poverty, and material deprivation. The World Health Organization (WHO) 22 postulatedthat 80% of chronic illnesses were in low and middle income countries, indicating that illnessinterfaces with poverty and other socio-economic challenges. The WHO noted this aptly when itstated that “...People who are already poor are the most likely to suffer financially from chronicdiseases, which often deepen poverty and damage long term economic prospects.”22 Statistics forrevealed that 15.1% of Jamaicans reported having had an illness in a 4-week period, and this was17.8% for females and 17.2% for rural residents who are more likely to be in poverty comparedto their male, and urban or periurban counterparts.21 Clearly, there is a poverty gender disparity as well as a poverty area of residencedisproportionality in Jamaica, but no study has sought to elucidate whether there are differencesin reproductive health matters among women in sexual union or not, and the area of residencethat they dwell. Statistics showed that in 2009, 53.7% of Jamaicans were aged 15-49 years, and54.7% of females were between the ages of 15 to 49 years old.23 The percentage of populationages 15 to 49 years old, particularly women, is a substantial group which cannot be left 131
  • unresearched moreso because of the prevalence of HIV/AIDS (8th leading cause of moralityamong Jamaican females for 2006 and 200723) virus and unwanted pregnancies among thiscohort. This age cohort is a critical part of the productive age for employed, indicating itsimportance (or lack of) to production and development of the nation. Outside of poverty and the aforementioned reproductive health issues, we still do notknow about the reproductive health matters of women aged 15-49 years who are in a sexualunion versus those in non-sexual unions because no study emerged than elucidate important onthese cohorts. The current study will evaluate the demographic, reproductive and healthcharacteristics of women aged 15-49 years old who are in a sexual union or not in Jamaica andtheir area of residence as well as factors which determine (1) good-to-very good health status; (2)method of contraception; (3) had sex in the last 3 months; (4) high church attendance; and (5)physically forced to have sexual intercourse, with emphasis on those who are in a sexual unionor not in Jamaica.Methods and materialsSampleThe current research used the dataset from a national descriptive cross-sectional survey. Thesurvey was conducted by the National Family Planning Board in 2008 on Jamaican womenamong the reproductive ages and males aged 15-24 years old (2008 Reproductive Health Survey,RHS). This study extracted only females aged 15-49 years from 2008 Reproductive HealthSurvey. The study population was 8,259 women. Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (or 132
  • enumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomasand St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica comparedto Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8%.1 In stage 2, the households were clustered into primary sampling units (PSUs), and eachPSU constituted an ED, which in turn was comprised of 80 households. The previous samplingframe was in need of updating, and so this was performed between January and May 2002. Theprevious sampling frame was in need of updating, and so this was carried out between January2002 and May 2002. The new sampling frame formed the basis upon which the sampling sizewas computed for the interviewers to use. Stage 3 was the final selection of one eligible female from each sampled household andthis 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 instrumentadministered was a 35-page questionnaire. A total of 175 instruments were pre-tested.Modifications were made to the pre-tested instrument (questionnaire), after which the finalexercise was carried out. Validity and reliability of the data were conducted by manystatisticians, statistical agency, and university scholars before the data was used as the data arefor 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 populationof female aged 15 to 49 years in the nation.1 133
  • Statistical analysesData were entered, stored and retrieved using SPSS for Window, Version 17.0 (SPSS Inc;Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographiccharacteristics of the sample (frequency, mean, standard deviation (SD), and range). All metricvariables were tested for normality (age at first sexual debut, crowding, age, and years ofschooling). Where skewness was found to be less than 0.5, the variable was used in its currentform and a value more than 0.5 was normalized by natural log, or another method. Independentsample t-test was used to examine differences in age at sexual debut between those whofrequently attend churches and those who infrequently visit churches and F-statistic wasemployed for age of respondents by age at sexual debut. Chi-square was used to examine thestatistical association between two non-metric variables. Finally, stepwise multiple logisticregression analyses were used to fit the data because the dependent variable is a dichotomousnominal measure. Thus, only explanatory variables (i.e. statistically significant variables) areshown in each Table. Where collinearity existed (r > 0.7), variables were entered independentlyinto the model to determine those that should be retained during the final model construction. Toderive accurate tests of statistical significance, we used SUDDAN statistical software (ResearchTriangle Institute, Research Triangle Park, NC), and this adjusted for the survey’s complexsampling design. A p-value < 0.05 (two-tailed) was used to establish statistical significance.MeasuresKey variables: Age at first sexual debut (or initiation or intercourse) was measured based on arespondent’s answer to the question “At what age did you have your first intercourse? Crowdingis the total number of persons in a dwelling (excluding kitchen, bathroom and verandah). Age isthe number of years a person is alive up to his/her last birthday (in years). Contraceptive method 134
  • 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 beganusing contraception was taken from “How old were you when you first used contraception? Areaof 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 thereference group). Currently having sex is measured from “Have you had sexual intercourse in thelast 30 days?” (1=yes, 0 = otherwise). Education is measured from the question “How manyyears did you attend school?” Marital status is measured from the following question “Are youlegally married now?”, “Are you living with a common-law partner now? (that is, are you livingas man and wife now with a partner to whom you are not legally married?)”, “Do you have avisiting 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 yourfirst period started (first started menstruation)?” Gynaecological examination is taken from“Have you ever had a gynaecological examination?” (1 = yes, 0 = no). Pregnancy was assessedby “Are you pregnant now?” (1=yes, 0 = otherwise or no). Religiosity was evaluated from thequestion “With what frequency do you attend religious services?” The options range from atleast once per week to only on special occasions (such as weddings, funerals, christenings etcetera) (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’tknow and refused to answer (1= yes, 0 = otherwise). Age at first sexual debut, age at menarche, 135
  • age at first contraceptive use, and years of schooling were used as continuous variables. Earlysexual debut is having sexual intercourse before the statutory legal age to do so (in Jamaica, thisis 16 years old).Sexual union denotes the pairing of male and female for the purpose of reproductive matters.ResultsDescriptive statistics: Table 6.1 presents information on the demographic characteristics ofsample by currently in or not in a sexual union. The findings revealed that 2.5 times morewomen aged 15-49 years were in a sexual union (71.2%) compared to those not in a sexualunion. Of those in a sexual union 38.8% were in visiting relationships followed by common-lawrelationships (36.7%) and 24.5% were married women. Women who are in sexual unions enterin these unions 4 months earlier than those who were currently not in a sexual union, but latterbegan having sexual relations 5.9 years early than those currently in a sexual union. Figure 1 shows that respondents in the poorest 20% were most likely to be in sexualunions (74.5%) compared with those in other income quintiles. However, 62.3% of those in thepoorest 20% were in common-law or visiting relationship than married people compared with46.8% of those in the wealthiest 20% (χ2 = 347.53, P < 0.0001). Table 6.2 depicts information on the reproductive health matters of the sample by thosecurrently in or not in a sexual union. Table 6.2 showed that women in a sexual union were lesslikely to report having 2+ sexual partners (6.0%) compared to those who were currently not in asexual union (10.9%). However, the latter were more likely to use a condom (56.1%) andreported having HIV/AIDS (25.7%) compared to those in a sexual union – condom usage(44.1%), HIV/AIDS (14.2%). 136
  • Table 6.3 exhibits information on the demographic characteristic of sample by area ofresidence. The findings indicate that women in periurban areas were wealthier (33.5%) thanthose in urban areas (29.7%) as well as rural locations (17.3%). In addition to the aforementioned issue, rural women enter in sexual unions 6 monthsearlier than periurban women and 7 months later than those who reside in urban zones (Table6.3). However, periurban women begin having sexual intercourse the earliest (24.3 ± 23.5 years)compared to those in urban (28.1±28.5 years) and rural women (25.6 ± 25.9 years). Multivariate analyses: Table 6.4 presents information on logistic regression analyses ofexplanatory variables for good-to-very good health status of sampled population. Women inperiurban areas were 18% less likely to report good-to-very good health compared to ruralwomen. However, no statistical difference emerged in the self-rated health status between thosein or not in a sexual union. In addition, women who were physical forced into sexual intercoursewere 37% less likely to report good-to-very good health status. Table 6.5 shows the logistic regression of method of contraception. Based on thestepwise regression results eight variables emerged as statistical significant factors of method ofcontraception, and they explain 34.4% of method of contraception. The findings revealed thatwomen who had sexual intercourse in the last 30 days were 7.7 times more likely to use amethod of contraception the last time they had sexual relation, the employed were 1.2 timesmore likely, those in the wealthiest 20% were 1.4 time more likely, those who reported good-to-very good health status were 1.2 times more likely as well as those in a sexual union (OR = 1.8,95% CI = 1.4 – 2.4). Seven variables emerged as statistical significant factors explaining 63% of women aged15-49 years having had sexual relations in the last 30 days (Table 6.6). Furthermore, women 137
  • who indicated that they are currently in a sexual union were 73.8 times more likely to have hadsex in the last 30 days. Table 6.7 shows explanatory variables of high church attendance. The findings revealedthat seven variables emerged as statistical significant factors of high church attendance. Ruralwomen exhibited the greatest church attendance. Furthermore those who reported having hadsexual intercourse in the last 30 days were 34% less likely to attend church on a regular basis (atleast once per week). Using stepwise logistic regression, nine variables emerged as statistically significantvariables accounting for 24% of those who were physically forced into sexual relations (Table6.8). Women who reside in periurban areas were 1.3 times more likely to be physically forcedinto sexual relations compared to those in rural areas (OR = 1.3, 95% CI = 1.03 - 1.68).Furthermore, those who were in sexual unions were 38% less likely to be physical forced intosexual relations compared to those who did not indicated being in a sexual union. Table 6.9 shows variables that explain women who are currently in or not in a sexualunion. Twelve of the initial variables emerged as statistically significant factors explaining whoare currently in or not in an intimate union (R2 = 59.0%).DiscussionIn Jamaica, intimate unions (sexual unions) among women aged 15 to 49 years were 2.5 timesmore likely than non-intimate unions (in 2008). The sexual unions were (1) marriage (24.5%),common-law (36.7%), and visiting relationships (38.8%). Previous empirical studies revealedthat many Jamaican males are in multiple sexual relationships and that 1 in every 3 malesconsistently used a condom with their steady intimate partners24-26, suggesting that females whoare in sexual unions are exposed to sexually transmitted infections, particularly HIV/AIDS. The 138
  • aforementioned issue justifies statistics on the prevalence of the HIV/AIDS virus in Jamaica.27, 28Despite the history of millions of dollars spent on the HIV/AIDS virus, reproductive healtheducation and other sex education programmes in the Caribbean, particular Jamaica, the virushas been increasing27, 35 embodied here is the resultant effect of intimate encounters. Statistics revealed that the mean age at first coitus among females Jamaicans in 2002 was15.8 years and 13.5 years for males.1 Clearly from the aforementioned finding, intimate unionscommence at an early age in Jamaica, which is also typically the case in the United States29 aswell as other developing nations. Previous studies have shown that in Antigua and Barbuda,Haiti, Guyana, Trinidad and Tobago and Dominica Republic, one in six women between the agesof 15 and 24 become sexually active before the age of 15 years.30, 31 However, researchers foundthat the “First sexual intercourse almost always take place outside of a formal union”32 and witholder men (for the females).33 The intimate unions that people enter and/or remain in are accounting for manyreproductive health matters such as HIV/AIDS and pregnancy. A dyadic of scholars (or group)found that, 2 in every 5 Jamaican women have been pregnant at least once, 4 in every 5adolescent women pregnancies were unplanned and 74% of females’ ages 15-17 years old weresexually active compared to 47% of males of the same age.34 And that 1 in every 50 people in theCaribbean being infected with the HIV/AIDS virus; AIDS being the main cause of deaths amongpeople aged 15-44 years.28 The World Health Organization (WHO) offered some explanation forthe reproductive health issues which emerged in many nations when they opined that unsafesexual practices are a part of risk factors which account for increased mortality and morbidity inthe world.35 Inspite of the prevalence of the HIV/AIDS virus and unwanted pregnancy, women insexual unions (being it, visiting, common-law or marriage partnership) were not protecting 139
  • themselves from the probability of contracting the virus as a study found that 43.3% of Jamaicanwomen aged 15-19 years old and about 66% of those aged 15-49 years reported using a condomin the last 30 days1 as well as 41.2% of females aged 15-74 years old used a condom20, indicatingnot only premarital sexual relations, but also risky lifestyle practices.1 The current work found that those who are currently in intimate unions (cohabitingunions) were 29.9 times more likely to have sexual intercourse; 1.8 times more likely to use amethod of contraception; 1.4 times more likely to want to have more children; mostly likely tobe in the poorest 20% (62.3%) compared with those in the wealthiest 20% (40.0%), 1.6 timesmore likely to have done a HIV test than a those in non-intimate unions (non-cohabiting), butthey were less likely to use a condom. Knowing that women aged 15-49 years old who areinvolved in sexual unions want to have more children, inconsistent condom usage is inevitable,which means that they are exposed to sexually transmitted infections (as well as humanpapillomavirus (HPV)), cervical cancers, pregnancy and other risky sexual issues, which issupported by the literature.9 One of the issues which emerged from this work is the fact that women aged 15-49 inintimate union years old were less educated and more likely to be employed than those in non-cohabiting unions. Being less educated than their non-intimate counterparts and dwelling incrowded household, they are having to subscribing to the dictates of their partners because ofeconomic vulnerability. A study by Wilks and colleagues comparing results for 2000 and 2008found that self-reported unemployment increased by 7.1%20 and within the context that rate ofunemployment is greater for female than males21, the economic vulnerability of women in sexualunions means that they are handing the vetoing powers of their reproductive rights to their malecounterparts in exchange for socioeconomic assistance or survivability. It is this reality that 140
  • justifies the high rates of contracting the HIV/AIDS virus because they desire more children,suggesting a likelihood of inconsistent condom usage among them and their sexual partners. Within the context that biological sex is a fundamental structural part of the social life ofwomen in intimate unions (22 out of every 25 had sex in the last 30 days), these highly sexedindividuals coupled with data showing that 66% of them (Jamaican women) used a method ofcontraception, then economic vulnerability among these women denotes that the gains made insex education is likely to be eroded because of material deprivation. Women who are currently inan intimate union although they are more likely to be employed compared with those who arecurrently not in a sexual union, this fact does not provide economic independency because theoccupational type will be lower as a result of the lower level of education. Poverty is, therefore,accounting for the educational disparity between those in sexual union status and those currentnot in an intimate relationship, and thereby creating other socioeconomic problems. For the current work, almost 10 in every 25 women aged 15-49 years old who areinvolved in sexual unions are in visiting cohabitations, 3 out of every 4 women in the poorest20% were in intimate unions and 14 out of every 25 being unemployed, the economicdependency is fostering the reduced sexual autonomy of these people. Embedded in the currentfindings is the reality that cohabitation among Jamaican women is continuously changingbecause of money and material resources. Such an issue highlights the challenge of restoringsexual rights among women, and how sexually transmitted infections can be easily transmittedbecause men are still dominating reproductive rights of women owing to their economic power.This is also offering some explanations why low-income and/or lowly educated women opt forintimate relationship than those in the wealthy income groups and their reproductive healthmatters are controlled by the male as intimate unions are used as an avenue of escape from 141
  • economic challenges and material deprivation. The current work revealed that 22.3% morewomen aged 15-49 years who are in common-law or visiting unions were in the poorest 20%compared to those in the wealthiest 20% and that they had the lowest rate of involvementmarriage than women in other income quintiles. Those results have implication for theorizing onreproductive health intervention programmes, the role of gender in reproductive health choicesas well as retardation of economics in reproductive choices of women. Almost 15 out of every 25 respondents dwelled in rural areas, and rural poverty was 1.9times more than urban poverty, rural poverty was 1.6 times more than periurban poverty. Money(or the lack of it) explains the high cohabitation as women seek assistance from older males whoare more accomplished financial. Because one in every 2 women aged 15-49 years old wereunemployed rural residents, the economic challenge will be greater in among rural women whichare offset by assistance from different males. Thus, it is for this very reason why women enterinto sexual unions earlier than those in non-cohabiting unions. Although women who are currently in sexual unions enter these 4 months earlier thanthose who are not in one, they commence sexual intercourse 5.9 years later. Delaying sexualintercourse does not mean that these women asexual compared to those not in intimate unions,but the contrary is the case. Continuing, they were higher sexual being, less educated, morelikely to be unemployed and in the poorest 20%, making them apart of the economicallyvulnerable group. Thus, this study is forward a perspective that intimate unions among Jamaicanwomen aged 15-49 years old, therefore, is for economic gains and thereby justifies the highprevalence of sexual intercourse in these relationships. Women in cohabiting union, despite their economic vulnerability, are less likely to havemultiple sexual partners (2+) and reported having HIV/AIDS, suggesting that they fear for 142
  • partnership dissolution because if the male becomes aware of their infidelity, the union maycease from operating. Such information envelope the risky sexual lifestyle practices of those whoare currently not in an intimate union, which is owing to their economic independency. Thus,they have more control over their reproductive health matters, choice of sexual activity andsexual freedom than those in intimate unions. Despite a greater degree of educated women beingamong those who are in non-sexual union, they are more engaged in risky sexual practices thatspeaks to the disjoined between knowledge or education and sexual behaviour. This could beascribed to culture in the Caribbean as emerged from Chevannes’ work, which revealed thatsubtly cohered into risky sexual practices in order to established there capacity to bear childrenfollowing entering into puberty.36 The sexual relationship that is entered into by women aged 15-49 years is a byproduct ofearly socialization. This is captured into aptly in an ethnographic studies carried out in someCaribbean communities. Chevannes opined that “By the time small children reach the age ofseven 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.”36 Chevannes findings highlight the rationale behind the highprevalence of sexual relations among women aged 15-49 years old who are currently involved inan intimate union. In 2007/08, a nationally representative probability survey of 2, 843 Jamaicansaged 15-74 years old revealed 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% offemales; and of those aged 15-24 years old, 36.1% of males had multiple partners to 15.4% offemales.20 143
  • Intimacy is not only a as a result of the socialization of the individual, but it is also anexplanation of the choices which are made by people. Women are making particular choices (ornot) on reproductive health matters based on their socioeconomic situation, and these affect theirentrance into sexual partners and intimate unions. This work unearths that material deprivationand socioeconomic challenges of women affect intimate unions, choices on reproductive healthmatters and their current realities. It is for this reason that periurban residents, who are thewealthiest among the different area of residents, and justifies why those in the wealthiest 20%reported a greater good-to-very good health status in reference to those in the poorest 20%, andthey are more likely to use a condom. Money (or, insufficient financial resource), therefore, isfostering better health status as well as lifestyle practices of women, which concurs with theliterature.38-42 Previous studies have shown that those in the lower socioeconomic status are less healthythan those in the wealthy socioeconomic groups41, 42 which is supported by the current findings.Another research found that poverty was greater among chronically ill people than the non-chronically ill, 43 and the WHO39 opined that 80% of chronic illnesses were in low and middleincome countries. Poverty is not only associated with illness and ill-health, but also with higherrates of mortality and intimate partnership. This work ascertained that 25.4% of women whowere in intimate unions were classified in the poorest 20% of socioeconomic income comparedwith 21.4% of those in non-intimate unions. Thus with poverty being greater in rural area, it isaffecting health status of rural women and it is also influencing their reproductive health choicesas they are unable to effectively address those matters without the assistance of males, therebyaccounting for the higher indulgence into sexual unions. 144
  • A group of scholars, using Grounded theory found that “…96% of the mothers voiced ageneral distrust of men, yet that distrust did not deter them from involvement in intimateunions.”37 The rationales for such behaviours are embedded in (1) the culture, (2) economicvulnerability and (3) material deprivation. With the downturn in the global economy and itseffect on the Jamaican economy, the new economic reality of material deprivation and economichardship among women is creating increased premarital cohabitation, and less commitment tomarriage or the permanence of intimate unions. Another reality which is occurring in Jamaica is the prevalence of multiple sexualrelationships, particular among men, and this is not resulting in high condom usage amongwomen in sexual unions. Chevannes noted that in the Caribbean males are given sexual freedom,sexual autonomy and sexual promiscuity is a part of the social setting36, and this is known bywomen. While women may distrust men because of their sexual promiscuity, which is culturallybased, the current work showed that low condom usage is higher in intimate relationships, whichconcurs with Burton and colleagues’ study.37 Statistics revealed that in 2008 of the 22,152marriages that were entered into, 94% of the females were less than 50 years compared to 89%for males, and 44.1% of females less than 30 years old compared with 32.5% of males of thesame ages. The information provide an insight into the cultural disparity of marriage between thegenders, and the reality that women enter into intimate unions with older men who are likely tobe promiscuous and more financial secure. This also holds true in non-married sexual unionswhich was found by scholars who stated that the “First sexual intercourse almost always takeplace outside of a formal union”32 with older men. Using data which were collected in 2000 as part of the Ministry of Health’sHIV/AIDS/STD Survey in Jamaica, Gibbison24 opined that “Males in general have multiple 145
  • sexual partners and less than a third use condoms on a consistent basis with their regular sexpartners.…Clearly, women in certain regions or subpopulations face an increased risk ofcontracting sexually transmitted infections due to the sexual choices of their partners.”Chevannes’ work showed that the cultural underpinnings in the Caribbean offers much reasonfor the lifestyle practices and choices of men and women, and creates a justification for therationale of women subscribing to the culture instead of wanting an idealistic world.37 Thisresearch offers some explanation for the aforementioned issues as poverty is eroding the goodlifestyle and sexual practices of women irrespective of knowing that their choices are risky, andunderstanding the sexual freedom on their male partners. Such issues correspond with highdistrust of women for men, but do not militate against intimate unions or inconsistent condomusage because of the economic power of men. The disproportionate economic power between thegenders dictates reproductive health matters of women as the economic benefits outweigh therisk of HIV/AIDS or other sexually transmitted infections. Thus, the risk associated with thechoices made by women is enveloped within the disproportionate economic power between thegenders, and this means that they are likely to experience morality associated with economicvulnerability. Douglas postulated that the major cause of mortality among women aged 15-44 years inthe Caribbean is AIDS18 and Wilks et al forwarded that sexually transmitted infections (STI) isgreater among males (18.1%) than females (11.0%) and that 41% of males had 2+ partnerscompared to 8.4% of females, 20 yet inconsistent condom usage and low condom usage is foundamong women who indicated being in an intimate union. This research is forwarding that sexualpromiscuity among women as well as inconsistent condom usage and reduced sexual autonomyis associated with economic hardships. Within the context of their socioeconomic realities, in an 146
  • attempt to address the economic hardship, women enter into non-stable intimate unions (visitingunions) as a source of survivability. Thus, they will engaged into those unions, knowing that themale is already involved in a sexual union (visiting or extra marital relationship) as a means ofproviding for themselves and children, and not because of sexual freedom. It is this reality whichjustifies why 3 out of every 4 women in a sexual union were engaged in either common-law orvisiting unions as these are easier to form, and provide some source of income because they areinvolved with older men who are able to offer assistance compared to younger men. The matterbecomes even more complex in rural communities with less males, more women of thereproductive ages who are unemployed, of low educational attainment, living with families whoare unable to offer much financial assistance and they females are unable to move to urbancentres because their families residing in those areas are living in inner city communities withlittle opportunities. There is another side to the discourse on intimate or non-intimate unions, which isemotional satisfaction and physical pleasure. Sexual unions are not merely about economicstability, but this relates to emotional satisfaction and physical pleasure.44 It can be argued thatlower prevalence of multiple sexual partners among women in intimate unions that the degree ofemotional satisfaction would be greater as women sex is associate with higher emotionalsatisfaction. Koo, Rie & Park’s study revealed that being married was a ‘good’ cause for anincrease in psychological and subjective wellbeing in old age.45 Delbés & Gaymu study that reads “The widowed have a less positive attitude towards lifethan married people, which is not an unexpected result.46 Another research, using a sample of1049 Austrians from ages 14 years and over, found that married individuals reported bettersubjective health - related quality of life index (8.3 ) than divorced persons (7.6) or singles 147
  • (7.7).47 Other studies have shown that married people have a lower mortality risk in the healthycategory than the ‘nonmarried’48 which explains why they take less life-threatening risks49,50 andare happier than non-married people.51 Intimate unions, therefore, are providing economicopportunities for women aged 15-49 years as well as positive affective psychological conditions(emotional satisfaction) as explained by Soons and Kalmijn, which supports longer and betterquality of life.52 Because married women have more access to shared financial resources as a result oftheir male partners’ resources as well as the stability of those unions, many women seek thispartnership. With more material resources in married and common-law union, women in suchrelationship are able to seek more medical care, which accounts for better health and moreproductive contribution to economic growth. A study by Bourne offered more of an explanationof interconnectedness among poverty, unemployment, not seeking medical care, morality andeconomic conditions in the nations.53 He found that there was a (1) positive statistical correlationbetween poverty and unemployment (R2 = 0.48); (2) positive association between not seekingmedical care and unemployment (R2 = 0.58); (3) positive relationship between not seekingmedical care and poverty (R2 = 0.58); (4) positive correlation between poverty and inflation (R2= 0.73); (5) negative statistical association between seeking medical care and inflation (R2 =0.67); and (6) a negative correlation between not seeking medical care and mortality (R2 = 0.56).Bourne’s work has provided some insight into the justification for high negative affectiveconditions and poverty, poverty and seeking sexual partnerships, poverty and death, economichardship and poor health, disparity in reproductive rights owing to gender differences, andacceptance of men’s sexual promiscuity. 148
  • While poverty is retarding women’s sexual autonomy, economic independency andreproductive health freedom, the positive affective psychological conditions which emergedfrom economic independency is equally creating challenges for policy makers. As women whoare economic independent, employed, educated and are able to seek medical care as well asdecide what they want for life are engaged in more risky sexual practices than those whoinvolved in intimate unions out of (or not) economic vulnerability. Thus, the economic powerthat men acquire from material resources explains their power over vulnerable women who seekfinancial assistance, and clearly this is equally the case among economically power women.These economically power women are more likely to reside in periurban areas, wealthier, moreeducated, more likely to currently not in an intimate unions, but they are more likely to have 2+sexual partners not use a condom on the last sexual encounter, which are feature of Jamaicanmales. Chevannes argued that the culture accounts for sexual expressions of males, and whilethis is true, economics appears to be at the root of these behaviours as the sexual freedom ofmales in Caribbean as this is found to be the case among economically power women whobetween 14 and 50 years in Jamaica.ConclusionBiological sex is fundamentally structured into cohabitation between men and women,particularly among women aged 15-49 years old in Jamaica. The current findings showed thatthose in the poorest 20% were most likely to be in intimate unions, it can be extrapolated fromthat finding that sexual intercourse is used by women as a means of addressing economic andmaterial deprivation. Poverty is greatest in rural zones, which accounts for the lower health statusamong the sample as well as cohabitation, lower educational attainment, and greater householdcrowding. Continuing, lower educational achievement and household crowding were found 149
  • among those in intimate unions, justifying the rationale why they are in highly sexed unions as ameans of obtaining economic resources. On the other hand, women who are currently not inintimate unions were more educated, wealthier and this provides them with economicindependency. The economic independency provides them with sexual freedom, sexualautonomy and choice of reproductive health matters than those in romantic unions, whichexplains their risky sexual practices and higher HIV infections. Involvement into sexual unions among women in the reproductive ages is highly basedon sexual intercourse and economic gains, which should be used to guide policy formulation andintervention programmes. Even though biological sex is lower among women aged 15-49 yearswho are currently not in a romantic union, their greater degree of education is not influencingbetter sexual practices as they are more likely to have multiple sexual partners (2+) and lesslikely to use methods of contraception. As such, as women become economically independent,the gains to intimate unions decline, meaning that employment and education provide womenwith the same power and choice over their reproductive rights and sexual freedom as thosecurrent had by men. Thus, sexual union is engaged into because of its gains (emotionalsatisfaction, positive affective psychological conditions, and economic benefits).54 Those issueshighlight the need to institute intervention programmes geared towards both those in sexual andnot in romantic unions. Because poverty can reduce health status and sexual autonomy38,55 and a group ofresearchers went further to say that money buys health,56 although this is not necessarily the caseamong Jamaican females as Bourne55 found that income does not reduce health conditions, a sexeducation programmes must recognize these facts. Poverty reduces the gains of an interventionprogrammes as it incapacities an individual from good nutrition, educational advancement, 150
  • adequate physical milieu, long life and better choices.57,58 As such, poverty, unemployment andarea of residence impinge on how women live58 dictate entrance into intimate partnership, whichhighlight the multisectoral approach that must be taken in order to establish sexual education orlifestyle intervention programmes because economic disparity is critical in a thrust against riskysexual practices and sexual autonomy. In summary, intimate unions that are entered into among women aged 15 to 49 years aredriven by sexual intercourse and economic situation, and are entered into because of gains. Onthe contrary, women who are currently not in a sexual union were more likely to be moreeducated, use a condom, wealthier and these are responsibility for their economic independency,sexual autonomy and risky sexual practices. Despite women distrust for men as a result of thecultured sexual freedom, this has not fundamentally affected the structure of intimate partnershipbecause economics is important to entrance into sexual relationship. Those findings highlight aneed to institute measures to alleviate gendered poverty and gendered economic inequality. Buteconomics independency among women of the reproductive ages must be met by interventionprogrammes fashioned to address sexual promiscuity, sexual freedom, and risky sexual practices.As such, a safe-sex social norm intervention programme needs to be developed for women aged15 to 49 years old; particular those who are wealthy, educated, live in periurban and rural areasas well as those in sexual unions.DisclosuresThe authors report no conflict of interest with this work.DisclaimerThe researchers would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researchers. 151
  • AcknowledgementThe 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 (Reproductive HealthSurvey, RHS) available for use in this study, and the National Family Planning Board forcommissioning the survey. 152
  • References1. Jamaica, National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston: NFPB; 20052. Family Care International. Commitments to Sexual and Reproductive Health and Rights for All. Framework for Action. New York, NY: Family Care International; 19953. US Department of Health and Services (2006). Gender Differences in Reproductive Health. Department of Health and Human Services, Centre for Disease Control, USAID and Jamaica National Family Planning Board.4. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010).5. Miller KS, Clarke LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents. Family Planning Perspectives; 29, 1997:212-214.6. Warren CW, Powell D, Morris L, Jackson J, Hamilton P. Fertility and family planning among young adults in Jamaica. Int Family Planning Perspectives 1988; 14(4):137-141.7. Eggleston E, Jackson J and Hardee K. Sexual attitudes and behavior among young adolescents in Jamaica. Guttmacher. International Family Planning Perspectives; 25(2), 1999.8. Williamson LM, Parkes A, Wight D, Petticrew M, Hart GJ. Limits to modern contraceptive use among young women in developing countries: A systematic review of qualitative research. Reproductive Health 2009; 6:39. Henry-Lee A. Women’s reasons for discontinuing contraceptive use within 12 months: Jamaica. Reproductive Health Matters 2001; 9(17):213-220.10. World Health Organization (WHO). Reproductive health research at WHO: A new beginning. Biennial report 1998-1999. Geneva: WHO; 2000.11. World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009.12. Fatusi AO, and Blum, RW. Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC Public Health; 8, 2008.13. 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, 34:200-208.14. Penfold SC, Teijlingen ERV, Tucker JS. Factors associated with self-reported first sexual intercourse in Scottish adolescents. BMC Research Notes 2009; 2:42.15. Rosenthal DA, Smith AMA, De Visser R. Personal and social factors influencing age at first sexual intercourse. Archives of Social Behavior 1999; 28(4):319-333.16. 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):119-7.17. State Council AIDS Working Committee Office and UN Theme Group on HIV/AIDS in China: A joint assessment of HIV/AIDS prevention, treatment and care in China (2005). Beijing 2005.18. 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. 153
  • 19. 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; 9:305.20. 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; 2008.21. Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). 2008. Jamaica Survey of Living Conditions, 2007. Kingston: PIOJ, STATIN.22. World Health Organization (WHO). Preventing Chronic Diseases a vital investment. Geneva: WHO; 2005.23. Statistical Institute of Jamaica (STATIN). Demographic statistics, 2007, 2009. Kingston: STATIN; 2008, 2010.24. Gibbison GA. Attitude towards intimate partner violence against women and risky sexual choices of Jamaican males. West Indian Med J 2007; 56(1):66-71.25. Ward M The reproductive and sexual health of Jamaican youth. Advocates for Youth. Washington DC. Advocates for Youth; 2001.26. Bourne PA, Charles CAD. Contraception usage among young adult men in a developing country. Open Access J of Contraception 2010; 1:51-59.27. Pan American Health Organization (PAHO). Health in the Americas, 2007, volume II – Countries. Washington, D.C.; 2007: pp.448-464.28. 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. 62-76.29. Santelli JS, Brener ND, Lowry R, Bhatt A, Zabin LS. Multiple sexual partners among U.S. adolescents and young adults. Family Planning Perspectives 1998; 30:271-275.30. Rawlins J. Teenage Pregnancy: A study in three communities in Trinidad and Tobago. Paper presented at the Caribbean Health Research Conference 2007, Jamaica.31. Jamaica Observer. Study shows Jamaican Girls Encounter Violent Sexual Relationships. Jamaica Observer (15 April 2009).32. US Department of Health and Services (2006). Gender Differences in Reproductive Health. Department of Health and Human Services, Centre for Disease Control, USAID and Jamaica National Family Planning Board.33. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010).34. Crawford TV, McGrowder DA, Crawford A. Access to contraception by minors in Jamaica: a public concern. North Am J of Med Sci 2009; 1(5):247-255.35. World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009.36. 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; 2001.37. Burton LM, Cherlin A, Winn DM, Estacion A, Holder-Taylor C. The role of trust in low- income mothers’ intimate unions. J Marriage Fam 2009; 71(5):1107-1124.38. Marmot M. The influence of Income on Health: Views of an Epidemiologist. Does money really matter? Or is it a marker for something else? Health Affairs. 2002; 21: 31- 46.39. World Health Organization. Preventing Chronic Diseases a vital investment. Geneva: WHO; 2005. 154
  • 40. Pan American Health Organization, (PAHO). Investment in health: Social and economic returns, Scientific and Technical Publication, No. 582. Washington DC: PAHO, WHO; 2001.41. Fox J ed. Health inequalities in European Countries. Aldershot: Gower Publishing Company Limited; 1989.42. Illsley R, Svenson PG, ed. Health inequalities in Europe. Soc Sci Med 1990; 31(special issue):223-420.43. Van Agt HME, Stronks K, Mackenbach JP. Chronic illness and poverty in the Netherlands. Eur J of Public Health 2000; 10:197-200.44. Waite LJ, Joyner K. Emotional satisfaction and physical pleasure in sexual unions: Time horizon, sexual behavior, and sexual exclusivity. J of Marriage and Family 2001; 63(1): 247-264.45. Koo J, Rie J, Park K. Age and gender differences in affect and subjective wellbeing. Geriatrics and Gerontology International, 2004; 4:S268-S270.46. Delbés C, Gaymu J. The shock of widowed on the eve of old age: Male and female experience. Demography 2002; 3: 885-914.47. Prause W, Saletu B, Tribl GG, Rieder A, Rosengerger A, Bolitschek J, Holzinger B, et al. Effects of socio-demographic variables on health-related quality of life determined by the quality of life index—German version. Human psychopharmacology Clinical and Expremental. 2005; 20:359-365.48. Goldman N. Marriage selection and mortality patterns: Inferences and fallacies. Demography 1993; 30:189-208.49. Smith KR, Waitzman NJ. Double jeopardy: Interaction effects of martial and poverty status on the risk of mortality. Demography 1994; 31:487-507.50. Umberson D. Family status and health behaviors: Social control as a dimension of social integration. Journal of Health and Social Behavior 1987; 28:306-19.51. Diener E. Subjective wellbeing. Psychological Bulletin, 1984; 95:542-575.52. Soons JPM, Kalmijn M. Is marriage more than cohabitation? Wellbeing differences in 30 European Countries. Journal of Marriage and Family 2009; 71(5):1141-1157.53. Bourne PA. Impact of poverty, not seeking medical care, unemployment, inflation, self- reported illness, health insurance on mortality in Jamaica. North American Journal of Medical Sciences 2009; 1(3):99-109.54. Becker GS. A Theory of Marriage: Part I. Journal of Political Economy, 1973; 81, 812-846.55. Bourne PA. Health of Females in Jamaica: using two cross-sectional surveys. North Am J Med Sci. 2009;1: 272-278.56. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997; 34:159-70.57. Bourne PA. Health status and Medical Care-Seeking Behaviour of the poorest 20% in Jamaica. International Journal of Collaborative Research on Internal Medicine & Public Health, 2009;1(6&7):167-185.58. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. International Journal of Collaborative Research on Internal Medicine & Public Health, 2009;1(5):132-155. 155
  • Figure 1: Intimate unions (married, common-law and visiting) by population income quintiles 156
  • Table 6.1: Demographic characteristics of sample by currently in or not in a sexual unionCharacteristic Sample Currently in or not in a χ2, P sexual union Not in In sexual sexual union union n (%) n (%) n (%)Area of residence 0.36, 0.837 Urban 1198 (14.5) 354 (14.9) 844 (14.3) Periurban 2283 (27.6) 656 (27.6) 1627 (27.7) Rural 4778 (57.9) 1371 (57.6) 3407 (58.0)Currently in a sexual union No 2381 (28.8) NA NA Yes 5878 (71.2) NA NAIncome quintile 30.00,< 0.0001 Poorest 20% 2001 (24.2) 510 (21.4) 1491 (25.4) Second poor 1716 (20.8) 469 (19.7) 1247 (21.2) Middle 1668 (20.2) 476 (20.0) 1192 (20.3) Second wealthy 1650 (20.0) 544 (22.8) 1106 (18.8) Wealthiest 20% 1224 (14.8) 382 (16.0) 842 (14.3)Marital status 8259.0, <0.0001 Married 1441 (17.4) 0 (0.0) 1441 (24.5) Common-law 2158 (26.1) 0 (0.0) 2158 (36.7) Visiting 2279 (27.6) 0 (0.0) 2279 (38.8) Separated, divorced & widowed 1344 (16.3) 1344 (56.4) 0 (0.0) Single 1037 (12.6) 1037 (43.6) 0 (0.0)High church attendance 231.09, <0.0001 No 5403 (65.4) 1260 (52.9) 4143 (70.5) Yes 2856 (34.6) 1121 (47.1) 1735 (29.5)Employed 123.07, <0.0001 No 4857 (58.8) 1625 (68.2) 3232 (55.0) Yes 3402 (41.2) 756 (31.8) 2646 (45.0) t-test, PAge enter into first sexual union 18.7 (4.3) 18.9 (4.2) 18.6 (4.4) t= 2.40, 0.017Age at first contraceptive use 19.0 (3.9) 19.0 (3.8) 19.1 (4.1) t= 1.29,0.195Age of sexual debut 15.0 (5.8) 10.8 (8.5) 16.7 (2.6) t=-31.99,<0.0001Age of menarche 13.0 (1.5) 12.8 (1.5) 13.0 (1.6) t=-4.82,<0.0001Crowding 1.7 (0.5) 1.6 (0.5) 1.7 (0.5) t=-8.13,<0.0001Age of respondents 31.6 (9.9) 28.1 (11.5) 32.9 (8.8) t=-18.27,<0.0001 157
  • Table 6.2: Reproductive health matters by currently in or not in a sexual union Currently in a sexual unionCharacteristic Sample Not in In a sexual χ2, P sexual union union n (%) n (%) n (%)Had sex in last 30 days 4121.57,<0.0001 No 2873 (34.8) 2087 (87.7) 786 (13.4) Yes 5386 (65.2) 294 (12.3) 5092 (86.6)Gynaecological examination 210.99, <0.0001 No 4664 (56.5) 1643 (69.0) 3028 (51.5) Yes 3588 (43.4) 738 (31.0) 2850 (48.5)Physically forced to have sex 3.21,0.073 No 6622 (91.7) 1216 (90.5) 5406 (92.0) Yes 600 (8.3) 128 (9.5) 472 (8.0)Ever done HIV test 467.05,<0.0001 No 3016 (45.8) 1404 (64.5) 1600 (36.3) Yes 3560 (54.2) 769 (35.3) 2797 (63.5)Currently used method of contraception 867.07, <0.0001 No 2580 (35.7) 1011 (68.3) 1571 (27.3) Yes 4647 (64.3) 469 (31.7) 4178 (72.7)Want to have more children 0.007, 0.934 No 3898 (58.4) 845 (58.3) 3053 (58.4) Yes 2780 (41.6) 605 (41.7) 2175 (41.6)Sexually abused 83.87, <0.0001 No 7844 (95.0) 2179 (91.5) 5665 (96.4) Yes 415 (5.0) 202 (8.5) 213 (3.6)Have HIV/AIDS (self-reported) 155.07, <0.0001 No 6815 (82.5) 1770 (74.3) 5045 (85.8) Yes 1444 (17.5) 611 (25.7) 833 (14.2)Last method of contraception 35.83, <0.0001 Injection 393 (15.4) 132 (13.3) 261 (16.8) Pill 723 (28.4) 242 (24.3) 481 (31.0) Condom 1243 (48.8) 559 (56.1) 684 (44.1) Emergency oral contraception 45 (1.8) 13 (1.3) 32 (2.1) Withdrawal or natural method 139 (5.5) 48 (4.8) 91 (5.9) Other 5 (0.2) 2 (0.2) 3 (0.2)Number of sexual partners in last 12 39.16, <0.0001months 1 6129 (93.0) 721 (88.1) 5408 (93.7) 2+ 438 (6.6) 89 (10.9) 349 (6.0) No response 22 (0.3) 8 (1.0) 14 (0.2) 158
  • Table 6.3: Demographic characteristic of sample by area of residence Area of residenceCharacteristic χ2, P Urban Periurban Rural n (%) n (%) n (%)Socioeconomic status 319.06, 0.0001 Lower class 172 (14.4) 407 (17.8) 1320 (27.6) Middle class 670 (55.9) 1111 (48.7) 2633 (55.1) Upper class 356 (29.7) 765 (33.5) 825 (17.3)High church attendance 21.36, <0.0001 No 854 (71.3) 1475 (64.6) 3074 (64.3) Yes 344 (28.7) 808 (35.4) 1704 (35.7)Employed 111.64, <0.0001 No 598 (49.9) 1220 (53.4) 3039 (63.6) Yes 600 (50.1) 1063 (46.6) 1739 (36.4)Currently in a sexual union 0.36, 0.835 No 354 (29.5) 656 (28.7) 1371 (28.7) Yes 844 (70.5) 844 (70.5) 3407 (71.3)Have HIV/AIDS 33.35, <0.0001 No 268 (74.9) 345 (57.5) 831 (60.0) Yes 87 (24.3) 246 (41.0) 540 (39.0) Don’t know 3 (0.8) 9 (1.5) 13 (0.9)Had sex in last 30 days 0.13, 0.939 No 415 (39.6) 801 (35.1) 1657 (34.7) Yes 783 (65.4) 1482 (64.9) 3121 (65.3)Health status 89.79, <0.0001 Very good 234 (19.6) 705 (31.2) 1256 (26.4) Good 679 (56.8) 937 (41.4) 2290 (48.1) Moderate 256 (21.4) 535 (23.6) 1032 (21.7) Poor 26 (2.2) 86 (3.8) 178 (3.7)Marital status 64.12, <0.001 Married 148 (12.4) 429 (18.8) 864 (18.1) Common-law 293 (24.5) 582 (25.5) 1283 (26.9) Visiting 403 (33.6) 616 (27.0) 1260 (26.4) Separated, divorced & widowed 187 (15.6) 420 (18.4) 737 (15.4) Single 167 (13.9) 236 (10.3) 634 (13.3)Want more children 7.04, 0.030 No 551 (58.2) 1049 (55.9) 2298 (59.6) Yes 395 (41.8) 827 (44.1) 1558 (40.4) F statistic, PAge enter into first sexual union 18.0 (4.0) 19.1 (4.7) 18.6 (4.3) 26.17 <0.0001Age at first contraceptive use 19.1 (4.1) 19.2 (3.8) 18.9 (3.8) 4.69, 0.009Age of sexual debut 28.1 (28.5) 24.3 (23.5) 25.6 (25.9) 7.94, <0.0001Age of menarche 12.8 (1.6) 12.9 (1.6) 13.0 (1.5) 9.83, <0.0001Crowding 1.7 (0.5) 1.6 (0.5) 1.7 (0.5) 29.22, <0.0001Age of respondents 31.4 (10.3) 32.1 (9.8) 31.3 (9.9) 5.86, 0.002 159
  • Table 6.4: Logistic regression analyses: Explanatory variables of good-to-very good health status Explanatory variables Std. Wald Odds β coefficient error statistic ratio CI (95%) Periurban -0.195 0.08 5.42 0.82 0.70 - 0.97 Reference group (rural area) 1.00 Physically forced to have sex (1=yes) -0.463 0.13 13.70 0.63 0.49 - 0.80 Currently using method of contraception 0.232 0.08 8.10 1.26 1.08 - 1.48 Age of sexual debut 0.042 0.02 6.32 1.04 1.01 - 1.08 Years of schooling 0.044 0.02 4.22 1.05 1.00 - 1.09 Age -0.045 0.01 57.59 0.96 0.95 - 0.97 Employed (1=yes) 0.198 0.08 6.52 1.22 1.05 - 1.42 Logged fertility -0.200 0.08 6.94 0.82 0.71 - 0.95 Wealthiest 20% 0.364 0.13 8.45 1.44 1.13 - 1.84 Second poor 0.213 0.10 5.05 1.24 1.03 - 1.49 Reference group (poorest 20%) 1.00Model chi-square = 198.25, P<0.0001-2 Log likelihood = 4133.85Nagelkerke r-squared = 0.18n = 5781Hosmer and Lemeshow test, χ2 = 4.87, P = 0.772Overall correct classification = 71.9%Correct classification of cases in good-to-very good health status = 97.9%Correct classification of cases not in good-to-very good health status = 60.0% 160
  • Table 6.5: Logistic regression analyses: Explanatory variables of method of contraception Wald Odds Explanatory variable β coefficient Std. error statistic ratio CI (95%) Had sex in last 30 days (1=yes) 2.04 0.12 294.50 7.66 6.07 - 9.66 Age -0.05 0.01 69.29 0.95 0.94 - 0.96 Employed (1=yes) 0.19 0.09 4.74 1.21 1.02 - 1.43 Logged fertility 0.80 0.08 94.34 2.22 1.89 - 2.60 Wealthiest %20 0.30 0.13 5.79 1.35 1.06 - 1.73 Reference group (1=poorest 20%) 1.00 Visiting 0.27 0.10 6.90 1.31 1.07 - 1.61 Reference group (1=single) 1.00 Health status (1=good-to-very good) 0.21 0.09 4.85 1.23 1.02 - 1.47 Currently in a sexual union (1=yes) 0.60 0.14 17.92 1.82 1.38 - 2.41 Constant -0.19 0.25 0.59 0.83Model chi-square = 1021.31, P<0.0001-2 Log likelihood = 3530.81Nagelkerke r-squared = 0.344n = 5781Hosmer and Lemeshow test, χ2 = 4.87, P = 0.772Overall correct classification = 71.9%Correct classification of cases in good-to-very good health status = 97.9%Correct classification of cases not in good-to-very good health status = 60.0% 161
  • Table 6.6: Logistic regression analyses: Explanatory variables of had sex in last 3 months Explanatory variables Std. Wald Odds β coefficient error statistic ratio CI (95%) Gynaecological exam (1=yes) 0.30 0.12 6.81 1.35 1.08 - 1.70 Age -0.03 0.01 13.57 0.97 0.96 - 0.99 High church attendance (1=once per wk) -0.39 0.13 9.76 0.68 0.53 - 0.86 Second poor 0.50 0.15 11.75 1.66 1.24 - 2.21 Reference group (poorest 20%) 1.00 Visiting -1.25 0.13 86.47 0.29 0.22 - 0.37 Reference group (Single) 1.00 Currently used method contraception 2.01 0.12 295.75 7.47 5.94 - 9.40 Currently in a sexual union (1=yes) 53.82 - 4.30 0.16 714.89 73.77 101.11 Constant -1.99 0.32 38.28 0.14Model chi-square = 2005.66, P<0.0001-2 Log likelihood = 2097.69Nagelkerke r-squared = 0.63n = 5781Hosmer and Lemeshow test, χ2 = 11.31, P = 0.0.19Overall correct classification = 88.9%Correct classification of cases in had sex in last 3 months = 95.8%Correct classification of cases not in had sex in last 3 months = 68.8% 162
  • Table 6.7: Logistic regression analyses: Explanatory variables of high church attendance Wald Odds Explanatory variables β coefficient Std. error statistic ratio CI (95%) Peri-Urban -0.19 0.09 4.29 0.83 0.69 - 0.99 Urban -0.45 0.12 13.58 0.64 0.50 - 0.81 Reference group (rural) 1.00 Age of sexual debut 0.05 0.02 10.11 1.05 1.02 - 1.09 Years of school 0.06 0.02 7.73 1.06 1.02 - 1.11 Age 0.04 0.01 39.71 1.04 1.03 - 1.05 Common-law -2.11 0.11 346.30 0.12 0.10 - 0.15 Visiting -2.04 0.11 318.09 0.13 0.10 - 0.16 Separated, divorced & widowed -1.34 0.15 79.09 0.26 0.20 - 0.35 Reference group (single) 1.00 Currently used method contraception -0.22 0.10 5.05 0.80 0.66 - 0.97 Had sex in last 30 days (1=yes) -0.42 0.13 9.84 0.66 0.51 - 0.86 Constant -1.63 0.42 15.25 0.20Model chi-square = 811.16, P < 0.0001-2 Log likelihood = 3814.64Nagelkerke r-squared = 0.28n = 5781Hosmer and Lemeshow test, χ2 = 4.46, P = 0.81Overall correct classification = 74.6%Correct classification of cases in high church attendance = 53.5%Correct classification of cases not in high church attendance = 85.3% 163
  • Table 6.8: Logistic regression analyses: Explanatory variables of physically forced to have sex Std. Wald Odds Explanatory variable β coefficient error statistic ratio CI (95%) PeriUrban 0.27 0.13 4.72 1.32 1.03 - 1.68 Reference group (rural) 1.00 Gynaecological exam (1=yes) 0.25 0.12 4.29 1.29 1.01 - 1.63 Age of menarche 0.08 0.04 4.01 1.08 1.00 - 1.16 Age of sexual debut -0.08 0.03 8.36 0.93 0.88 - 0.98 Age -0.04 0.01 16.68 0.96 0.95 - 0.98 Logged fertility 0.40 0.12 11.47 1.50 1.19 - 1.89 Visiting 0.40 0.14 8.82 1.50 1.15 - 1.96 Reference group (single) 1.00 Health status (1=good-to-very good) -0.47 0.13 14.30 0.62 0.49 - 0.80 Currently in a sexual union (1=yes) -0.47 0.15 9.35 0.62 0.46 - 0.84 Constant -0.65 0.66 0.97 0.52Model chi-square = 70.36, P<0.0001-2 Log likelihood = 215.37Nagelkerke r-squared = 0.24n = 5781Hosmer and Lemeshow test, χ2 = 6.99, P = 0.54Overall correct classification = 91.0%Correct classification of cases in physically forced to have sex = 100.0%Correct classification of cases not in physically forced to have sex = 100.0% 164
  • Table 6.9: Logistic regression: Explanatory variables of currently in a sexual union Std. Wald P Odds Characteristic β coefficient error statistic ratio CI (95%) Years of schooling -0.07 0.03 4.66 0.031 0.94 0.88 - 0.99 Age 0.03 0.01 12.35 <0.0001 1.03 1.01 -1.04 Crowding 0.25 0.12 4.48 0.034 1.29 1.02 - 1.63 High church attendance (1=yes) -0.13 0.11 1.26 0.263 0.88 0.71 - 1.10 Age of menarche 0.06 0.03 3.34 0.068 1.06 1.00 - 1.14 Had sex in last 30 days 3.40 0.13 713.41 <0.0001 29.85 23.27 - 38.30 Age of sexual debut -0.01 0.02 0.35 0.554 0.99 0.94 - 1.03 Good-to-very good health status (1=yes) -0.01 0.12 0.01 0.953 0.99 0.78 - 1.26 Did HIV/AIDS test 0.47 0.11 18.17 <0.0001 1.60 1.29 - 1.99 Physically forced to have sexual intercourse -0.06 0.19 0.09 0.763 0.95 0.65 - 1.37 Periurban -0.22 0.12 3.13 0.007 0.81 0.63 - 1.02 Urban -0.23 0.16 2.05 0.152 0.80 0.59 - 1.09 Reference group (Rural) 1.00 Currently used method of contraception 0.56 0.13 19.30 <0.0001 1.76 1.37 - 2.26 Like to have more children 0.37 0.13 7.83 0.005 1.44 1.12 - 1.86 Wealthiest 20% -0.28 0.08 12.39 <0.0001 0.75 0.64 – 0.88 Second wealthy -0.36 0.07 24.55 <0.0001 0.70 0.60 – 0.80 Middle class -0.16 0.08 4.30 0.038 0.86 0.74 – 0.99 Second poor -0.10 0.08 1.62 0.203 0.91 0.79 – 1.05 Reference group (Poorest 20%) 1.00 Age began using contraception 0.00 0.02 0.001 0.982 1.00 0.97 - 1.03 Age into first sexual union -0.01 0.02 0.07 0.798 1.00 0.97 – 1.03 Gynaecological examination 0.22 0.12 3.77 0.045 1.25 1.00 – 1.57 Employed (1=yes) 0.64 0.05 149.09 <0.0001 1.9 1.72– 2.11 Number of sexual partners in last 12 months -0.833 0.19 19.57 <0.0001 0.44 0.30 – 0.63 Constant -2.29 0.71 10.47 0.001 0.10Model chi-square = 1672.81, P < 0.0001 -2 Log likelihood = 1633.47Nagelkerke r-squared = 0.59 n = 5781Hosmer and Lemeshow test, χ2 = 5.96, P = 0.65 Overall correct classification = 89.4%Correct classification of cases in sexual union = 91.1%Correct classification of cases not in sexual union = 82.0% 165
  • Chapter 7Females with multiple sexual partners and their reproductive health matters:A comprehensive analysis of women aged 15-49 years in a developing nation Paul A. BourneIntroductionFor millennia, females with multiple sexual partners have been called names including whores,prostitutes, sexually promiscuous, and other negative terminologies. Irrespective of the socialconstruction that is used to label these individuals; the reality is, they do exist and must beplanned for among the female population. It is well established that sexual promiscuity, lowcondom usage and early sexual initiation account for some of the increase in HIV/AIDS, teenagepregnancies and abortions in the developing world [1-8]. This provides a rationale for theimportance of understanding those who have multiple sexual partners (commercial or otherwise).Unlike some disciplines which are more concerned about the social behaviour of this cohort,public health, in seeking to promote a healthy lifestyle, needs a comprehensive knowledge of thereproductive health matters of all individuals. The reality is that people who are promiscuous andinfrequently use condoms have a greater probability of contracting sexually transmittedinfections, in particular HIV/AIDS and the human papillomavirus (HPV) [9]. Before publichealth practitioners can commence any elaborate health intervention programmes to address thereproductive health matters of a population or a sub-population, they must first understand thecohort in question. Studies which have examined commercial sex workers [10-12] are not the same as aninquiry into the health status, health care-seeking behaviour and reproductive health matters of 166
  • those with multiple sex partners. While a commercial sex worker has multiple sexual partners,there are people who do not exchange sexual favours for money or any other transferablecommodity. A commercial sex worker is, therefore, a sub-set of those with multiple sexualpartners and not the other way around. In 2007/08, according to Wilks et al. [13], using a sampleof 2,848 randomly sampled Jamaicans aged 15-74 years; they found that 24.1% indicated havingat least 2 sexual partners (females, 8.4%; males, 41.0%). In Kenya in 1999 it was estimated that6.9% of women nationally were engaged in commercial sex activities (exchanging sex formoney, gifts or favours). While there were no statistics on the prevalence of commercial sexworkers in Jamaica, not all of the 24.1% of those with multiple sexual partners [13] arecommercial sex workers. However, using figures from the Reproductive Health Survey for 2002,2.2% of Jamaican women aged 15-49 years were involved in the commercial sex trade [14]. Clearly, there are substantially more females who have had multiple sexual partnerscompared to those who are engaged in the commercial sex trade. Studies which have examinedcommercial sex workers have researched reproductive health matters, in particular condomusage, STIs, HIV/AIDS, unwanted pregnancies [10,12,15], and violence against theseindividuals [12,16]. Wilks et al. [13] found that more females of ages 15-24 years had multiplesexual partners (15.2%) compared to females aged 25-34 years (11.1%); 35-44 years (6.6%); 45-54 years (2.6%); 55-64 years (1.0%) and 65-74 years (0.2%); and that 41% of young females(ages 15-24 years) were reporting having sex once per week, whereas only 25% indicated thatthey never had sexual relations. While the aforementioned information provides pertinentmaterial that can be used to understand promiscuity in females at a particular age cohort,reproductive health goes beyond this, suggesting the potency of more information. The literatureshowed that studies on females with multiple sexual partners have limited their inquiry to age 167
  • and gender composition, risk factors, ever having had sexual intercourse, factors associated withthe odds of having multiple sexual partners, the rationale for multiple sexual partners and theincreased risk of contracting human papillomavirus [13, 17-20]. The empirical evidence on females with multiple sexual partners has omitted in a singlestudy the (1) reproductive health matters of females who have multiple sexual partners, (2)socio-demographic characteristics of the study population, (3) associations between age ofrespondent, years of schooling, age of menarche, age of first intercourse, age when the personbegan using contraception and age of person with whom they first had sexual intercourse, (4)prevalence of those who were sexually assaulted, (5) age cohort of females who were raped, and(6) factors which account for current contraceptive usage. There is, therefore, a gap in theliterature, and this research seeks to fill the void. The aims of the current study are to elucidate(1) reproductive health matters of females who have multiple sexual partners, (2) socio-demographic characteristics of the study population, (3) associations between age of respondent,years of schooling, age of menarche, age of first intercourse, age when the person began usingcontraception and age of person with whom they first had sexual intercourse, (4) prevalence ofthose who were sexually assaulted, (5) age cohort of females who were raped, and (6) factorswhich account for current method of contraception.Methods The current study extracted a sample of 225 respondents who indicated having hadmultiple sex partners. The only inclusion/exclusion criterion for this study was having two ormore sexual partners. We used data from the Reproductive Health Survey, 2002 conducted bythe National Family Planning Board. Since 1997, the National Family Planning Board (NFPB)has been collecting information on women (ages 15-49 years) in Jamaica regarding contraception 168
  • usage and/or reproductive health. In 2002, the Reproductive Health Survey (RHS) collected dataon women ages 15-49 years and men 15-24 years. The current study extracted the sample of onlywomen (ages 15-49 years) given the nature of the research. The sample was 7,168 women,representing a response rate of 91.8%. Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais classified into four health regions. Region 1 consists of Kingston, St. Andrew, St. Thomas andSt. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that region 1 comprised 46.5% of Jamaica, comparedto Region 2, 14.1%; Region 3, 17.6% and Region 4, 21.8% [14]. Stage 2 saw the clustering of households into primary sampling units (PSUs), with eachPSU constituting an ED, which in turn consisted of 80 households. The previous sampling framewas in need of updating, and so this was carried out between January 2002 and May 2002. Thenew sampling frame formed the basis upon which the sampling size was computed for theinterviewers to use. Stage 3 was the final selection of one eligible female, and this was done bythe 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 interviewersadministered a 35-page questionnaire. The data collection began on Saturday, October 26, 2002 169
  • and was completed on May 9, 2003. The data was weighted in order to represent the populationof women ages 15 to 49 years in the nation [14].Statistical methodsWe used the Statistical Packages for the Social Sciences (SPSS) for Windows, Version 16.0(SPSS Inc; Chicago, IL, USA). Frequencies and means were computed on the basis ofsociodemographic characteristics, and other variables. We also performed χ2 tests to compareassociations in non-metric variables and Pearson’s Product Moment Correlation for metricvariables. Multiple logistic regressions were used to analyze factors that explained currentmethod of contraception. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the final modelconstruction [21]. To derive accurate tests of statistical significance, we used SUDDANstatistical software (Research Triangle Institute, Research Triangle Park, NC), and this wasadjusted for the survey’s complex sampling design.MeasuresCrowding is the total number of persons in a dwelling (excluding kitchen, bathroom andverandah). 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 amethod of contraception? …”, and if the answer is yes “Which method of contraception do youuse?” Age at which the person began using contraception was taken from “How old were youwhen you first used contraception? Area of residence is measured from “In which area do youreside?” The options were rural, semi-urban and urban. Currently having sex is measured from“Have you had sexual intercourse in the last 30 days?” Education is measured from the question“How many years did you attend school?” Marital status is measured from the following 170
  • 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 legallymarried?)”, “Do you have a visiting partner, that is, a more or less steady partner with whom youhave sexual relations?”, and “Are you currently single?” Age at first sexual intercourse ismeasured from “At what age did you have your first intercourse?” Gynaecological examinationis taken from “Have you ever had a gynaecological examination?” Pregnancy was assessed by“Are you pregnant now?” Religiosity was evaluated from the question “With what frequency doyou attend religious services?” The options range from at least once per week to only on specialoccasions (such as weddings, funerals, christenings et cetera). Subjective social class is measuredfrom “In which class do you belong?” The options are lower, middle or upper social hierarchy.Analytic ModelUsing logistic regression, this study seeks to examine factors associated with the method ofcontraception usage among females with multiple sexual partners in Jamaica. Different socialfactors influence women’s choices and their decision to use a method of contraception, and thisstudy used Grossman’s model [22] which established the use of econometric analysis todetermine the use of health demand. Grossman’s model has been modified and used by manyscholars to examine health, health outcome and other health-related issues.ResultsA significant statistical association existed between number of sexual partners and commercialsexual encounter (χ2 = 39.4, P < 0.0001, Figure 7.1). Figure 7.1 shows that 69.2% of femaleswith 2 sexual partners were paid for the sexual encounter compared to 11.5% of those with 3sexual partners, 3.8% of those with 4 sexual partners, and 11.5% of those with 11+ sexualpartners. 171
  • The socio-demographic characteristics of the study population are presented in Table 7.1.Table 7.1 shows that on average females’ first sexual encounter was with males at least 9.5 yearsolder than them. Almost 29% of the sample indicated that they had been sexually assaultedduring their lifetime, while 51% indicated that they were sexually assaulted on their first sexualencounter. Almost 33% of the study population was 15-24 years of age, compared to 16.4% ages 25-29 years, 20.9% ages 30-34 years, 14.2% ages 35-39 years, 10.7% aged 40-44 years and 4.9%aged 45-49 years. Half of the commercial sex workers indicated that they had been sexually assaulted, and19.2% stated they were sexually assaulted on their first sexual encounter. Of those who hadindicated being commercial sex workers, 32% had done this between 2-5 times, 16% between 6-10 times, and 44% at least 11 times. When the commercial sex workers were asked when theybegan this activity, 31% indicated during school, 46% reported after leaving school and 23%remarked both. Of the 54% of the respondents who indicated being currently sexually active (in the last30 days), 8.5% were in urban zones, 25.8% were in semi-urban areas and 65.8% were in ruralareas (χ2 = 13.09, P = 0.001). Furthermore, 48.3% of the currently sexually active females used acondom the last time (χ2 = 34.76, P < 0.0001). Table 7.2 presents information on the number of sexual partners, condom usage andfrequency of condom usage with steady and non-steady partners. Fifty-seven percent of the studypopulation had more than 11 sexual partners, and condom usage was relatively inconsistent. There was no significant statistical association between age cohort of study populationand those who reported being forced (or not forced) to have sexual intercourse (χ2 = 16.3, P < 172
  • 0.177). However, information can be provided on those who indicated being sexually assaultedby age cohort: 15-19 years, 12.1%; 20-24 years, 27.3%; 25-29 years, 12.1%; 30-34 years, 12.1%;35-39 years, 21.2%; 40-44 years, 12.1%; and 44-49 years, 3.0%. Almost 17% of the sample shared sanitary conveniences, 11.6% reported having a pelvicor urinary tract infection, 23.4% had done a Pap smear, and 11.7% were commercial sexworkers. Table 7.3 presents information on age of respondent, years of schooling, age ofmenarche, age of first intercourse, age when the person began using contraception and age ofperson with whom they had their first sexual intercourse. Based on Table 7.3, a positivestatistical correlation existed between age of respondent and age of person with whom theindividual had their first sexual intercourse (r = 0.28, P = 0.15).Multivariate analyses Table 7.4 presents information on possible factors which account for using a method ofcontraception. Using logistic regression analyses, four variables emerged as statisticallysignificant factors of method of contraception. The model had statistically significant predictivepower (model (Chi-square (17) = 30.79, P < 0.021); Hosmer and Lemeshow goodness of fit test,χ2 = 4.01, P = 0.80), and correctly classified 97.3% of the sample. Four factors account for34.2% of method of contraception among those who indicated having multiple sexual partners.Method of contraception can be accounted for by social class (lower class, Odds ratio (OR) =0.32, 95% CI = 0.03 – 0.60); age at first sexual intercourse (OR = 0.90, 95% CI = 0.68 – 1.21);employment status (employed, OR = 5.07, 95% CI = 1.06 – 24.36); and marital status (marriedor common-law, OR = 0.09, 95% CI = 0.02 – 0.38). 173
  • Limitations of studyThis study examines females with multiple sexual partners and their reproductive health matters,and was extracted from a cross-sectional survey. Using a nationally representative cross-sectional data denotes that the work can be used to generalize about the population of femaleswho indicated having multiple sexual partners (2+); however, it cannot be used to makepredictions, forecast, establish trends and causality.Discussion This study revealed that sexual promiscuity is associated with the risk of sexual violenceas 29 out of every 100 females who had multiple sexual partners were sexually assaulted and thefigure is as high as 1 in every 2 among those who are commercial sex workers. Almost 12% ofsexually promiscuous female Jamaicans were commercial sex workers. There is a high level ofinconsistent condom usage among the sample with a non-steady partner compared to their steadysexual partners. Furthermore, female sexual promiscuity is higher in rural areas, among thosewith post-secondary education, middle class, and those in visiting unions. Three out of every 4women in the sample were middle-to-upper class respondents; middle class women were 1.7times more likely than lower class women to have multiple sexual partners; rural women were1.9 times more likely than semi-urban women to have multiple sexual partners and this was 3.7times more than urban women compared to rural women. Of the 54% of respondents whoindicated being currently sexually active (in last 30 days), 8.5% were in urban zones, 25.8%were in semi-urban areas and 65.8% were in rural areas. Continuing, 48.3% of the currentlysexually active females used a condom the last time. Method of contraception can be accountedfor by social class; age at first sexual intercourse; employment status; and marital status (marriedor common-law). 174
  • The percentage of the current study population represents 3.2% of the females aged 15-49years in Jamaica [37], suggesting that the percentage of females with multiple sexual partners inthis research is less than that observed in female undergraduate students in China (5.31%) [17].However, female Jamaicans were having first coitus almost 3 years earlier than Chineseundergraduate women [17]. Another difference which emerged in the comparison wasinconsistent condom usage. There were clear dissimilarities between the survey of femaleundergraduate students in China and the current study. Inconsistent condom usage among femaleundergraduate students with multiple sexual partners was 38.6% compared to 56% amongfemales with steady partners and 46% among those with non-steady partners. Hence, thisjustifies the present work which found an inverse statistical association between age of sexualdebut and method of contraception. This means that women who become engaged in later sexualactivities are more likely to involved less risky sexual practices, and that encouraging latersexual debut will reduce fertility, STIs, and cost of caring for high school dropouts. The risk behaviour among females in this research highlights the fact that policy-makersneed to use the empirical evidence provided herein to formulate preventative strategies targetedat this group. The high percentage of inconsistent condom usage among promiscuous femalesdemonstrates that need for urgent public health intervention to address the pending public healthproblems which may surface from the current realities. A study by Eversley and Newstetter [23]found that “…females who are exposed to multiple partners do have a significantly higherchance of encountering a male in a high risk category...” which speaks to a justification for thehigh HIV/AIDS prevalence in the developing nations, particularly Jamaica [10]. Clearly embedded in the findings of the current research is the high rate of sexualviolence against women in commercial sex work, and to a lesser extent, females with multiple 175
  • sexual partners. Sexual violence against women commenced with forced sexual encountersduring their adolescent years by older men. In this study, males who initiate sexual intercoursewith adolescent females were about 10 years older. So they are not only older and sexually moreexperienced, but they have more material resources compared to the adolescent females, whichopens these vulnerable females to various sexually transmitted infections, in particularHIV/AIDS, and the human papillomavirus (HPV) [9]. Within the context of this study, whichfound an inverse association between age at first sexual encounter and method of contraceptionuse, it follows that many adolescent females would be 10% less likely to use a method ofprotection against sexually transmitted infection. The socio-economic challenges faced by many Jamaica, in particular those who are poor;include how to avoid the temptations of being lured by sexual predators, who offer materialresources to these vulnerable individuals. The costs of sexually transmitted infections areenormous, but not limited to the individual, and this extends to the wider society [20]. It is thisreality which public health practitioners must evaluate when deciding not to immediately addressfuture public health problems associated with multiple sexual partners, early sexual initiation,sexual violence, sexually transmitted infections, and sexual promiscuity. Thus, early sexualinitiation among Jamaican females accounts for the multiple sexual relationships, and this withinthe context of the increasing HIV/AIDs means that adolescent promiscuity must be lowered,altered, and discouraged. Beside the evident enjoyment from the sexual coitus, during theencounter for adolescents, they must be made aware of the risk factors associated with multiplesexual partners and promiscuity. One of the findings which emerged from this work is the percentage of females whocommence commercial sex work during school. Based on the findings, 3 in every 10 commercial 176
  • sex workers in Jamaica admitted that this began during school years, which speaks to (1) thesocial pressure of peer groups in regard to sexual initiation, (2) sex traders recruiting school girls,(3) social decay in the general society, and (4) economic challenges faced by many families.Early sexual initiation, multiple sexual partners and sexual promiscuity are, therefore, by-products of socio-economic ills of the Jamaican society. With the high percentage of commercialsex workers who commence their craft during school, this speaks to the economic cost ofsurvivability and how it plays a role in influencing adolescents in such activities. With sexualinitiation beginning during adolescent years, multiple sexual partners are the outcome in our day.[20]. Whether it is early sexual initiation, illicit drug use or any other factors [20], the reality inJamaica is that 33 out of every 100 females who indicated having multiple sexual partners werebetween 15 and 24 years (16 out of every 100 aged 15-19 years), and most of the individualsresided in rural area, with post-secondary education. Previous studies have established a directassociation between education and health status, and other factors and health [24-35], and eventhough education opens possible opportunities for the recipient, the economic hardship offemales in Jamaica is eroding this reality. Poverty hampers economic freedom and choice, and sodespite one’s willingness, many realities are circumvented. The poor are held in a vicious cycleof continuous poverty, and on the onset of health conditions poverty could extend to the family.With the reality that the prevalence rate of poverty, since 1990, is at least twice as high in ruralas in urban areas, [36], the economic difficulty is accounting for rural females having manysexual partners, as this is in keeping with the needed assistance. Still, some of these females,although they receive gifts, money, material items and other articles, for being with males in asexual relationship, it is not construed as commercial sex work. 177
  • Economic deprivation is, therefore, creating sexual promiscuity as can be demonstratedby the current findings. This research found that employed females with multiple sexual partnerswere 5.1 times more likely to use a method of contraception. Thus, unemployed females givemales vetoing power over reproductive health, because they do not want the males to withdrawthe needed material and other forms of support. Statistics showed that unemployment amongfemales is greater than that for males [37], and with the context that poverty is greater for theformer group than the latter and among rural residents [36], a part of the survivability strategy offemales is to rely on males for financial support. It should not be surprising that poverty, whichalong with unemployment is higher in rural Jamaica, sees more multiple sex partners in thosezones. Furthermore, males who have economic power, are more likely to be employed andreceive greater emoluments, are still able to wield this power, even over their spouses. In thiswork, married women or females in common-law unions were 91% less likely to use a method ofcontraception as against leaving it up to the male to make the decision. It is the opportunity costof his economic provision for the household. Previous studies have established that there is a statistical association between povertyand illness [38-43]. Poverty does not only have an impact on illness, it causes pre-mature deaths,lower quality of life, lower life (and unhealthy life) expectancy, low development, high rates ofpregnancy and social degradation of the community [44]. The WHO [44] opined that 80% ofchronic illnesses were in low and middle income countries, suggesting that illness interfaces withpoverty and other socio-economic challenges. The WHO captures this aptly “...People who arealready poor are the most likely to suffer financially from chronic diseases, which often deepenpoverty and damage long term economic prospects” [44]. Another by-product of poverty ismultiple partner relationships, as females use these to reduce the cost of unemployment, poverty 178
  • and material deprivation. While multiple sexual relations increase the risk of sexually transmittedinfections, the price of poverty is not the same as contracting some sexually transmittedinfections such as gonorrhea, Chlamydia, and syphilis, Although the individual does not computethe cost of promiscuity in this manner, the burden of escaping poverty is such that theconsequences of certain actions are sometimes not considered, and this is more the case amongadolescents. When poverty is coalesced with unemployment, the consequences can be devastating forthe individual as well as the society. According to Bourne [45], a moderate and direct correlationexisted between the prevalence of poverty (in %) and unemployment (R2 = 0.48); not seekingmedical care (in %) and prevalence of poverty (in %, R2 = 0.58); and the prevalence of povertyand mortality (R2 = 0.51). People have a desire to live, and with the reality that poverty affectsmortality, and the direct association between poverty and unemployment, the alleviation frompoverty for females, in particular rural dwellers, is having multiple sex partners. While somesexually transmitted infections can be fatal, the use of a condom reduces this probability, whichpoints to a high condom usage among the study population. Outside of the aforementioned issues on women aged 15-49 years who indicated havingmultiple sexual partners, the current study highlights some variables which account for theircontraceptive use. Again, 18 out of every 25 women aged 15-49 years old who had multiplesexual partners used a method of contraception, and this study examined factors which accountfor this choice. This research showed that four social factors account for 34.2% of choice ofusing a method of contraception. Like a study done by Degni, Ojanlatva and Essen [46], thepresent findings highlight that changes in women conditions to life (employment, marital andsubjective social statuses) influence contraceptive use (or non-use). In this study, women in the 179
  • lower socioeconomic status were 68% less likely to use a method of contraception in reference tothose in the wealthy stratum, and that those who were employed were 5.1 times more likely touse a method of contraception, which concurs with previous studies [46-49]. Embedded in thosefinding is the incapacitating power of economic dependency over women sexual freedom andautonomy, and how money and economic opportunities influence choices over their reproductivehealth matters. While the current work concurs with Degni, Ojanlatva and Essen’s research that socialfactors are related with contraceptive use, mainly from changes to their life status [46], it showedthat only employment status positively influences increased contraceptive use. Married women,lower subjective social status and age at first sexual debut negatively associated with reducedmethod of contraception. And that marital status (ie. married respondents) contributed the mostto the reduction in contraceptive use. Thus, a stable union, particularly marriage, changes thedynamics of contraceptive use and opens an avenue of risky sexual practices as some of thosewho are engaged in sexual promiscuity are married women. Previous studies have established that the education of the wife [47] or the women’seducation level and their husbands level of education [50] as having an effect on contraceptiveuse. While married women who are engaged in multiple sexual partnerships were less likely touse a method of contraception in the current study, educational level was not statisticalassociated with contraceptive use which is contrary to previous studies [47, 50]. However,another research using data from the Pakistan Demographic and Health Survey of 1990-91,which examined the effect of selected socio-cultural and supply factors on contraceptive use asreported by married women of reproductive ages found that (1) woman’s age, (2) number ofliving children, (3) education, and (4) place of residence positively affect their contraceptive use. 180
  • None of those social factors were found to be associated with positive contraceptive use amongthe current sample, and different explanation for increased contraceptive use among women ofthe reproductive years who are engaged in multiple sexual partnerships. Using a sample of national probability sample of Jamaican women in the reproductiveages, Bourne et al. [49], women with multiple sexual partners were about two times more likelyto use a method of contraception (OR = 1.85, 95% CI: 1.57–2.17), that those in the lowersocioeconomic stratum were 17% less likely to do so (OR = 0.83, 95% CI: 0.73–0.95). Whilethose in the present sample were more likely to use a method of contraception (20 out of every25) compared with women of the reproductive ages (17 out of every 25), disaggregating theformer group provides invaluable information on those in promiscuous relationships. Clearly,poverty is a retarding factor influencing contraceptive use of women aged 15-49 years whoindicated having multiple partnerships compared to general population of women aged 15-49years. According to Bourne et al. [49], those in the poor income class were 17% less likely to usea method of contraception, while this work found that women in the same socioeconomicstratum were 68% less likely to use a method of contraception. It can be extrapolated from thefindings that poverty will cripple good sexual practices, and justifying women involvement inmultiple sexual partnerships and inconsistent contraceptive uses. A previous study found that “…inconsistent pill or condom use was associated mainlywith partnership” [51], and this work provides further clarity to that finding. It was revealed thatinconsistent condom usage was lesser among women with their steady partners (11 out of every25) than with non-steady partners (14 out of every 25). By using condom usage (ie. 17 out ofevery 25 women of the reproductive ages who indicated their involvement in multiplerelationships) for family planning interventions, measures would be overstating needed 181
  • approaches for among women in steady sexual unions. Likewise the moderate consistency ofcondom use with non-steady sexual partners denotes that women would be exposed toHIV/AIDS and other sexually transmitted infections because of their sexual expression andinvolvement with older men. The current work showed that women begin their sexual debut withmen that were about 10 years their seniors, and these men engaged in risky sexual practices withother women in the past. The aforementioned proposition can be supported by a study conductedby Wilks et al. [13] which found that 41% of males aged 15-74 years indicated having multiplepartners (2+) compared with 8.4% of females of the same age. Continuing, they found that18.3% of the males reported having had a STI compared with 11.0% of females [13]. It can bededuced from the aforementioned findings that women in multiple sexual relationships whoinfrequently used a condom is highly exposed to more disease causing pathogens.ConclusionLabelling females who have multiple sexual partners as whores, prostitutes and commercial sexworkers is not providing an understanding of the key components which account for thebehaviour, and that the lessons to be learnt by public health practitioners to ameliorate thispractice will be overlooked if they become concerned with the stereotype. Efforts to changepolygamy, quasi-polygamy, and other forms of multiple sexual partnerships cannot commencewith negative critiques of those people, but with a comprehensive analysis of those involved inorder to provide an understanding of practices, and so appropriate measures can be modeledbased on the lessons emerged from the research. Clearly, economics play a large part in promiscuity among females in Jamaica, andmerely providing intervention programmes which are not multisectorial, particularly to address 182
  • the economic gender and area socioeconomic disparities, will not effectively address this publichealth challenge (multiple concurrent partnerships). The present research found that 14 out of 25females who indicated having had multiple sexual partners (2+) in the last 12 months resided inrural areas; in the lower socioeconomic class; 18 out of every 25 were pregnant; 20 out of 25currently used a method of contraception; 17 out of every 25 used a condom on the last sexualencounter; in visiting sexual unions, those in married or common-unions were less likely to use amethod of contraception; people who shared sanitary convenience were less likely to used amethod of contraception as well as those in the upper class. Those findings highlight thecomplexities of women aged 15-49 years old who are engaged in multiple sexual partnerships,and these provide understanding of the nature of measures which are needed to address thispublic health phenomenon. Using cross-sectional survey data, Bourne and Rhule [29] found that poverty wassynonymous with rural areas, females and ill people. Bourne and Rhule’s work can provide someexplanation for the (1) inconsistent condom usage; (2) rural females; (3) high pregnancies; (4)age of sexual debut, and (5) lower socioeconomic status of women in multiple sexualpartnerships as poverty incapacitates not only health status but also reproductive health choices,sexual autonomy and risky sexual practices among women in their reproductive years. This studyshowed that sexual promiscuity is not positively influencing good sexual practices of womenwho indicated having 2+ sexual partners as only 17 out of every 25 of them used a condom onthe last sexual encounter which was the same for the female reproductive population ofJamaicans [14], and that 11 out of every 25 consistently used a condom with their steady partnersand 14 out of every 25 consistently used a condom with non-steady sexual partners. 183
  • Rural poverty is twice greater than urban poverty in Jamaica [36] and within the contextof this study that found that rural women aged 15-49 years were more likely to be engaged insexual promiscuity and from the lower socioeconomic class, these suggest that they would bemore likely to be less educated, and that the opportunity costs of poverty are (1) risky sexualpractices; (2) poor sexual reproductive health choices, and (3) sexual promiscuity for financialeconomic gains. As such, multiple partnerships cannot be addressed by merely using sexeducation programmes in or out of school and interventions that do not coalesce themultidimensional nature of the issues which are highlighted in this research, particularly income-gender disparity and more opportunities for women in rural areas. Poverty is more than erodingthe quality of life of women in Jamaica, but it is also retarding their human and reproductiverights. Poverty is, therefore, silently tranquilizing the sexual freedom and choices of women, andcannot be allowed to continue as it infringes on the basic rights of women. In summary, the early initiation of adolescent females into commercial sex work cannotbe left unaddressed as the prevalence rate is high. Serious efforts are needed to comprehend,alleviate and rectify such a practice, which is engaged in many school-aged females. The presentfindings are far reaching, but should not be taken as the totality of the research necessary forunderstanding this phenomenon. Clearly, a multilevel approach is needed to address multiplesexual partnerships among females in Jamaica. Furthermore, public health practitioners need toinstitute measures to address the multiple sexual relationships among those from middle toupper class more than the lower class women as the ratio is alarming high among the former thanthe latter group.Conflict of interestThe author has no conflict of interest to report.Disclaimer 184
  • The researcher would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researcher.AcknowledgementThe 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 available for use in thisstudy, and the National Family Planning Board for commissioning the survey. 185
  • References 1. Norman LR. Predictors of consistent condom use: A hierarchical analysis of adults from Kenya, Tanzania and Trinidad. Int J of STD & AIDS 2003 14:584-590. 2. Hernandez-Giron CA, Cruz-Valdez A, Quiterio-Trenado M, et al. Factors associated with condom use in the male population of Mexico City. Int J of STD & AIDS 1999; 10:112- 117. 3. Kaestle CE, Halpern CT, Miller WC, et al. Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J Epidemiol 2005; 161:774-780. 4. Andersson-Ellstrom A, Forssman L, Milsorn I. Age of sexual debut related to life-style and reproductive health factors in a group of Swedish teenage girls. Acta Obstet Gynecol Scand 1996; 75:484-489. 5. Coker AL, Richter DL, Valois RF, et al. Correlates and consequences of early initiation of sexual intercourse. J Sch Health 1994; 64:372-377. 6. George C, Alary M, Otis J. Correlates of sexual activity and inconsistent condom use among high-school girls in Dominica. West India Med J 2007; 56:433-438. 7. Davis KR, Weller SC. The effectiveness of condoms in reducing heterosexual transmission of HIV. Fam Plann Perspect 1999; 31:272-279. 8. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. The Cochrane Library, Issue 2. Oxford: Update Software; 2003. 9. Cooper D, Hoffman M, Carrara H, et al. Determinants of sexual activity and its relation to cervical cancer risk among South African women. BMC Public Health; 2007; 7. 10. Duncan J, Gebre Y, Grant Y, et al. HIV prevalence and related behaviors among sex workers in Jamaica. Sexually Transmitted Diseases 2010; 37:306-310. 11. Kishore J, Joshi TK. Health status and health seeking behaviour of male workers in Delhi. Indian J Community Med 2001; 26:192-917. 12. Elmore-Meegan M, Conroy RM, Agala CB. Sex workers in Kenya, numbers of clients and associated risks: An exploratory survey. Reproductive Health Matters 2004; 12:50- 57. 13. Wilks R, Younger N, Tulloch-Reid M, et al. Jamaica Health and Lifestyle Survey 2007- 2008. Technical Report. Kingston: Epidemiology Research Unit, Tropical Medicine Research Institute, University of the West Indies, Mona; 2008. 14. National Family Planning Board (NFPB). Reproductive Health Survey 2002. Kingston: NFPB; 2005. 15. Jayasree AK. Searching for justice for body and self in a coercive environment: Sex work in Kerala, India. Reproductive Health Matters 2004; 12:58-67. 16. Case histories from the Drop-in Centre Clinics. Thiruvananthapuram and Thrissur: Foundation for Integrated Research in Mental Health; 1999-2001. In: Jayasree AK. Searching for justice for body and self in a coercive environment: Sex work in Kerala, India. Reproductive Health Matters 2004; 12:58-67. 17. 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. 18. Shelton JD. Why multiple sexual partners? Lancet 2009; 374:367-369. 186
  • 19. Van Doornum GJ, Prins M, Juffermans LH, et al. Regional distribution and incidence of human papillomavirus infections among heterosexual men and women with multiple sexual partners: A prospective study. Genitourin Med 1994; 70:240-246.20. Santelli JS, Brener ND, Lowry R, et al. Multiple sexual partners among U.S. adolescents and young adults. Fam Planning Perspective 1998; 30:271-275.21. Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton & Lange Publisher, 1996.22. Grossman M. The demand for health - a theoretical and empirical investigation. New York: National Bureau of Economic Research, 1972.23. Eversley RB, Newstetter A. AIDS risk among women with multiple sexual partners: HIV risk screening data from a family planning population. Int Conf AIDS 1989; 5:750.24. Bourne PA. A theoretical framework of good health status of Jamaicans: using econometric analysis to model good health status over the life course. North Am J of Med Sci, 2009; 1: 86-95.25. Hutchinson G, Simeon DT, Bain BC, Wyatt GE, Tucker MB, LeFranc E. Social and Health determinants of well-being and life satisfaction in Jamaica. Inter J of Soc Psychiatry 2004; 50:43-53.26. Bourne PA. An epidemiological transition of health conditions, and health status of the old-old-to-oldest-old in Jamaica: a comparative analysis. North Am J of Med Sci. 2009; 1:211-219.27. Bourne PA. Good Health Status of Older and Oldest Elderly in Jamaica: Are there differences between rural and urban areas? Open Geriatric Medicine J. 2009; 2:18-27.28. Bourne PA. Social determinants of self-evaluated good health status of rural men in Jamaica. J Rural and Remote Health 2009; 9: 1280.29. Bourne PA, Rhule J. Good Health Status of Rural Women in the Reproductive Ages. Inter J Collaborative Research on Internal Medicine & Public Health, 2009; 1:132-155.30. Bourne PA, McGrowder DA. Rural health in Jamaica: Examining and refining the predictive factors of good health status of rural residents. J Rural and Remote Health 2009; 9:1116.31. Bourne PA. Medical Sociology: Modelling Well-being for elderly People in Jamaica. West Indian Med J 2008; 57:596-04.32. Bourne PA. Health Determinants: Using Secondary Data to Model Predictors of Wellbeing of Jamaicans. West Indian Med J 2008; 57:476-81.33. Smith JP, Kington R. Demographic and Economic Correlates of Health in Old Age. Demography 1997; 34:159-70.34. Wilkinson RG, Marmot M. Social Determinants of Health. The Solid Facts, 2nd ed. Copenhagen: World Health Organization; 2003.35. Solar O, Irwin A. A Conceptual Framework for Analysis and Action on the Social Determinants of Health. Discussion paper for the Commission on Social Determinants of Health DRAFT April 2007. Available from http://www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf (Accessed April 29, 2009).36. Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 1989- 2007. Kingston: PIOJ & STATIN; 1990-2008. 187
  • 37. Planning Institute of Jamaica (PIOJ). Economic and Social Survey Jamaica 1990-2008. Kingston: PIOJ; 1991-2009.38. Wagstaff A Poverty, equity, and health: Some research findings. In: Equity and health: Views from Pan American Sanitary Bureau. Pan American Health Organization, Occasional publication No. 8, Washington DC, US; 2001: pp.56-60.39. Marmot M. The influence of Income on Health: Views of an Epidemiologist. Does money really matter? Or is it a marker for something else? Health Affairs. 2002; 21: 31- 46.40. Pan American Health Organization (PAHO). Investment in health: Social and economic returns, Scientific and Technical Publication, No. 582. Washington DC: PAHO, WHO; 2001.41. Pan American Health Organization (PAHO). Equity and health: Views from the Pan American Sanitary Bureau, Occasional Publication, No. 8. Washington DC: PAHO, WHO; 2001.42. Alleyne GAO. Health and economic growth. In: Pan American Health Organisation. Equity and health: Views from the Pan American Sanitary Bureau, Occasional Publication No. 8. Washington DC; 2001: pp. 265-269.43. Van Agt HME, Stronks K, Mackenbach JP. Chronic illness and poverty in the Netherlands. Eur J of Public Health 2000; 10:197-200.44. World Health Organization (WHO). Preventing Chronic Diseases a vital investment. Geneva: WHO; 2005.45. Bourne PA. Impact of poverty, not seeking medical care, unemployment, inflation, self- reported illness, health insurance on mortality in Jamaica. North Am J of Med Sci 2009; 1:99-109.46. Degni F, Ojanlatva A, Essen B. Factors associated with married Iranian Women’s contraceptive use in Turku, Finland. Iranian Studies 2010; 43(3): 379-39047. DSouza RM. Factors influencing the use of contraception in an urban slum in Karachi, Pakistan. Journal of Health & Population in Developing Countries. 200348. Alpu O, Kurt G. The Effect of Socio-economic and Demographic Factors on contraceptive Use and Induced Abortion in Turkey. American Journal of Applied Sciences 1 (4): 332-337, 2004.49. Bourne PA, Charles CAD, Crawford TV, Kerr-Campbell MD, Francis CG, South-Bourne N. Current use of contraceptive method among women in a middle-income developing country. Open Access Journal of Contraception 2010:1 39–49.50. Tehrani FR, Farahani FKA, Hashemi MS. Factors influencing contraceptive use in Tehran Fam Pract 2003; 20(4): 49351. Frost J, Darroch JE. Factors Associated with Contraceptive Choice and Inconsistent Method Use, United States, 2004. Perspectives on Sexual and Reproductive Health 2008;40(2):94-104. 188
  • Figure 7.1. Paid (or not paid) for sex by number of sexual partners 189
  • Table 7.1. Sociodemographic characteristic of sample, n = 225Characteristic n %Religiosity At least once a week 56 24.9 At least once a month 49 21.8 Less than once a month 30 13.3 Only on special occasions (weddings, funerals, christening) 62 27.6 Does not attend at all 25 11.1 No response 3 1.3Marital status Legally married 18 8.0 Common-law 44 19.6 Visiting 107 47.5 Divorced, separated, widowed 44 19.6 Single 12 5.3Currently pregnant Yes 3 1.3 No 221 98.7Ever been pregnant Yes 160 72.1 No 62 27.9Ever been forced to have sex Yes 65 29.1 No 157 70.4 Not sure 1 0.5Currently having sex (in the last 30 days) Yes 120 53.6 No 104 46.4Currently using a method of contraception Yes 175 77.8 No 50 22.2Employment status Unemployed 143 63.6 Employed 82 36.4Area of residence Urban 34 15.1 Semi-urban 65 28.9 Rural 126 56.0Socioeconomic class Lower 95 42.2 Middle 56 24.9 Upper 74 32.9Years of schooling mean (SD)Age mean (SD) 29.6 years (8.7 years)Age of first sexual intercourse mean (SD) 16.0 years (2.7 years)Age of person had first sexual intercourse with mean (SD) 25.7 years (19 years) 190
  • Table 7.2. Number of sexual partners, condom usage and frequency of condom usage by studypopulation, n = 225Characteristic n %Number of sexual partners (in last 12 months) 2 84 37.3 3 5 2.2 4 3 1.4 7 3 1.4 10 1 0.4 11+ 129 57.3Currently using a condom Yes 148 65.8 No 77 34.2Frequency of condom usage with steady partner Always 60 44.1 Most times 66 48.5 Seldom 8 5.9 Never 2 1.5Frequency of condom usage with non-steady partner Always 44 54.3 Most times 30 37.0 Seldom 1 1.3 Never 6 7.4 191
  • Table 7.3. Age of respondent, years of schooling, age of menarche, age of first intercourse, age began using contraception and age ofperson whom you had first sexual intercourse with Years of Age of Age at first Age began using Age of whom you had Age schooling menarche intercourse contraception sexual intercourse Age of respondent 1 225 Years of schooling -.097 1 0.147 223 223 Age of menarche -0.052 -0.009 1 0.441 0.898 224 222 224 Age at first intercourse 0.291(** 0.169(*) 0.056 1 ) 0.023 0.000 0.450 182 181 182 182 Age began using contraception 0.500(**) 0.033 0.017 0.563(**) 1 0.000 0.643 0.814 0.000 195 194 195 167 195 Age of whom you had sexual 0.282(*) -0.111 -0.039 -0.031 0.029 1 intercourse 0.015 0.345 0.741 0.798 0.813 74 74 74 69 69 74* Correlation is significant at the 0.05 level (2-tailed).** Correlation is significant at the 0.01 level (2-tailed). 192
  • Table 7.4: Logistic regression analyses: Variables of currently using a method of contraception Wald Odds Variable β Coefficient Std Error statistic ratio 95% CI Forced into sexual encounter(1=yes) -1.18 0.73 2.58 0.31 0.07 - 1.30 Semi-urban -1.38 1.50 0.85 0.25 0.01 - 4.74 Rural -1.86 1.47 1.60 0.16 0.01 - 2.78 Urban (reference group) 1.00 Lower class -1.13 1.18 0.90 0.32* 0.03 - 0.60 Middle class -2.56 1.04 6.14 0.08 0.01 - 0.59 Upper class (reference group) 1.00 0.56 0.92 0.36 1.74 0.29 - 10.62 Pelvic or urinary tract infection Age at first sexual encounter -0.10 0.15 0.45 0.90* 0.68 - 1.21 Shared sanitary convenience (1=yes) 0.58 0.89 0.43 1.79 0.32 - 10.15 Frequent church attendance (1=at least one per week) 2.10 1.19 3.13 8.16 0.80 - 83.42 Employed (1=yes) 1.62 0.80 4.12 5.07* 1.06 - 24.36 Age of respondents -0.07 0.05 1.51 0.94 0.85 - 1.04 Years of schooling -0.04 0.11 0.11 0.96 0.78 - 1.20 Age at menarche 0.02 0.07 0.10 1.02 0.89 - 1.17 Age began using contraceptive method 0.07 0.12 0.33 1.07 0.85 - 1.35 Crowding 1.25 0.79 2.53 3.50 0.75 - 16.35 Pap Smear (1=yes) -0.85 0.70 1.45 0.43 0.11 - 1.70 Married or common-law union -2.44 0.75 10.52 0.09** 0.02 - 0.381 Model chi-square (17) = 30.79, P < 0.021-2 Log likelihood = 82.93Nagelkerke r-squared = 0.342Hosmer and Lemeshow test, χ2 = 4.61, P = 0.80Overall correct classification = 88.5%Correct classification of cases of condom usage at first sexual intercourse = 97.3%Correct classification of cases of not using condom at first sexual intercourse = 16.7%*P < 0.05, **P < 0.01, ***P < 0.001 193
  • Chapter 8Sexually assaulted females on their sexual debut: Reproductive health matters Paul A. BourneIntroductionPrevious studies which have examined reproductive health matters and/or sexual relations havereported on the general population, adolescents, commercial sex workers, minors, universitystudents, young adults, women, teenage mothers and males,1-12 but little is known of such issuesamong females who were sexually assaulted on their sexual debut. While a plethora of researchexists on the value of some information, which has been used to guide policy formulation,pertinent information on reproductive health matters regarding those who were sexuallyassaulted is missing from the literature. Moreover, this paucity of research in developing nationsdenotes that little information is known about the pertinent issue, which could enhance policyformulation and future research. The Caribbean region is experiencing the second highest prevalence of HIV infection inthe world behind South Africa, 11,13,14 indicating that inconsistent condom usage is a cause of thishigh mortality.15 Previous studies have found that condom usage, particularly latex condoms, canreduce HIV infection by at least 80%,16,17 indicating that condom usage can prevent sexuallytransmitted infections.16-19 While this may be optional for some women, those who are raped (orsexually assaulted) most often do not have the luxury of a choice in insisting that their attackersuse a condom. Forced sexual encounters sometimes result in unwanted pregnancies, abortions, 194
  • psychological challenges (guilt, depression, fear, frustration and withdrawal), HIV/AIDS, andother sexually transmitted infections (herpes, gonorrhoea, Hepatitis B, et cetera). Rape, or sexual assault, is a sexual activity involving two or more individuals in whichone partner is brought into the encounter against his/her will. Sexual assault is not limited towomen, but the individual (male or female) is physically or otherwise forced into sexualrelations against his/her will. Sexual assault is not only a social problem, but Amar postulatedthat it is a public health issue.19 Within the context of inconsistent condom usage and theincreasing risk of sexually transmitted infections, forced sexual experience is, therefore, a publichealth concern. Another issue is the percentage of women who have had this experience duringtheir lifetime. According to Luce and colleagues, about 1 in every 3 women have experiencedsexual violence during their lifetime, and women are more at risk than men.20 They continuedthat particular groups are more vulnerable to this practice. These include adolescents, children,‘persons with substance abuse problems’, commercial sex workers, the poor or homeless, andpeople who are incarcerated. According to Luce and colleagues,20 the treatment for those who have been sexuallyassaulted ranges from immediate to long-term care. They outlined that “Immediate care includesthe treatment of injuries, prophylaxis for sexually transmitted infections, administration ofemergency contraception to prevent pregnancy, and the sensitive management of psychologicalissues. Presentations to the family physician may include self-destructive behaviours, chronicpelvic pain, and difficulty with pelvic examinations,”20 and these could include long-termpsychophysical problems. Sexual assault on a woman, therefore, is a violation of femalesexuality, human rights and sexual autonomy. In order to address this rights violation, some 195
  • countries subscribe to the aforementioned notion that rape or sexual assault is a crime, whichrequires its being reported to the local police. Rape also includes having sexual relations with aminor (in Jamaica, individuals under 18 years of age), which denotes that a minor under the lawcannot consent to have sexual intercourse with another individual. While the reporting of sexual violence against women is important,21 there are otherissues which cannot be omitted in the gamut of events. These issues include reproductive healthbehaviour, and future contraceptive usage among women who were sexually assaulted on theirfirst sexual encounter. Studies have examined human immunodeficiency virus post-exposureprophylaxis (HIV PEP) in women post sexual assault,22 and rightfully so, as well as the ethicalissues in data collection,23 and intimate partner sexual violence,24 but little is known aboutcurrent reproductive health practices of sexually assaulted women, and factors which account fortheir present use of contraceptives. This study, therefore, seeks to elucidate information onreproductive health matters regarding those who were sexually assaulted on their first sexualencounter, as well as factors which influence their current method of contraception.MethodSample Since 1997, the National Family Planning Board (NFPB) has been collecting informationon women (ages 15-49 years) in Jamaica regarding contraception usage and/or reproductivehealth. In 2002, the Reproductive Health Survey (RHS) collected data on women ages 15-49years and men 15-24 years. The current study extracted the sample of only women (ages 15-49years) who reported having been sexually assaulted on their sexual debut. The sample was 747women,25 and this represents a study population of 10.4% of the surveyed females (7,168). 196
  • The Statistical Institute of Jamaica (STATIN) provided the interviewers and supervisors,who were trained by McFarlane Consultancy to carry out the survey. The interviewersadministered a 35-page questionnaire. The data collection began on Saturday, October 26, 2002and was completed on May 9, 2003. The data was weighted in order to represent the populationof women ages 15 to 49 years in the nation.25Procedure Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts - EDs). This was calculated based on probability proportion to size.Jamaica is classified into four health regions. Region 1 consists of Kingston, St. Andrew, St.Thomas and St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is madeup 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, 14.1%; Region 3, 17.6% and Region 4, 21.8%. 25 Stage 2 saw the clustering of households into primary sampling units (PSUs), with eachPSU constituting an ED, which in turn consisted of 80 households. The previous sampling framewas in need of updating, and so this was carried out between January 2002 and May 2002. Thenew sampling frame formed the basis upon which the sampling size was computed for theinterviewers to use. Stage 3 was the final selection of one eligible female, and this was done bythe interviewer on visiting the household.MeasuresSocio-demographic variables. The socio-demographic information consisted of age, area ofresidence (1 = semi-urban, 0 = other; 1 = rural, 0 = other, and urban area is the reference group); 197
  • employment status (0 = unemployed, 1 = employed); frequent church attendance (0 = otherwise,1 = at least once per week); shared sanitary conveniences (0 = no, 1 = yes); and social class (1 =middle class, 0 = other; 1 = upper class, 0 = other, lower class is the reference group). Religiositywas evaluated from the question “With what frequency do you attend religious services?” Theoptions ranged from at least once per week to only on special occasions (such as weddings,funerals, christenings et cetera). 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 tohis/her last birthday (in years). Age of first sexual intercourse is measured from “At what age didyou have your first intercourse?” Education is measured from the question “How many years didyou attend school?” Marital status is measured from the following question “Are you legallymarried now?”, “Are you living with a common-law partner now? (that is, are you living as manand wife now with a partner to whom you are not legally married?)”, “Do you have a visitingpartner, that is, a more or less steady partner with whom you have sexual relations?”, and “Areyou currently single?” Contraceptive method comes from the question “Are you and your partner currentlyusing a method of contraception? …”, and if the answer is yes “Which method of contraceptiondo you use?” Age at which the person began using contraception was taken from “How old wereyou when you first used contraception? Area of residence is measured from “In which area doyou reside?” The options were rural, semi-urban and urban. Currently having sex is measuredfrom “Have you had sexual intercourse in the last 30 days?” Gynaecological examination istaken from “Have you ever had a gynaecological examination?” Pregnancy was assessed by“Are you pregnant now?” 198
  • Sexual assault is any sexual activity (genital, oral, or anal penetration) between two or morepeople in which one person has not given consent (against their will or involvement).Statistical Analysis Statistical analyses were conducted by the Statistical Packages for the Social Sciences(SPSS) for Windows, Version 16.0 (SPSS Inc; Chicago, IL, USA). Descriptive statistics wereperformed on the socio-demographic variables of the study population; and Chi-Squarecorrelations were used to show the bivariate relations involving categorical variables. A multiplelogistic regression model was conducted to explain the factors which account for currentcontraceptive usage among females of reproductive age, who were sexually assaulted on theirfirst sexual encounter. The independent variables included in the regression model were age ofrespondents, years of schooling, crowding, age of first sexual initiation, frequent churchattendance, employment status, number of sexual partners, number of pregnancies that resultedin live births, number of abortions, pelvic inflammatory disease or urinary tract infections, sharedsanitary conveniences, area of residence, and marital status. The dependent variable of thelogistic regression model was the current method of contraception of the study population. Where collinearity existed (r > 0.7), variables were entered independently into the modelto determine those that should be retained during the final model construction.26 To deriveaccurate tests of statistical significance, we used SUDDAN statistical software (ResearchTriangle Institute, Research Triangle Park, NC), and this was adjusted for the survey’s complexsampling design. Results Table 8.1 presents the socio-demographic characteristics of the study population (n =747): mean age of respondents was 32.0 years (SD = 8.6 years), and 41.1% were employed. 199
  • Table 8.2 shows information on the fertility of the study population. Almost 4 percent ofthe study population have had an abortion, 20.3% have had a miscarriage, 7.6% have had stillbirths and 84.5% have had live births. Table 8.3 examines last pelvic examination, Pap smear, pelvic inflammatory disease, andurinary tract infection. Almost 32% of the study population had never done a Pap smear and 46%a pelvic examination. Table 8.4 shows information on knowledge, method and practice of contraceptive usageof the study population. Almost 46% indicated that they always used a condom with a steadypartner, as did 17.2% of those with a non-steady partner. Almost 93% of the study population who were forced into their first sexual encounterwere aged 15-19 years, 6% were 20-24 years, 0.8% were 25-29 years and 0.3% were 30-34 yearsold. When the study population was asked “Have you ever in your lifetime been sexuallyassaulted?, 84.6% reported yes. And the individual(s) who carried out this activity was/werehusband(s), 17.3%; visiting partner, 8.7%; boyfriend, 30.6%; friend, 18.3%; casual acquaintance,11.7%; mother’s partner, 1.6%; father, 0.3%; other relative(s), 9.3%, and gang raped, 2.2%. Themajority of the study population was sexually assaulted once, 47.8%; followed by 2-5 times,31.4%; 6-10 times, 5.4%; 11+ times, 9.9%, not sure, 5.4%. Furthermore, almost 85% of thosewho were raped stated that this occurred at their first sexual initiation, and 6.3% of the samplewere commercial sex workers (being paid for sexual encounters). Using logistic regression analyses, four variables emerged as statistically significantpredictors of current contraceptive usage in this sample (Table 8.5): age at first sexual initiation(OR = 1.16, 95% CI = 1.03 – 1.31); frequent church attendees (OR = 0.43, 95% CI = 0.25 – 200
  • 0.77); number of pregnancies that resulted in live births (OR = 1.26, 95% CI = 1.05 – 1.52); andshared sanitary conveniences (OR = 0.55, 95% CI = 0.31 – 1.00). This model had statistically significant predictor power (Model χ2 = 30.59, P = 0.006;Hosmer and Lemeshow goodness of fit χ2= 4.04, P = 0.854), and correctly classified 76.3% ofthe sample.DiscussionThere are some significant findings which emerged on the current reproductive health practicesof women ages 15-49 years who have been sexually assaulted in Jamaica. Fifty-two out of every100 of the study population always use a condom, which is substantially greater than that forJamaican women of reproductive age (13 out of every 100), and 68 out of every 100 women whowere sexually assaulted currently used a method of contraception compared to 64 out of every100 women in reproductive years.27 Despite those positive reproductive health decisions ofwomen who were sexually assaulted in the past, public health practitioners and policy makersmust implement policies which would address the lower age of the sexual debut for such women(median age = 16.0 years) than women of the reproductive ages of 15-49 years (median age =17.0 years). Statistics from the Jamaican Ministry of Health noted that in 2006, 1,509 cases of sexualassault/rape were seen at the accident and emergency departments at public hospitals, of which94% were females.28 Of the females who have been sexually assaulted/raped, 85.8% werebetween 5 and 29 years of age. The current research provides clarity regarding those who weresexually assaulted in Jamaica, and their reproductive health choices. Furthermore, this studyrevealed that for 93% of women who were sexually assaulted, the act occurred in theiradolescent years (15-19 years old). It can be extrapolated from the findings that there is under- 201
  • reporting of rapes, as fewer victims attended hospitals than those who reported being sexuallyassaulted. This is not atypical, as a study by Jones29 postulated that this is a worldwidephenomenon. However, Boxley et al.30, using information from the US Select Committee onChildren, Youth and Families in 1990, postulated that between 20 and 50% of rapes occurredagainst adolescents. Although the current study and that of Boxley and colleagues were indifferent periods, and possess some problems for effective comparison, more rapes wereperpetrated against women occurred during their adolescent years in Jamaica. In 1996, statisticson American teens (16-19 years) noted that they were three and a half times more likely than thegeneral population to be victims of rape, attempted rape or sexual assault.31 Another issue which emerged in this research which must be addressed by policy-makersis the typology of individuals who commit the sexual act against women on their first sexualencounter (in adolescent years) and the fact that the majority of perpetrators do not use acondom. While some of the positives which emerged in the present work about reproductivehabits suggest that women who have had coerced sex (raped, forced, experienced any form ofsexual violence) in Jamaica on their sexual debut have a higher degree of particular reproductivehealth activities; 1 in every 4 of them have reported suffering from a pelvic inflammatory diseaseor a urinary tract infection, which indicates that there are profound psychosocial matters (shame,anger, guilt, and depression) which arise from sexual violence against women, in particularadolescents. The forced sexual initiation of adolescent women in Jamaica and their subsequentreproductive health practices and choices, coupled with sexually transmitted infections, inparticular HIV disease,32 suggests that those realities must be addressed by public healthpractitioners, as they point to a public health concern for currently vulnerable adolescent 202
  • females, and the future psychosocial challenges that will arise. Although the number of womenin the study population who have reported forced sexual initiation is lower than that in Lima,Peru, (40%); Bamenda, Cameroon (37.3%); nine Caribbean nations (47.6%); Ghana (21.0%,three urban towns); and South Africa (28.4%, Transkei), but greater than for the United States(9.1%),33 the reality of suicide increasing with this experience means that we cannot allow closerelatives, associates and family members (men) to continue to rape adolescent females; policiesmust be geared towards preventing those bad experiences and bringing the perpetrators to justice. Outside of the prevention of sexual violence against women, arresting the perpetratorsand addressing the mental health of the victims, policies should be directed toward reducinggender, income and area-of-residence inequality, as these account for the vulnerability of femalesto such gruesome practices. Those social factors coupled with the biological factors and thetrauma of sexual violence against a woman, will produce mental health issues in raped victims ifthey are left unaddressed. Mental health is a part of public health,34 indicating that thepsychological status will influence their reproductive health choices, and that public health needsto understand these new findings. Statistics from the Jamaican Ministry of Health28 showed that130 people attempted suicide and were treated at public hospital accident and emergencydepartments in 2006, of which 77.6% were females. While we cannot state the percentage ofcases that were as a result of sexual violence, 80.8% of females who attempted suicide in 2006were aged 10-29 years, 26.3% of females who had AIDS in the same period were ages 10-29years, and 75% of females who were treated for sexual assault in accident and emergencydepartments in public hospitals in Jamaica in the same period were of the same age cohort.28Furthermore statistics from the Jamaican Ministry of Health revealed that in 2006, 15% offemales who were sexually assaulted (or raped) were less than 10 years of age,28 indicating that 203
  • sexual debut by assault is a public health concern, and from the current findings the perpetratorsare men who know their victims. Clearly “Coerced sex may result in sexual gratification on the part of the perpetrator,though its underlying purpose is frequently the expression of power and dominance over theperson assaulted”33 which denotes that a multifaceted approach is needed to address the currentrealities of females who are poor, live in rural areas, are unemployed, uneducated, mentally andphysically challenged, economically vulnerable, and those who are forced into prostitution andthe trafficking of people for sexual exploitation. Poverty and other social factors reduce thesexual autonomy of females as well as removing their sexual rights. A female should havedominion over her body and her sexuality,35 which denotes that public health needs to integratethis into the social justice of reproductive health matters for raped victims. As this will provide aperspective that will guide how policies are fashioned in the future, data are collected from rapedvictims, and reported by all stake-holders. The challenges of policy-makers go beyond the afore-mentioned, as an understanding of power, money and autonomy are important in nationalpolicies and programmes, being key factors inunderstanding the reproductive health and rights ofwomen,36 and sexual violence against them. Sexual violence against women, poverty, income-and-gender inequality, power, andmental health issues such as depression, planned suicide, attempted suicide, loneliness, feelingsof guilt and low interest or pleasure in usual activities37 account for contemporary reproductivehealth practices. It is for those reasons that public health intervention and programmes must takea multifaceted approach in understanding sexual violence and the reproductive health of thesexually assaulted, providing an outreach for those victims. Wilks et al.’s study revealed asignificant statistical association between gender of Jamaicans (ages 15-74 years) and feelings of 204
  • guilt/worthlessness (females, 11.4%; males, 8.6%).37 We can extrapolate and juxtapose on Wilkset al.’s study, based on the current research, that sexual violence against females during theiradolescent years by close friends, relatives and family members is accounting for somepercentage of women expressing a sense of guilt and/or worthlessness in Jamaica. Empiricalevidence exists that shows a strong statistical correlation between health and future economicgrowth,38 which encapsulates the devastating effects of sexual assault on future productivity.With this reality, the future challenges of public health are to address the social inequality andpsychological issues which have arisen, reduced sexual autonomy, and the future depletion ofhealth and economic growth owing to sexual violence. Amar postulated that “Forced sex is a public health issue affecting many collegewomen.”19 The sexual practices, reproductive health matters, demographic characteristics ofsexually assaulted victims, and factors which account for contraception use among the studypopulation, indicate that Amar’s work extends to women who were sexually assaulted on theirsexual debut. According to Wilks et al.,37 75% of Jamaican women (ages 15-74 years) used acontraceptive method compared to 68% of women in this study population. Another reproductivehealth disparity between Wilks et al.’s work and the study population is frequency of sexualencounters, 58.4% and 37.5% respectively. In 2002, the contraceptive prevalence for females(ages 15-49 years) in Jamaica was 66% and this was 68% for females who were sexuallyassaulted. Another issue which emerged from the current research is that the earlier a female hadsexual intercourse (sexually assault); she is 1.2 times more likely to currently use a method ofcontraception. Embedded in this is the latent psychological fear of sexual intercourse, and howthis influences the reproductive health choices of sexually assaulted victims. The reproductivehealth disparity between the study population and females of reproductive age is the fact that as 205
  • the latter cohort becomes older, they are 2% less likely to use a method of contraception,27 whilethis was not a factor for the former cohort. The present work demonstrates the importance of thepublic health concern regarding sexual assault against women in Jamaica. With more women inJamaica who have been sexually assaulted during their adolescent years than in the UnitedStates,31 this reinforces the potency of the public health dilemma in Jamaica and the need tourgently address the problem. Is there is different socialization of sexually assaulted females who shared sanitaryconveniences? Using Bourne et al.’s work,27 which found that female Jamaicans of reproductiveage who were currently sexually active (having sexual intercourse in the last 30 days) were 2.3times more likely to use a contraceptive method, then one would assume that females who hadthe experience of being sexually assaulted in the past who share sanitary conveniences with otherhouseholds would be more likely to use a method of contraception. This, however, is not the casein the current work, which found that sexually assaulted females who shared sanitaryconveniences with other households were 45% less likely to currently use a method ofcontraception. There are unresolved issues which emerged from these findings, and this requiresimmediate research and public health intervention. Another issue which must be addressed ishow many sexually assaulted women are reporting being raped? Luce et al. opined that “Sexual assault is under-reported, and more than half of allassaults are committed by someone known to the survivor.”20 The close relationship between thevictims and the perpetrators is such that public health practitioners need to implement asensitization programmes for mothers to use as a benchmark in observation of sexual violenceagainst their adolescent or younger children and family members, close friends and otherrelatives. This study highlighted a public health problem more graphic than the description 206
  • offered by Luce et al, as it found that almost 70% of cases were perpetrated by individuals whowere well known to the women in Jamaica (husband, visiting partner, boyfriend, friend, mother’spartner and father). The under-reporting of sexual assault cases, therefore, should not come as asurprise to people, as the victims must weigh the consequence of their reporting with the realityof the social challenges that this may have on the family, associates and relatives. Otherrationales for the under-reporting of rape cases are guilt, shame, sexually transmitted infections,sexual exposure to Hepatitis B, HIV/AIDS, and unwanted pregnancy that can account for thevictim’s unwillingness to come forward after the sexual encounter, and these can have long-termconsequences on the individual. The next traumatic experience of many of these raped victims is the additional guilt ofabortion. Abortion in Jamaica is illegal unless it endangers the life of the mother. Within thiscontext abortion is a social taboo, and females who have to use this service must carry with themthe biological reality as well as the psychosocial guilt of the experience. Some 3.1% of the studypopulation had undergone an abortion, and only 30.4% indicated that this affected their lives.Furthermore, some of the women in this study have even had as many as two abortions.Irrespective as to whether those cases were as a result of rape, these females require psychiatriccare and social support from the society. This is within the Jamaican reality of females’dependency on males for financial assistance, as in 2005 the labour force participation for maleswas 73% compared to 55% for females, and the unemployment rate for the latter group was15.8% compared to 7.6% for the former cohort.32 The challenges faced by many women inJamaica provide the reality of the males’ economic supremacy, intimidation and vetoing powersof over females, even their own sexuality, sexual autonomy and social justice in relation tosexuality and rights. Public health specialists and policy-makers need to be cognizant of the 207
  • intimidator’s power over the victims, and within the context of the economic power of males andthe degree of financial support wielded by them, instituting measures to address sexuallyassaulted victims. These must include prohibition, strategies to encounter intimidation, sexualexploitation and socioeconomic independency.Conclusion In summary, the factors which account for contraceptive use among women ofreproductive age, 15-49 years, who have been sexually assaulted, are significantly different fromthose which affect other women of reproductive age, suggesting that policies on reproductivehealth matters for the former group should be different to that of the latter group. Women ofreproductive age, whose first sexual encounter was a sexual assault, are clearly held hostage byfriends, family and relatives and close associates. Although the sexual violence haspsychologically scarred its victims, the findings which emerged from this study highlightsignificant reproductive health, in contrast to non-raped females. Thus, the current researchprovides invaluable information upon which policies, initiatives and programmes can befashioned, to address the present reproductive health realities of women who have been sexuallyassaulted in Jamaica. Sexual violence against women, in particular sexual assault for their first sexualinitiation, means that sexual autonomy is no longer a choice for those individuals. As such,researchers in the Caribbean need to study the health-seeking behaviour, disease typology,mental health, quality of life, satisfaction with life, self-actualization, image of self and currentpromiscuity of those who were sexually assaulted on their first sexual encounter, in order tounderstand how policies can be integrated into public health programmes for these women.Finally, forced sexual initiation and coercion during childhood constitute a violation of a 208
  • female’s sexual autonomy and reproductive health rights, as well as psychological innocence,which cannot be rectified merely by the prosecution of the perpetrators and immediatepsychophysical trauma care, but also by ongoing programmes throughout their entire lives.DisclosuresThe authors report not conflict of interest with this work.DisclaimerThe researchers would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researchers.AcknowledgementThe 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 (Jamaica Survey ofLiving Conditions, 2002) available for use in this study, and the National Family Planning Boardfor commissioning the survey. 209
  • References 1. Warren CW, Powell D, Morris L, et al. Fertility and family planning among young adults in Jamaica. Int Family Planning Perspectives 1988;14(4):137-141. 2. Camins A, Henrich C, Ruchkin V, et al. Psychosocial predictors of sexual initiation and high-risk sexual behaviors in early adolescence. Child and Adolescent Psychiatry and Mental Health 2007;1:14 3. Maharaj RG, Nunes P, Renwick S. Health risk behaviours among adolescents in the English-speaking Caribbean: A review. Child and Adolescent Psychiatry and Mental Health 2009; 3:10. 4. Henry-Lee A. Women’s reasons for discontinuing contraceptive use within 12 months: Jamaica. Reproductive Health Matters 2001; 9(17):213-220. 5. Williamson LM, Parkes A, Wight D, et al. Limits to modern contraceptive use among young women in developing countries: A systematic review of qualitative research. Reproductive Health 2009;6:3 6. Hernandez-Giron CA, Cruz-Valdez A, Quiterio-Trenado M, et al. Factors associated with condom use in the male population of Mexico City. Int J of STD & AIDS 1999; 10:112- 117. 7. Norman LR. Predictors of consistent condom use: A hierarchical analysis of adults from Kenya, Tanzania and Trinidad. Int. J of STD & AIDS 2003; 14:584-590. 8. Okonofua FE. Factors associated with adolescent pregnancy in rural Nigeria. J of Youth and Adolescence 1995; 24(4):419-438. 9. Feyisetan B, Pebley AR. Premarital sexuality in urban Nigeria. Studies in Family Planning 1989; 20(6):343-354. 10. Orubuloye IO, Caldwell JC, Caldwell P. Sexual networking in Ekiti district of Nigeria. Studies in Family Planning 1991; 22(2):108-113. 11. McGrath N, Nyirenda M, Hosegood V, Newell M-L. Age at first sex in rural South Africa. Sex Transm Infect 2009; 85(Suppl 1):i49-i55. 12. Cremin I, Mushati P, Hallett T, et al. Measuring trends in age at first sex and age at marriage in Manicaland, Zimbabwe. Sex Transm Infect 2009; 85(Suppl 1):i34-i40. 13. Thomas T. Youth Reproductive and Sexual Health in Jamaica. Washington DC., Advocates for Youth; 2006. 14. George C, Alary M, Otis J. Correlates of sexual activity and inconsistent condom use among high-school girls in Dominica. West Indian Med J 2007; 56(5):433-438. 15. Nnedu ON, McCorvey S, Campbell-Forrester S, et al. Factors influencing condom use among sexually transmitted infection clinic patients in Montego Bay, Jamaica. The Open Reproductive Science J 2008; 1:45-50. 16. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. The Cochrane Library, Issue 2. Oxford: Update Software; 2003. 17. United States Department of Health and Human Services (US DHHS). Scientific review panel confirms condom are effective against HIV/AIDS, but epidemiological studies are insufficient for other STDs. [press release] July 20, 2002. Available at www.hhs.gov/news/press/2001pre/20010720.html. 18. Davis KR, Weller SC. The effectiveness of condoms in reducing heterosexual transmission of HIV. Fam Plann Perspect 199931:272-279. 210
  • 19. Amar AF. Applying the theory of planned behavior to reporting of forced sex by African- American college women. J Natl Black Nurses Assoc 2009; 20(2):13-19.20. Luce H, Schrager S, Gilchrist V. Sexual assault of women. Am Fam Physician 2010; 81(4):489-495.21. Chen Y, Ullman SE. Women’s reporting of sexual and physical assaults to police in the National Violence Against Women Survey. Violence Against Women 2010; 16(3):2620279.22. Wieczorek K. A forensic nursing protocol for initiating human immunodeficiency virus post-exposure prophylaxis following sexual assault. J Forensic Nurs 2010; 6(1):29-39.23. Duma SE, Khayile TD, Daniels F. Managing ethical issues in sexual violence research using a pilot study. Curationis 2009; 32(1):52-58.24. Vakili M, Nadrian H, Fathipoor M, Boniadi F, Morowatisharifabad MA. Prevalence and determinants of intimate partner violence against women in Kazeroon, Islanmic Republic of Iran. Violence Vict 2010; 25(1):116-127.25. Jamaica National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston: NFPB; 2005.26. Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton & Lange Publisher, 1996.27. Bourne PA, Charles CAD, Crawford TV, et al. Current use of contraceptive method among women in a middle-income developing country. Open Access J of Contraception 2010;1:39-49.28. Jamaican Ministry of Health (MoH). Annual Report, 2006. Kinston: Policy, Planning and Development Division, Planning and Evaluation Branch; MoH;200829. Jones MJ. Fromm the footnotes and into the text: Victimization of Jamaican women. In Harriott A ed. Understanding crime in Jamaica: New challenges for public policy. Kingston; University of the West Indies Press; 2003: pp.113-132.30. Boxley J, Lawrence L, Gruchow H. A preliminary study of Eighth Grade Students’ attitude toward rape myths and women’s roles. J of School Health 1995;65(3):31. Bureau of Justice Statistics, U.S. Department of Justice. National Crime Victimization Survey. Washington DC: Bureau of Justice Statistics, U.S. Department of Justice; 1996.32. Pan American Health Organization (PAHO). Health in the Americas, 2007 – Volume II - Countries. Scientific and Technical Publication No. 622. Washington DC; PAHO; 2007: pp. 448-465.33. World Health Organization (WHO). World report on violence and health. Geneva: WHO; 2002: pp 147-182.34. Hutchinson G. Emerging challenges for mental health in the Caribbean. In: Morgan O, ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005:pp. 224-233.35. Berer M. Sexuality, rights and social justice. Reproductive Health Matters 2004; 12(23):6-11.36. Berer M. Power, money and autonomy in National Policies and Programmes. Reproductive Health Matters 2003; 12(23):6-13.37. Wilks R, Younger N, Tulloch-Reid M, et al. Jamaica Health and Lifestyle Survey 2007- 2008. Technical Report. Kingston: Epidemiology Research Unit, Tropical Medicine Research Institute, University of the West Indies, Mona; 2008. 211
  • 38. Mayer D, Mora H, Cermeno R, et al. Health, growth, and income distribution in Latin America and Caribbean: A study of determinants and regional and local behavior. In: Pan American Health Organization (PAHO). Investment in heath: Social and economic returns. Scientific and Technical Publication No. 582. Washington DC: PAHO; 2001; pp. 3-34. 212
  • Table 8.1: Socio-demographic characteristics of the study respondents, n = 747Characteristic n %Shared sanitary convenience with other household No 567 76.5 Yes 174 23.5Employment status Employed 307 41.1 Unemployed (including students) 440 58.9Main source of financial support Partner 28 48.3 Other 30 51.7Marital status Legally married and living with partner 131 17.5 Common-law 222 29.7 Visiting 230 30.8 Married but not living with partner 34 4.6 Not currently in union 130 17.4Sexually assaulted (without a condom used) Yes 427 85.1 No 75 14.9Area of residence Urban 104 13.9 Semi-urban 224 29.6 Rural 422 56.5Socioeconomic class Lower 241 32.3 Middle 318 42.6 Upper 188 25.1Years of schooling Median (range) 12.0 (Range = 2 to 29)Age median (range) 32.0 yrs (8.6 yrs)Crowding median (range) 2 person ( 1 – 2 person) 213
  • Table 8.2: Fertility issues of study populationCharacteristic n %Currently pregnant Yes 35 4.7 No 703 94.1 Not sure 9 1.2Ever been pregnant Yes 626 87.9 No 86 12.1Want to be pregnant Yes 93 12.4 No 35 4.7 Did not respond 619 82.9Currently sexually active (in last 30 days) Yes 467 37.5 No 280 62.5Number of pregnancies that resulted in live births median (range) 3 (1 – 11)Number of pregnancies that resulted in still births median (range) 0 (0 – 3)Number of pregnancies result in miscarriages median (range) 0 (0 – 4)Number of abortions median (range) 0 (0 – 2)Reason for abortion (last abortion) Pregnant threaten life 7 30.4 Could not afford to have a child 7 30.4 Did not want the pregnancy (respondent) 3 13.0 Partner did not want the pregnancy 1 4.3 Other 5 21.7Age at first menarche Median (Range) 13.0 years ( 8 – 19 yrs.)Age at first sexual intercourse Median (Range) 16.0 (8 – 33 yrs.) 214
  • Table 8.3: Pelvic examination, Pap smear, pelvic inflamatory disease and urinary tract infectionCharacteristic n %Pelvic examination Yes 343 45.9 No 402 53.8 Don’t remember 2 0.3Last pelvic examination 0 - < 12 months 142 41.4 1 - < 2 years 80 23.3 2 - < 3 years 31 9.1 3+ years 82 23.9 Don’t remember 8 2.3Pap smear 0 - < 12 months 165 22.1 1 - < 2 years 96 12.9 2 - < 3 years 74 9.9 3+ years 166 22.2 Never did 242 32.4 Don’t remember 4 0.5Pelvic inflamatory disease or urinary tract infection Yes 152 20.3 No 595 79.7Pelvic inflamatory disease, yes 3.3%Urinary tract infection, yes 18.3% 215
  • Table 8.4: Knowledge and practice of contraceptive usage of study populationCharacteristic n %Ever used a method of contraception Yes 713 95.4 No 34 4.6Currently using a method of contraception (during last sexualencounter) Yes 504 67.7 No 241 32.3Method of contraception to prevent pregnancy (first method) Tubal ligation 101 21.9 Vasectomy 1 0.2 Injection 80 17.3 Pill 94 20.3 Emergency contraceptive 1 0.2 IUD or coil 6 1.3 Withdrawal 28 6.1 Rhythm 2 0.4 Condom 149 32.3Method of contraception to prevent STIs (second method) Tubal ligation 4 1.6 Vasectomy 1 0.4 Injection 48 18.6 Pill 69 26.7 Emergency contraceptive 2 0.8 IUD or coil 3 1.2 Withdrawal 17 6.2 Rhythm 0 0.0 Condom 114 44.2Frequency of condom usage (steady or main partner) Always 94 45.9 Most times 84 41.0 Seldom 22 10.7 Never 5 2.5Frequency of condom usage (non-steady partner) Always 35 52.2 Most times 13 19.4 Seldom 0 0.0 Never 19 28.4 216
  • Table 8.5: Logistic regression: Variables of current method of contraception (during last sexualencounter) Wald Odds Characteristic β coefficient statistic ratio CI (95%) Age of respondents -0.04 2.93 0.97 0.93 - 1.01 Years of schooling -0.03 0.31 0.97 0.87 - 1.08 Crowding 0.32 0.76 1.37 0.67 - 2.79 Age at first sexual initiation 0.15 5.60 1.16** 1.03 - 1.31 Frequent church attendance -0.84 8.24 0.43** 0.25 - 0.77 Employment status ( 1= employed) 0.32 1.40 1.38 0.81 - 2.34 Number of sexual partners in last 30 days 0.14 0.03 1.15 0.22 - 5.92 Number of pregnancy that resulted in live birth 0.23 5.93 1.26* 1.05 - 1.52 Pelvic inflamatory disease or urinary tract infection -0.49 2.67 0.61 0.34 - 1.10 Shared convenience (1 = yes) -0.59 3.87 0.55* 0.31 – 1.00 Semi-urban 0.41 1.08 1.51 0.69 - 3.28 Rural 0.35 0.95 1.43 0.70 - 2.91 †Urban 1.00 Middle class 0.07 0.05 1.08 0.58 - 2.00 Upper class 0.55 1.53 1.73 0.73 - 4.11 †Lower 1.00 Number of abortion -0.41 0.89 0.35 0.29 - 1.55Model χ2 = 30.59, P = 0.006-2 Log likelihood = 376.44Nagelkerke R2 = 0.119Hosmer and Lemeshow goodness of fit χ2= 4.04, P = 0.854Overall correct classification = 76.3%Correct classification of cases of self-reported having urinary tract infection or pelvic inflamatory disease = 97.5%Correct classification of cases of not having urinary tract infection or pelvic inflamatory disease = 8.0%†Reference group*P < 0.05, **P < 0.01, ***P < 0.001 217
  • Chapter 9Reproductive health matters among Infrequent versus Frequent young adult- male-church attendees Paul A. BourneIntroductionIn a recently conducted research, Bourne and Charles [1] claimed that church attendance and agereduced men’s involvement in sexual activities. This abstraction suggests that religiosity canincrease age of sexual debut, abstinence for a time and lowers sexual promiscuity among youngmales. The extrapolations from Bourne and Charles’ work of increased age of sexual initiation,lowering the frequency of premarital sexual encounters and abstinence due to religion might bestretching the positives of religious socialization on the sexual practices, choices and decisions ofyoung males. One study which explored sexual initiation of persons within the age range of 15-44 years, found that protestants (similar to those of non-religion) were more likely to have theirfirst sexual initiation within their 16th year, compared to the Catholics (within their 17th year) andthose of other religion (18th year) [2]. It seems that the cultural values imparted by religion andparticular religious denominations may have a time deterrent on early sexual initiation andpossibly lowering the rates of HIV/AIDS among young people (ages 15-44 years) in developingcountries. Many studies have shown different factors influencing first sexual initiation, includingchurch attendance [3-6], but that those researches examined adolescents, middle-school, innercity youths or the young population. With the findings from the Jamaican Reproductive Health Surveys (RHS) [7] that theaverage age at first sexual initiation in Jamaica is 15.8 for females and 13.5 for males, and that inAntigua and Barbuda, Haiti, Guyana, Trinidad and Tobago and Dominica Republic, one in six 218
  • women between the ages of 15 and 24 became sexually active before the age of 15 years [8].Clearly, in many developing countries, premarital sexual encounters commenced in adolescents,and this accounts for the high prevalence of HIV/AIDS. Statistics from the Jamaican Ministry ofHealth (MoHJ) showed that the prevalence of HIV has been increasing [9], particularly amongyoung adults (ages 15-44 years), and that this is equally the same in other Caribbean islands [10,11], in the Americas [12] and in the developing nations [13, 14]. Some cultural practices whichemerged from the aforementioned findings highlight the need for something to stem the tide ofinconsistent condom usage, high HIV/AIDS infections, increase age of first sexual encounters,and multiple sexual relationships among young people. Increasingly and rightfully so attention has been placed on HIV/AIDS in developingnations, but little focus is given to church attendance as a measure of lowering the virus andincreasing age at sexual debut. Sexual encounter is mostly contracting through sexual activities,indicating that if religiosity can change the HIV/AIDS reality and alter age of sexual debut, thenit must be examined. According to Mechanic, “The concept of culture refers in a general sense tothe designs for adapting to the social and physical environments that characteristic the life of aparticular population” [15, pp. 33], “The most important feature of culture is that it can betransmitted and thus the young can acquire adaptive repertories through the learning process, or,…” [11, pp. 37], and “The subculture within which the child is socialized affects not only his[her] thoughts and values in a general sense but also his [her] life chances and personality” [11,pp. 38]. The church (or synagogue, mosque, temple) is an agent of socialization which meansthat its principles, teaching and ideology might influence the cultural perspectives and practicesof people, similarly this could be the case among young men. 219
  • While Mechanic’s arguments were constructed with reference to children, the same mightbe the case among adults or elders [11]. The teaching of the church is not specialized to children,but its cultural values extend to attendees. Church attendees ranged from occasional to frequentindividuals, which have some bearing on the internalization of the teachings and by expansion onpractices. One of the purposes of public health is to restore people’s health, suggesting that if thechurch may offer some explanation for altering age of first sexual initiation, promiscuity, andimprovements in health, then public health needs to know. Ironically, most Jamaicans are religious and the churches are the fourth most trustedinstitution in the country[16], yet the society is experiencing high HIV/AIDS prevalence andincidence among young adults and children [10,12]. In addition to the aforementioned issue,other realities according to Crawford, McGrowder and Crawford [17] are, 2 in every 5 Jamaicanwomen have been pregnant at least once, 4 in every 5 adolescent women pregnancies wereunplanned and 74% of females aged 15-17 years old were sexually active compared to 47% ofmales of the same age. Despite the paradoxicity of a religious society and the high prevalence ofHIV/AIDS, multiple sexual relationships, promiscuity and lowered age of first sexual initiation,according to Kart [18], religious guidelines aid wellbeing in that through restrictive behaviouralhabits which are health risk such as smoking, drinking of alcohol, and even diet. A study on theMormons in Utah revealed that cancer rates were lower (by 80%) for those who adhere toChurch doctrine than those with weaker adherence [19, 20]. In a study of 147 volunteerAustralian males between 18 and 83 years old, Jurkovic and Walker [21] study found a highstress level of non-religious than compared to religious men. Previous studies have examined church attendance as an independent explanatoryvariable on sexual initiation, but none explored the differences between the reproductive health 220
  • matters among non-frequent versus frequent young adult-males church attendees. Thus, thisresearch will elucidate information on (1) the reproductive health matters disparities, (2) factorsthat influence age at first sexual debut, (3) factors accounting for consistent condom usage, (4)factors accounting for frequent church attendance, (5) predictors of social relationshipsMethodsSample: This paper used data from a national cross-sectional survey, 2002 Reproductive HealthSurvey (RHS). There are two sets of inclusion criteria, which are males and ages. The eligibilitycriterion for age was 15 to 24 years at last birthday. Since 1997, the National Family PlanningBoard (NFPB) has been collecting information on men (ages 15-24 years) and women (ages 15-49 years) in Jamaica regarding contraception usage and/or reproductive health. In 2002, theReproductive Health Survey (RHS) collected data on Jamaican men ages 15-24 years andwomen 15-49 years. The current study extracted a sample of 2,437 men. Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais classified into four health regions. Region 1 is composed of Kingston, St. Andrew, St. Thomasand St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that Region 1 comprised 46.5% of Jamaica comparedto Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8% [1, 7] In stage 2 the households were clustered into primary sampling units (PSUs), and eachPSU constituted an ED, which in turn was comprised of 80 households. The previous sampling 221
  • frame was in need of updating, and so this was performed between January and May 2002. Oncompletion of the exercise, the total number of households visited was 15,950 of which 17.5% ofthe inhabitants dwelled in urban areas, 27.7% resided in semi-urban zones and 54.8% lived inrural areas. Almost 18% of the households had eligible men (ages 15-24 years old, n = 2,795men). Sixteen percent of the eligible men resided in urban areas, 27.7% lived in semi-urban areasand 56.4% dwelled in rural areas. The new sampling frame formed the basis upon which thesampling size was computed for the interviewers to use. The sample represents a response rate of87.2%: 88.3% of eligible urban men, 88.0% of semi-urban and 86.7% of eligible ruralrespondents [1, 7]. Stage 3 was the final selection of one eligible male from each sampled household and thiswas 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 instrumentadministered 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-testingof the instrument was conducted between March 16 and 20, 2002. A total of 175 instrumentswere 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 wasweighted in order to represent the population of men ages 15 to 24 years in the nation [1, 7].Statistical methodsWe used the Statistical Packages for the Social Sciences (SPSS) for Windows, Version 16.0(SPSS Inc; Chicago, IL, USA). Frequencies and means were computed on the sociodemographiccharacteristics. We also performed χ2 tests and F-tests to evaluate associations and differences 222
  • among mean scores. Stepwise multiple logistic regressions were used to analyze factors thatexplain the current usage of a contraceptive method. Odds ratios were determined from the useof a binary logistic regression model. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the finalconstruction of the model [1, 22, 23]. To derive accurate tests of statistical significance, we usedSUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), andthis was adjusted for the survey’s complex sampling design. A P-value < 0.05 (two-tailed) wasused to determine statistical significance.MeasuresCrowding is the total number of persons in a dwelling (excluding kitchen, bathroom andverandah). 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. Thesemethods include tubal ligation, vasectomy, implant (Norplant), injection, emergencycontraceptive protection, pill, condom, foaming tablets, creams, jellies, diaphragm, abstinence,withdrawal, the rhythm method, calendar or Billings. The dependent variable for this study was acontraceptive method (i.e. condom) which was coded as a binary variable from those whoindicated yes and 0, otherwise. Non-steady sexual partner denotes casual sexual relations withsomeone with whom the individual is not having a common-law sexual relationship, visitingrelationship or to whom the individual is legally married. Thus, in a sexual union were thoserespondents who indicated being married, in a common-law union or in visiting relationship.Education is taken from the question, ‘How many years did you attend school?’ This is coded asprimary or below (0 – 9 years), secondary (10-12 years) and tertiary (13+ years). Shared facility 223
  • is taken from ‘Are these [sanitary conveniences] shared with another household? The options areshared, not shared or not stated. This was coded as 1 = shared and 0 = otherwise.Church attendance was taken from the question, “With what frequency do you attend religiousservices” [7]. Hence, frequent church attendees were individuals who indicated ‘At least once aweek’, infrequent was coded from at least once per month, less than once a month, only forspecial occasions (weddings, funerals, christenings, etc), and never based on ‘does not attend atall’. Number of sexual partners is taken from the question, ‘How many “baby mothers”(including wives) have you had? Age of sexual debut (initiation or relation) was taken from “Atwhat age did you have your first intercourse”[7]. Had sex (sexual relation or currently had sexualintercourse) meant “Have you had sexual intercourse in the last 30 days” [7], where 1= yes and 0= otherwise.ResultsDemographic characteristic of studied populationTable 9.1 presents the demographic characteristics of the studied population. On average males(ages 15-24 years old) begin having sexual intercourse at 14.7 years (SD = 3.1 years), 22.4%were frequent church attendees (at least once per week), and 47% reported having sexualrelations in the last 30 days.Bivariate analyses: Particular demographic characteristics of studied populationTable 9.2 examines particular demographic characteristics of studied population by frequency ofchurch (or synagogue, mosque, temple). The findings revealed that there is no significantstatistical difference among the mean age of sexual debut of respondents by frequency of churchattendance (F = 0.523, P = 0.593). 224
  • Table 9.3 explores information on particular demographic characteristics by age ofrespondents. Almost 67% of those ages 20-24 years old reported having had sexual intercoursein the last 30 days compared to 41% of those ages 15-19 years old (χ2 = 130.9, P < 0.0001).Further examination of the having had sexual intercourse in the last 30 days by age group ofrespondents controlled for frequency of church attendance: 45% of those ages 20-24 years oldwho reported having had sex in the last 30 days were frequent church attendance compared to31.1% of those ages 15-19 years old (χ2 = 7.2, P = 0.005). However, 72% of those ages 20-24years reported having had sexual intercourse in the last 30 days were infrequent church attendeescompared to 44.0% of those ages 15-19 years (χ2 = 90.3, P < 0.0001). In addition to theaforementioned, 67% of those ages 20-24 years had indicated having had sex in the last 30 daysreported having never attend church (χ2 = 27.6, P < 0.0001).Multivariate analysesThree variables emerged as statistically significant predictors of age of first sexual intercourseamong the studied population F statistic = 24.6, P = 0.0001: age of respondents (B = 1.23, 95%CI: 0.931 – 1.53), women pregnant for individual (B = -1.45, 95% CI: -2.40 – 0.50), andeducation (B = 0.90, 95% CI: 0.04 – 1.77) (Table 9.4) The explanatory variables which account for those who indicated having used a condomthe last time they had sexual relations (Model χ2 = 71.32, P-value < 0.0001), and the datacorrectly classified 85% of those who used a condom on their last sexual activity. The variableswere woman being frequent for respondent (OR = 0.07, 95% CI: 0.04 – 0.15), shared sanitaryconvenience (OR = 0.63, 95% CI: 0.44 – 0.90), and had sex in last 30 days (OR = 0.49, 95% CI:0.37 – 0.66) (Table 9.5) 225
  • Table 9.6 displays explanatory variables which account for males who frequently attendchurch (or synagogue, mosque or temple) Model χ2 = 61.7, P-value < 0.0001, Hosmer andLemeshow test, χ2 = 1.29, P = 0.996. Seven factors emerged as statistically significant predictors of those relationships (-2Loglikelihood =1904.04, R2 = 0.24; Model χ2 = 313.7, P-value < 0.0001; Hosmer and Lemeshowtest, χ2 = 10.1, P = 0.26), and 69% of the data were correctly classified (Table 9.7).DiscussionMany sociologists [24-26], political sociologists [16] and medical sociologist [15] havepostulated that the cultural values of a society are taught, transmitted and designed by variousinstitutions, particularly the family, church (or synagogue, mosque, temple), school, media, peergroup and political organizations. People, therefore, are agents of their socializations, suggestingthat perception, practices, social life, power relationships, intraprofessional rivalry, choices,norms and acceptable behaviour are fashioned by agents of socialization. It is embodied insociological theories that human behaviours are a part of a general social setting, and so people’sperspectives, choices and decision must be understood within a wider social context, as they aresocial animals. The agents of socialization socially construct a template of acceptable behaviour, andthese are imparted to members, particularly children-to-adolescents, of the society who areexpected to use these social patterns as framework for living. Males (including young adultsaged 15-24 years old) are social animals who are equally expected to live in a particular socialand geographical milieu and ascribe to and interpret the same social patterns as design by theagents of socialization. Implicit in this is how the church will help in the training of the young 226
  • males for their social roles in society, including their sexual behaviour and sexuality as well asother social institutions. The orientations of young males, who attend churches, listen, internalize and act upon theteachings of the institution. These teachings include abstinence, sex is for marriage, be faithful toone partner (married spouse), avoid premarital sexual activities among other social values whichshould play a role in guiding the young males. The churches among the agents of socializationare, therefore, responsible for the cultural values and norms of a society. It is this cultural valuesand norm of agents of socialization including the church which justify why 9 out of 25 youngmales who attend churches reported having had sex in the last 30 days compared to almost 15out of 25 who infrequently attend churches as well as why less young males aged 15-19 yearsindicated having had sexual relations in the last 30 days compared to young males aged 20-24years. Sometimes there are variations in social deviance among the agents of socialization,particularly the church, family and mass media. These were evident in this paper. The agents of socialization’s teaching, guidelines are frameworks and are among thesymptomology of a social pattern. Thus, the design of the agents of socialization about our sociallife which is used to determine social deviance. According to Mechanic, “The concept of culture,refers in a general sense in the design for adapting to the social and physical environments thatcharacterize the life of a particular population” [15, pp. 33]. It can be extrapolated fromMechanic’s postulations that the description of the church is a part of the orientation of children,young people and adults. The churches, therefore, should influence not only the orientation ofyoung males who are in their care, but they should guide secular pursuits, progress,perspectives, opportunities in life and attitudes in accordance with the social values taught byother institutions including the family. 227
  • There appears that a paradox exist in Jamaica as most people have been through theteachings of the church, despite this fact, the churches’ orientation, values, teachings andconstruct of the social world have not changed the reality that HIV/AIDS is among the fiveleading causes of morality among children and adolescents aged 15-44 years [15, 16]. Statisticsfrom the Pan American Health Organization of (PAHO) showed, in Dominica, that males aged25-44 years were the most affected by the HIV/AIDS virus [12, pp. 280-289]; in Bolivia, theages 25-34 years was the most infected (45%) compared to ages 15-24 years (26%) [12, pp. 114-129]; and in Chile, most of the infected people were ages 15-44 years, with the rate being 5 timesmore among males [12, pp. 197-217]. It appears that the orientation from the churches in theAmericas, which can expend to the developing nations, has not resulted in behaviourmodifications of young people, particularly males as is evident from the prevalence ofHIV/AIDS. The current research found that 79.1% of young males aged 15-24 years frequently-to-infrequently attend churches (frequently, 23%); 2.1 times more aged 15-19 years than those 20-24 years old; 67% aged 20-24 years old reported having had sex in the last 30 days compared to41% of those aged 15-19 years old; age of first sexual intercourse for those 15-19 years was 15.3years and 14.1 years for those aged 20-24 years; 45% of those aged 20-24 years old whoindicated having had sexual relations in the last 30 days frequently attend churches compared to31% of those aged 15-19 years. Is it the churches’ teachings, values and orientations that areinfluencing young males’ sexual behaviour or age and other factors? In this work, it was revealed that younger males (15-19 years) are more like to frequentlyattend churches than older males (aged 20-24 years old), age influences age of sexual debut, butthat there was no statistical difference between the mean age of males who frequently versus 228
  • non-frequently attend churches. However, a finding which emerged from the current research isthat involvement in extra-curricular activities was greater among those who are frequent churchattendees than non-frequent attendees. And that those in sexual unions were about 1.5 timesmore likely to be frequent attendees, frequent attendees to churches were more likely to havereported having had sex in the last 30 days. Moreover, 1 in every 2 young males aged 15-24years had sex in the last 30 days; 13 out of every 25 young males were in a sexual union, yetonly 3.9% were married. This research revealed that those who infrequently attend churches were 1.6 times morelikely to have had sexual relations in the last 30 days compared to frequent attendee, whichconcurs with Bourne and Charles’ work [1] that the churches influence sexual behaviour. Thecultural content and cultural life style of churches are impacting on reducing sexual practices ofyoung males, but it is found that it is not altering the age of first sexual relations. Clearly theorientations of churches on young males is offering some resistance against the peer group,media and other agents of socialization which are continuously exposing young people to sex,and sexual promiscuity. This means that the old definition of deviance as outlined by thechurches and the educational system are changing, and are being redefined by the media whichappears to have the supremacy in cultural orientations in contemporary societies. The churchesare offering frequent young males many extra-curricular activities, which should act as agents ofincreased abstinence, lowered sexual promiscuity, and the cultural conditioning of the media andthe peer groups are contributing to the insulation of young males from the values of right andwrong to the practice of choices. The media are defining sexual promiscuity, homosexuality, and other traditional andcultural values which were once condemned by the orientations of the churches as acceptable 229
  • behaviour. It is this very rationale which accounts for the high percentage of young males insexual union, but not married, having sex, and still they are frequent church attendees. Mechanic[15] provides some explanations for the challenges of traditional values and those incontemporary societies, when he said that, “The social response approach emphasizes themanner in which particular attributes become identified as different, the ways they are reacted toand defined, and the ultimate condemnation or approval that may follow” [15, pp. 46]. Clearlythe cultural values which were once primarily fashioned by religion are changing as newperspectives are being framed, which are more in keeping with science, positivism, and currentobservations. It is evident from this paper that the ideal type of family type, married or conjugal unions,are shifting in contemporary Caribbean societies, particular in Jamaica. Once again thetraditional values of churches are shifting, and new definitions are emerging which are acceptedby the social setting. The churches in Caribbean were mostly from Europe and later fromAmerican societies, and they used a Eurocentric ideology of the type of family structure that isaccepted from Afro-Caribbean peoples. Such a family structure was assumed to be the ideal typefor the Caribbean people as this was typically the case in British and American cultures. Whilethat family type (marital union) originated in Britain and America, Greenfield [27] and Smiths[28, 29] recognized that the Caribbean family was more diverse than a nuclear family typehousehold. Hence, Greenfield [27] coined the term sub-nuclear as a family type that definessome Caribbean households. Following their field work [27, 30], they recognized co-residentialconjugal unions which included common-law as well as extended families types. These unionsare not accepted by the church, but they are institutionalized in Caribbean societies. 230
  • Another Caribbean scholar [31] added a new dimension to the Caribbean family. Heidentified Caribbean families within ethnicity and class. Rodman found that the lower class wascharacterized by promiscuous sexual relationships, ‘illegal’ marital unions, illegitimate children,un-married mothers, deserting husbands and fathers and abandoned children. From Rodman’sfindings, the Caribbean family would lack defined obligations and a British and Americandefinition of a family structure, as Caribbean family structure sometimes did not have a malepresent and mothers were left to father children. Caribbean children were therefore, sometimesleft without a father and by extension bear the surnames of their mothers. This is anotherdisparity in Caribbean family types from that of other cultures. Barrow & Reddock [32] titled theaforementioned disparity as adopted flexibility. Based on functionalism, it may appear thatRodman’s findings were that of a dysfunctional family type. However, this is culturally specificto some Caribbean family types. The seemingly disorganized or dysfunctional family type is adisparity of structural functionalism which cannot be neglected in Afro-Caribbean families asthis is indeed an explanation of a family type. R. T. Smith applied a post modernist stance in examining Caribbean families [29]. Hebelieved that the Caribbean people must be understood within their culture, system, family andkinship as this will provide information on this group. The examination of Caribbean familiesmust be expanded from a black lower class, elite and middle class phenomena in order tounderstand the plural nature of Caribbean societies. A critical part of any study of Caribbeanfamilies is an examination of their Creole cultures these are shared experiences and meaningspassed down orally from one generation to the next. Hence, the irregular unions, illegitimacy andout-side children are aspects of Caribbean societies and so cannot be omitted from the discourse.It is the aforementioned rationale which accounts for the high non-marital unions among young 231
  • males in Jamaica, which is a social deviance from the traditional values of the church but themedia and parliament have sanctioned those unions. According to Mechanic, “As attitudes and values of the larger society change, definitionsof “sickness” and “badness” are also in flux, and concepts may be refined in terms of a newsocial consensus” [15, pp. 51]. Although David Mechanic’s perspective was in reference tohealth, it can be applied to sexual behaviour which was the focus of the current research. There isa general consensus that common-law unions are legally accepted in Jamaica and the widerCaribbean. Despite the aforementioned changing social accepted definition and perspective, thechurches still do not recognized those unions as ideal family types. The other institutions,particularly the family and the state as well as the media, influence the cultural values of theyoung males and this accounts for the greater percentage of them being engaged in those familytypes (common-law, visiting). Nevertheless, the young males who frequently attend churches are younger, almost one-half less likely to be engaged in sexual unions, and less like to use a condom. The currentfindings revealed that older young males aged 20-24 years appear to lose the orientations of thechurch and the cultural norms of the church fade away, giving rise to those of the family, mediaand new definitions of the wider society. With the current work showing that young males aged15-24 years are less likely to indicate having used a condom on their last sexual encountercoupled with the fact that those who reported having had sexual relations in the last 30 days weremore likely to be frequent attendees, it can be construed that some aspects of the cultural valuesof the church are used by the males. As the Caribbean male matures into the adolescent years, heis expected to have children, be a bread winner, not display weakness, be macho, and be sexualpromiscuous [33] in order to display coming of age, and manhood. The macho principle is such 232
  • that it influences health care seeking behaviour [34], as well as sexual behaviour. Those culturalvalues are not in keeping with the orientations and roles of the churches, but they play a moredominant role in gender identity than those of the church. It is those wider cultural values whichjustify the greater prevalence of HIV/AIDS among males older than 19 years to 44 years, inmany developing nations as peer group and the family expects a particular sexual behaviour fromthe male during adulthood. Inspite of the many churches which are in Jamaica, using a national probability sample of2,848 Jamaicans aged 15-74 years (in 2007/2008), Wilks et al found that 88% of males aged 15-24 years old have had sex in past, 42.4% had sex at least once per week, 48.9% reported havingmore than one sexual partners, and 24.3% have never had sexual relations. Wilks et al’s work isproviding public health with more understanding of the failure of the church and its interventionprogrammes, over the years. Clearly the church is guiding and reducing the sexual behaviour ofyoung males (15-19 years), but the statistics on reproductive health behaviour and HIV/AIDS issaying nothing good about the intervention programmes in the developing nations, particularly inJamaica. In an ethnographic study in Dominica, Jamaica, and Guyana, Chevannes [33] found thatthere is a ‘loose the bull and tie the heifer’ culture, which explains the inequality in the culture,social structure and churches’ values. And how the churches’ orientation and norms aregradually replaced with those of the family, mass media, peer group and wider social structure asyoung males pass 20 years. Chevannes’ work offered some clarification of the challenge of thecontemporary churches in maintaining abstinence, low promiscuity, and no sex before marriagefor young males. In Overflow, Guyana, Chevannes noted that “…, it [marriage] is the gateway tolegitimate sexual relationship, and it is presumed that until they are married a couple have never 233
  • had sexual intercourse, that the girl is a virgin” [33, pp. 63], “In Grannitree [Jamaica], once theyreach puberty girls are routinely told to be wary of boys and men, out of the fear of pregnancy,while parents turn a blind eye on their boys’ sexual adventures outside the yard” [33, pp. 54], inRiverbreeze, Dominica, “The sexual problem facing men is not whether to have sex before oroutside of marriage, or to get a women pregnant, or whether to have more than one women.What they face instead is the question of how open they ought to be about multiple partnerships”[33, pp. 114], and in Grannitree, “The sex role divisions, according to Mr. Wilson, start when,‘after they reach a certain age’, mother controls the girls and father the boys” [33, pp. 42]. Children observe and imitate the culture of the society, in particular their family duringchildhood and more so in the adolescence years. With the culture of sexual freedom for men,young males would have been socialized by their fathers about this practice. The wider society inthe Caribbean has a macho culture which expects men to be sexual adventurous, strong,heterosexuals and be fathers. All those are a part of the cultural abstractions in Caribbeansocieties that are imparted to young males, and these are competing with the culturalconditionality of the church. The laws are gradually changing to meet the new social realities ofthe people, (including common-law unions, sexual relationships which are non-conjugal), yet thechurches continue to hold steadfast to the traditional, and non-scientific abstractions. People areconditioned by the social and cultural settings within which they develop, and some of theabstractions are conflicting to the young people. Young males are experiencing sexual roleconfusion, socialization deficiency, cultural gaps, conditioned inequality, and contradictions incultural and social abstractions as well as values constipation which are not addressed inintervention programmes. 234
  • This paper revealed that there are two stages to influence of the churches’ values onsexual behaviour of young males. In stage 1 (I will call, Auronale), the young male child is in theadolescence years in which he is substantially guided by the abstractions and principles of thefamily which are congruent to those of the church, and because of this clear synergy, he is highlylikely to adhere to the cultural values of the family as well as those of the church relating tosexuality, sex and social civility. It is during the Auronale stage that the family expects the youngmale to be a child or adolescent and not an adult, which means that the churches’ values areinfused with those of the family for the socialization of the young while he is being trained forthe next stage. In stage 2 (I will refer to as, Eynaedorval), the individual is now an adult (20+years) and the family now expects that the male to be somewhat subscribing moreso to theculture of machoism. The Eynaedorval stage means the young male adult can now engage inmultiple sexual relationships, owned his reproductive health choices, expected to be involved inheterosexual relationship, and commence the process of economic independency and familyconstruction. It is this during the Eynaedorval stage that the frequent church attendance fails tohave the same hold over the young males compared to when he was in the Auronale stage. The cultural abstractions of the Eynaedorval stage depart from those of the churches’abstractions, as the family’s abstractions and that of the peer group become the dominantideology. In the Eynaedorval stage, the young male needs to establish his manhood,heterosexuality and this indicates a clear disjoint between expectations of the family, the societyand the churches. The young adult male needs to be culturally fitted, and so the cultural patternswhich were transmitted to him during the Auronale stage, will be acted out. It is this reasonwhich accounts for 8 out of 25 young males aged 20-24 years having had sex in the last 30 dayscompared to 5 out of 25 young males aged 15-19 years. The concepts of the culture are different 235
  • at particular time and stage, and the expectations, descriptions and orientations vary greatly intheir degree of abstraction in society making the cultural patterns interpreted by the young male.Therefore, Bourne and Charles’ work [1] which found that age and church attendance affectsexual behaviour is concurred by this research, and some explanations, clarification andprecisions are offered in this study for such a finding.ConclusionThe churches’ values still have some influence over the social life of young males, but more soduring the Auronale than the Eynaedorval stage. But clearly, the other institutions are helping torefashion the new culturally acceptable standards which are contravening to the traditional valuesand pattern offered by the churches. During the Auronale stage, young males who frequentlyattend churches are less engaged in sexual behaviour and sexual relations because the churches’values are in tandem with those of the family and wider society. However, with time a disparitydevelops between the cultural values of the church and the families as young males are expectedto display manhood. During the Eynaedorval stage, cultural inequality is evident in Caribbeansocieties as economic; children and social independencies are expected as a part of adulthoodwhich is different from those in the Auronale stage. The perspectives, practices, and choices of young males are not stationary across thelifetime. The cultural values of the churches which support the finding of age and churchattendance influence young males’ sexual behaviour are so because they are supported by thefamilies’ teaching than singled out by frequent church attendance. The practices identifiedamong young males in Jamaica, particularly those who are frequent church attendees, cannot beallowed to continue without public health policies and intervention programmes to address thoseissues. 236
  • The mass media, internet, social networks, telephone, scientific discoveries and advancesin technology are creating a new cultural era. The new era is currently being defined by societyand the expectations are not supporting the traditional values of the church. The new cultural andsocial milieu are more supporting scientific abstractions, mass media, information, and logicexplanations, which are clearly not rivaled by the teachings of religion. The churches, like publichealth, continue in the same old traditions that are not effective in ameliorating the socialrealities of young males. Public health specialists, more so than church leaders, need to revampthe approaches in leading with sexuality, sexual behaviour, and new cultural abstractions in orderto effectively and efficiently utilize financial resources to improve the health of the populationand subpopulations.DisclosuresThe author reports no conflict of interest in this work.DisclaimerThe researcher would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researcher.AcknowledgementThe 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 ReproductiveHealth Survey, RHS) available for use in this study, and the National Family Planning Board forcommissioning the survey as well as research assistant, Ms. Neva South-Bourne.References 1. Bourne PA, Charles CAD. Contraception usage among young adult men in a developing country. Open Access J of Contraception 2010; 1:51-59. 2. Sexual Initiation. American Sexual Behaviour. http://www.newstrategist.com/productdetails/Sex.SamplePgs.pdf (Accessed on April 1, 2010). 237
  • 3. Fatusi AO, and Blum, RW. Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC Public Health 2008; 8.4. 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, 34:200-208.5. Penfold SC, Teijlingen ERV, Tucker JS. Factors associated with self-reported first sexual intercourse in Scottish adolescents. BMC Research Notes 2009; 2:42.6. Rosenthal DA, Smith AMA, De Visser R. Personal and social factors influencing age at first sexual intercourse. Archives of Social Behavior 1999; 28(4):319-333.7. Jamaican National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston: NFPB; 2005.8. Rawlins J. Teenage Pregnancy: A study in three communities in Trinidad and Tobago. Paper presented at the Caribbean Health Research Conference 2007, Jamaica.9. Jamaican Ministry of Health (MoHJ). Annual Report, 1990-2007. Kingston: MoHJ; 1991-2008.10. 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. 62-76.11. Douglas DL. Perspectives on HIV/AIDS in the Caribbean. In: Morgan O, ed. Health issues in the Caribbean. Kingston: Ian Randle Publisher; 2005: pp.xi-xxi.12. Pan American Health Organization (PAHO). Health in the Americas 2007, volume II – countries. Washington D.C.; PAHO: 2007.13. World Health Organization (WHO). World health statistics, 2009. Geneva; WHO: 2009.14. Bourne PA, South-Bourne N, Francis CG. Knowledge, attitude and practices of adults of the reproductive years on reproductive health matters, with emphasis on HIV infected people in a Caribbean society. North Am J Med Sci 2010:2:381-388.15. Mechanic D. Medical sociology: A comprehensive text. 2nd ed. New York: The Free Press; 1978.16. Powell LA, Bourne, P. Waller L. Probing Jamaica’s Political culture: Main trends in the July-August 2006 Leadership and Governance Survey, volume I. Kingston: Centre for Leadership and Governance, Dept. of Government, The University of the West Indies, Mona, Jamaica; 2007.17. Crawford TV, McGrowder DA, Crawford A. Access to Contraception by Minors in Jamaica: A Public Health Concern. North AmJ. Med Sci. 2009; 1:247-255.18. Kart CS. The realities of aging: An introduction to gerontology, 3rd ed. Boston: Allyn and Bacon; 1990.19. Gardner JW, Lyon JL. Cancer in Utah Mormon men by lay priesthood level. American Journal of Epidemiology 1982; 116:243-257.20. Gardner JW, Lyon JL. Cancer in Utah Mormon women by church activity level. American Journal of Epidemiology 1982; 116:258-265.21. Jurkovic D, Walker GA. Examining masculine gender-role conflict and stress in relation to religious orientation and spiritual wellbeing in Australian men. Journal of Men’s Studies 2006; 14, 1:27-46.22. Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton & Lange Publisher; 1996. 238
  • 23. Cohen L, Holliday M. Statistics for Social Sciences. London, England: Harper and Row, 1982.24. Gosling RA, Hill M, Free LK, Taylor, S. Introduction to sociology. 7th ed. London: University of London Press; 2003.25. Haralambus M, Holborn M. Sociology: Themes and perspective. London; University Tutorial Press; 2002.26. Giddens A. Sociology. London: Polity Press; 1993.27. Greenfield S. English Rustics in Black Skin: A Study of Modern family forms in a Pre Industrial Society. New Haven, Conn., College and University Press; 1966.28. Smith MG. West Indian Family Structure. Seattle and London, University of Washington Press; 1962.29. Smith RT. The Matrifocal Family In: Goody J. The Character of Kinship. Cambridge: Cambridge University Press; 1973.30. Clarke E. My Mother who fathered me. London: George Allen and Unwin; 1970.31. Rodman H. Lower class families: The cultures of Poverty in Negro Trinidad. London: Oxford University press; 1971.32. Barrow C, Reddock R. eds. Caribbean sociology: Introductory Readings. Kingston: Ian Randle, markus Wiener, & James Currey; 2001.33. 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; 2001.34. Stakelum A, Boland J. Men talking. Kells: Department of Public Health, North Eastern Health Board, 2001.35. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. Jamaica health and lifestyle survey 2007-8. Technical report. Kingston: Epidemiology Research Unit, Tropical Medicine Research Institute, University of the West Indies, Mona; 2008. 239
  • Table 9.1: Demographic characteristics of studied population, n = 2,437Characteristic n %Church attendance Frequently 547 22.7 Infrequently 1357 56.4 Never 503 20.9Women current pregnant for No 2361 97.9 Yes 51 2.1In sexual union No 1358 55.7 Yes 1079 44.3Currently employed No 1605 65.9 Yes 832 34.1Shared sanitary convenience No 2067 86.0 Yes 337 14.0Condom usage (last time) No 342 17.3 Yes 1639 82.7Currently having sexual intercourse (in last 30 days) No 1054 53.2 Yes 927 46.8Age group 15 – 19 years 1432 58.8 20 – 24 years 1005 41.2Education attainment No formal 5 0.1 Primary 200 8.2 Secondary 1046 42.9 Tertiary 1164 47.8Area of residence Urban areas 394 16.2 Periurban 680 27.9 Other 1363 55.9Having non-partner sexual relations No 366 19.9 Yes 1469 80.1Marital status Married 96 3.9 Common-law 983 40.3 Visiting relationship 415 17.0 Single 943 38.7Age at first sexual encounter (sexual debut) mean (SD) 14.7 years (SD = 3.1 years) 240
  • Table 9.2: Particular demographic characteristics by frequency of church attendance, n = 2,437 Church (or synagogue, mosque, orCharacteristic temple) attendance χ2, P value Frequently Infrequently Never n (%) n (%) n (%)In sexual union 82.4, 0.0001 No 397 (72.6) 702 (51.7) 244 (48.5) Yes 150 (27.4) 655 (48.3) 259 (51.5)Age group 26.4, 0.0001 15 – 19 years old 372 (68.0) 766 (56.4) 273 (54.3) 20 – 24 years old 175 (32.0) 591 (43.6) 230 (45.7)Shared facility 28.1, 0.0001 No 493 (91.3) 1152 (86.0) 396 (79.8) Yes 47 (8.7) 187 (14.0) 100 (20.2)Used condom (last time) 13.7, 0.001 No 82 (22.8) 171 (14.7) 82 (18.8) Yes 278 (77.2) 990 (85.3) 354 (81.2)Currently having sex (in last 30 days) 48.6, 0.0001 No 228 (63.2) 491 (42.3) 197 (45.2) Yes 133 (36.8) 669 (57.7) 239 (54.8)Area of residence 11.7, 0.02 Urban 99 (18.1) 190 (14.0) 99 (19.7) Periurban 158 (28.9) 387 (28.5) 131 (26.0) Rural 290 (53.0) 780 (57.5) 273 (54.3)Women pregnant for 7.1, 0.029 No 542 (99.3) 1304 (97.3) 485 (97.8) Yes 4 (0.7) 36 (2.7) 11 (2.2)Having non-partner sex 11.5, 0.003 No 83 (26.6) 197 (17.9) 79 (19.6) Yes 229 (73.4) 901 (82.1) 325 (80.4)Age of sexual debut mean (SD) 14.5 yrs 14.7 yrs 14.8 yrs F = 0.59, 0.593 (2.9) (2.9) (3.5) 241
  • Table 9.3: Particular demographic characteristics by age cohort, n = 2,437 Age cohortCharacteristic 15 – 19 years 20 – 24 years χ2, P n (%) n (%)In sexual union 82.4, 0.0001 No 980 (68.4) 378 (37.6) Yes 452 (31.6) 627 (62.4)Shared facility 4.7, 0.018 No 1234 (87.3) 833 (84.1) Yes 180 (12.7) 157 (15.9)Used condom (last time) 0.176, 0.675 No 181 (17.6) 161 (16.9) Yes 847 (82.4) 792 (83.1)Currently having sex (in last 30 days) 130.9, 0.0001 No 608 (59.1) 319 (33.5) Yes 420 (40.9) 634 (66.5)Area of residence 6.7, 0.045 Urban 210 (14.7) 184 (18.3) Periurban 400 (27.9) 280 (27.9) Rural 822 (57.4) 541 (53.8)Women pregnant for 27.2, 0.0001 No 1412 (99.4) 949 (96.1) Yes 12 (0.8) 39 (3.9)Employed 497.0, 0.0001 No 1200 (83.8) 405 (40.3) Yes 232 (16.2) 600 (59.7)Educational level 27.9, 0.0001 No formal 128 (8.9) 77 (7.7) Primary 664 (46.4) 382 (38.0) Secondary 622 (43.4) 542 (53.9) Tertiary 18 (1.3) 4 (0.4)Frequent church attendance 26.4, 0.0001 Frequently 372 (26.4) 175 (17.6) Infrequently 766 (54.3) 591 (59.3) Never 273 (19.3) 230 (23.1)Age of sexual debut mean (SD) 15.3 yrs (3.5) 14.1 yrs (2.) t=7.724, 0.0001 242
  • Table 9.4: Multiple regression analyses: Explanatory variables of age of sexual debutDependent variable: Age of Unstandardizedsexual debut coefficient Std. Error CI (95%) Constant 14.12 0.11 13.92 - 14.33 Older age (20 -24 years old) 1.23 0.15 0.93 - 1.53 Women pregnant for -1.45 0.48 -2.40 - -0.50 Secondary level education 0.90 0.44 0.04 - 1.77 Primary (reference group)F statistic = 24.6, P = 0.0001R2 = 0.05 243
  • Table 9.5: Logistic regression analyses: Explanatory variables of currently using a condom (inlast 30 days) Dependent variable: Currently Std. Wald Odds using a condom (in last 30 days) β coefficient error statistic ratio CI (95%) Woman pregnant for -2.60 0.35 55.41 0.07 0.04 - 0.15 Shared sanitary convenience -0.47 0.18 6.51 0.63 0.44 - 0.90 Had sex (in last 30 days) -0.70 0.15 21.89 0.49 0.37 - 0.66 Constant 2.93 0.26 130.40 18.68-2Log likelihood =1267.74 R2 = 0.08Model χ2 = 71.32, P-value < 0.0001Hosmer and Lemeshow test, χ2 = 1.12, P = 0.94Overall correct classification = 84.7%Correct classification of cases that currently use a contraceptive method (condom) = 98.8%Correct classification of cases that did not currently use a contraceptive method = 9.9% 244
  • Table 9.6: Logistic regression analyses: Explanatory variables of frequent church attendance Dependent variable: Frequent Std. Wald Odds church attendance β coefficient error statistic ratio CI (95%) Involvement in extra- 0.34 0.15 5.40 1.40 1.05 - 1.87 curricular activities Not In sexual union 0.39 0.15 7.36 1.48 1.12 - 1.97 Tertiary level education -0.30 0.14 4.52 0.75 0.57 - 0.98 Primary (reference group) 1.00 Shared sanitary convenience -0.59 0.22 7.28 0.55 0.36 - 0.85 Had sex (in last 30 days) 0.62 0.15 18.22 1.87 1.40 - 2.49 Constant -2.52 0.24 113.54 0.08 2-2Log likelihood =1412.0, R = 0.06Model χ2 = 61.7, P-value < 0.0001Hosmer and Lemeshow test, χ2 = 1.29, P = 0.996Overall correct classification = 81.3% 245
  • Table 9.7: Logistic regression: Explanatory variables of those in sexual relationship Std. Wald Odds Dependent variable: In Sexual relationship β Coefficient error statistic ratio CI (95%) Young males (15-19 years) -0.37 0.13 8.58 0.69 0.54 - 0.89 Aged males (20-24 years, reference group) 1.00 Frequent church attendance -0.34 0.15 5.33 0.72 0.53 - 0.95 Periurban -0.49 0.12 17.46 0.62 0.49 - 0.77 Rural (reference group) 1.00 Women pregnant for 1.48 0.61 5.84 4.39 1.32 - 14.59 Employment (1=employed) 0.36 0.13 7.92 1.43 1.12 - 1.84 Had sex (in last 30 days) 1.39 0.12 142.08 4.00 3.19 - 5.03 Tertiary - 0.31 0.11 6.98 0.74 0.59 – 0.92 Primary (reference group) 1.00 Constant -0.80 0.34 5.44 0.45-2Log likelihood =1904.04, R2 = 0.24Model χ2 = 313.7, P-value < 0.0001Hosmer and Lemeshow test, χ2 = 10.1, P = 0.26Overall correct classification = 69.4%Correct classification of cases in sexual relationship = 71.2%Correct classification of cases that not in sexual relationship = 67.3% 246
  • Chapter 10 Multiple sexual partnerships among young adults in a tropically developing nation: A public health challenge Paul A. BourneIntroductionMany ethnographic studies which have been conducted, particularly in the English-speakingCaribbean nations, identified that contemporary sexual behaviour of males as having historicalantecedents [1, 2]. This makes for the understanding of sexual expressions, sexual relations,sexual identities and the disparity in role gendered sexuality [3]. Despite the revolution inknowledge through the use of the internet, media and educational achievements; promiscuity,transactional sex, and sexual-economic exchange, particularly among young people, peoples’behaviours are the by-product of the traditional beliefs on masculinity and provide insights intowhy males are less likely to engage in healthy lifestyle practices and more likely to be involvedin risky sexual behaviours than females. In a three-island study, Chevannes [1] noted that malesare given sexual freedom, sexual autonomy and sexual promiscuity is a part of the social setting.Thus, traditional masculine ideology is such that it retards healthy lifestyle choices and promotepremarital sexual behaviour among males, which is not supposed to be the case among females.These cultural values and social settings in the Caribbean as well as many African nations aresuch that they foster public health problems such as HIV/AIDS infections, other sexuallytransmitted infections and multiple sexual relationships. Douglas posited that the major cause of mortality among women aged 15-44 years in theCaribbean is AIDS (acquired immunodeficiency syndrome), and that 1 in every 50 Caribbean 247
  • national was infected with HIV (human immunodeficiency virus)/AIDS [4]. Another study notedthat “the HIV epidemic in Latin America is highly diverse. Several Caribbean island states haveworse epidemics than any country outside of sub-Saharan Africa.” [5] In 2007/2008, Wilks et al.conducted a study of some 2,848 Jamaicans between the ages of 15-74 years and found thatsexually transmitted infections (STI) is greater among males (18.1%) than females (11.0%) [6],which demonstrates some aspect to the beliefs of the masculinity ideology and its influence onchoices and health status. Greater promiscuity among males than females was noted by Wilks etal [6] who found that 41% of males had 2+ partners compared to 8.4% of females, and again thisreinforces the risk-taking behavioural lifestyle of males, which emerged from the traditionalmasculinity ideology. With human immunodeficiency virus (HIV) being the second leading cause of mortalityin the world [7-9], the first in the Caribbean (among 15-49 year olds) [10], the fact that 48.7% ofyoung males aged 15-24 years reported having multiple sexual partners (2+) compared to 15.2%of females of the same age, and 42.4% of young males had sex once per week compared to 41%of their female counterparts, the reality that sexual relation is primarily the medium throughwhich most people contract HIV/AIDS [5], promiscuity among young people must becomprehensively examined in order to effectively guide public health planning in addressingthose realities. While culturally Jamaican females with multiple sexual partners have been called names,including whores, prostitutes, promiscuous, commercial sex workers and ‘bitches’, males whopractice the same lifestyle are called macho, ‘gallis’, ‘girlie-girlie’ and these convey positivecosmologies. They are also called womanizers, but not the number of negative constructionswhich are ascribed to females who are engaged in multiple relationships or in promiscuous 248
  • activities. This is a cultural bias which demonstrates male power, male dominance in ideology,and the cultural disparities between the sexes with regard to sexuality. The cultural bias with regard to sexuality is captured in a study conducted by Eversleyand Newstetter [11] and consequences of respondents’ actions were noted in the findings.Eversley and Newstetter [11] that found “…females who are exposed to multiple partners dohave a significantly higher chance of encountering a male in a high risk category...” [11]. Yet,males are alluded for their sexual prowess, and females decried for their socially unacceptableand ‘whoring’ behaviour. Undoubtedly from the aforementioned studies, in 2007, with Jamaica’syouth’s population being about 20% [12], an extensive literature search revealed no empiricalevidences that have examined the reproductive health behaviour of youths with multiple sexualpartners. However, studies have examined commercial sex workers [13-15]; inconsistent use[16]; early sexual initiation [17]; multiple sexual partners [18-20], trends in HIV risk perception,condom use, sexual history, HIV testing and sexual behaviour [21-23], but in Jamaica there arepaucity of studies among youths in multiple sexual relationships on their reproductive healthbehaviour. Studies which have investigated those whom have multiple sexual partners [24-26] havefailed to explore (1) characteristics of young adults with regard to them having sexual intercoursewith recent, next recent and second next recent partner;(2) consistent condom usage in multiplesexual relationships; (3) number of sexual partners over different time intervals; and (4) factorswhich account for consistent condom usage. Thus, this research seeks to elucidate (1)characteristics of young adults with regard to them having sexual intercourse with recent, nextrecent and second next recent partner;(2) consistent condom usage in multiple sexualrelationships; (3) number of sexual partners over different time intervals; (4) factors which 249
  • account for consistent condom usage, and (5) factors which account for why people havemultiple sexual concurrent relationship.MethodSample The current study extracted a sample of 274 participants aged 15-24 years old, from anationally representative survey, who indicated having had 2+ sexual partners [27]. The survey(HIV/AIDS/STD National KABP) comprised 1,800 participants 15-49 years of age who residedin Jamaica at the time of the survey (May-August, 2004). The data was collected by HopeEnterprises Limited on the behalf of the Ministry of Health. A multi-staged sampling design wasused to collect the data. Each of the 14 parishes in the country is stratified into electoralconstituencies, with each constituency stratified into three areas – rural areas, parish capitals(urban areas) and main towns (semi-urban areas). The areas which comprised a constituencywere then stratified into primary sampling units (PSUs) or electoral enumeration districts (EDs). A random sample of each PSU was then selected based on probability proportional to size(PPS). Seventy-two EDs were selected for the study – 23 EDs in the urban areas, 25 EDs in thesemi-urban areas, and 24 EDs in the rural areas. Twenty-five households were systematicallychosen from each ED, and cluster sampling was carried out with all the people living in thehousehold of the designated ages interviewed for the survey [27].Data sources A questionnaire was used to collect the data from the participants. Trained interviewers usedface-to-face interviews to collect the data. The interviewers were trained for a 5-day period, ofwhich 2 days were devoted to field practices. Interviewers were assigned to a team comprisingtwo females, two males and a supervisor. Verbal consent was sought and given before the 250
  • interviews commenced. The participants were informed of their right to confidentiality and theirright to stop the interview at any time. No names, addresses or other personal information wascollected from the participants to ensure anonymity. The instrument used in the survey utilizedindicator measures and definitions consistent with UNAIDS and the USAID Priority PreventionIndicator [27].Statistical methodsThis study used the Statistical Packages for the Social Sciences (SPSS) for Windows, Version16.0 (SPSS Inc; Chicago, IL, USA). Frequencies and means were computed on thesociodemographic characteristics. Chi-square tests and F-tests were performed to evaluateassociations and differences among mean scores. Stepwise multiple logistic and multiple linearregressions were used to analyze factors that explain consistent condom usage and why peoplehave multiple sexual concurrent relationships. Odds ratios were determined from the use of abinary logistic regression model, and r-square for the weight of each significant variable in themultiple linear regressions. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the finalconstruction of the model. To derive accurate tests of statistical significance, the researcher usedSUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), andthis was adjusted for the survey’s complex sampling design. A P-value < 0.05 (two-tailed) wasused to determine statistical significance.MeasurementAge is the number of years a person is alive up to his/her last birthday (in years). Contraceptivemethod is any device or approach that is used to prevent pregnancy. These methods include tuballigation, vasectomy, implant (Norplant), injection, emergency contraceptive protection, pill, 251
  • condom, foaming tablets, creams, jellies, diaphragm, abstinence, withdrawal, the rhythm method,and calendar or Billings (1= yes, 0 = otherwise). The dependent variable for this study was acontraceptive method which was coded as a binary variable from those who indicated yes to anyof the afore-mentioned methods of contraception. Consistent condom usage is taken from thequestion “How often did you use a condom with this person over the last 12 months?” Theresponses ranged from every time, most times, occasionally and never. Consistent condom usagecomprised of only those who chose every time (1= yes or consistent use, 0 = otherwise).Education is taken from the question, ‘How many years did you attend school?’ This is coded asprimary or below (0 – 9 years), secondary (10-12 years) and tertiary (13+ years). Shared facilityis taken from ‘Are these [sanitary conveniences] shared with another household? The options areshared, not shared or not stated. This was coded as 1 = shared and 0 = otherwise. Number ofsexual partners is taken from the question, ‘With how many persons have you had sex duringthe: (1) last 4 weeks, (2) last 3 months, and (4) last 12 months? Age of sexual debut or firstsexual intercourse (or initiation) is taken from the question “At what age did you first have sex?”Responses were recorded in years. Sexually transmitted infections (STIs) recorded from “Haveyou ever had an STI (sexually transmitted infections)?” (1=yes, 0 = otherwise). HIV infectionwas measured using “Did you go back for the results yourself or were you contacted by a healthworker?” If the individual indicated that he/she was contacted by a health worker, this was usedto indicate a positive HIV result (1= HIV infected, 0 = otherwise). Early sexual initiation (ordebut, intercourse) is having sexual relations before ones 18th birthday (i.e. legal age ofindividual consent on sexual practices).Analytic models 252
  • Using logistic regression, this study seeks to examine factors associated with consistent condomusage among young Jamaican adults aged 15-24 years old. Different social factors influenceyoung people’s choices, and their decision to consistently use a condom. This study used Bourneet al.’s model [28], which established a connection between social variables and contraceptionusage among women, using econometric analyses. In keeping with the age cohort, Bourne et al.’smodel has been modified to reflect those factors that are likely to influence consistent condomusage. The current research will use the theoretical framework of Bourne et al.’s econometricanalysis to examine factors that are associated with the consistent condom usage among youngpeople aged 15-24 years in Jamaica. The variables used in this econometric model are based onthe literature as well as the dataset. The researcher will test the hypotheses that (1) consistentcondom usage among young people aged 15-24 years is determined by particularsociodemographic variables, and (2) Sociodemographic correlates of number of sexual partnersin the last 3 months. Based on the literature, the following variables were examined using logistic regression:Dependent – consistent condom usage. 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; forced to have sex; had STI; age of first sexualrelations; currently had sexual intercourse in the last 30 days; number of sexual partners;religiosity; currently in a sexual union; hearing family planning message; age at which beganusing contraceptive method; involvement in family planning programme, chance of contractingthe HIV virus, and having had sexual intercourse in the last 30 days. 253
  • The second analytic model used stepwise multiple linear regressions to examine factorswhich account for number of multiple sexual relationships. Bourne et al.’s model [28], whichestablished a connection between social variables and contraception, was used to establish thismodel. The dependent variable was logged by number of sexual partners (2+ partners) in the last3 months, and this was done in order to remove the skewness in the variable.ResultsTable 10.1 presents demographic characteristics of the study population. A sample of 247individuals was used for this study, representing 13.7% of the survey from which the sub-samplewas extracted. The findings revealed that consistent condom usage was high among the sample(74.3%; males, 77.3%; females, 61.7%) and that 4.3 times more young males indicated having2+ sexual partners compared to females. Of the study population, 22% had done a HIV test in thelast 12 months. Two percentage of the sample had positive HIV results, which represents 9.3%of those who were tested for the virus. Only 9.1% of young adults with multiple sexual partnersindicated having been engaged in commercial sexual encounters. Although the mean age of thosewho had their first sexual intercourse was 13.3 years, 36% had this experience before 13 years. Of those who indicated that they consistently used a condom, 50% of them stated theyhad no chance of contracting the HIV virus, 28.6% said they had a low chance, 9.5% mentioneda moderate chance and 11.9% reported a high chance. Furthermore, there was no statisticalassociation between consistent condom usage and HIV status (χ2 = 0.142, P = 0.706): 11.4% ofthose who consistently used a condom were HIV-positive compared to 7.7% of the inconsistentcondom users. Forty percentages of HIV-positive young adults were 24 years, the samepercentage was 18-20 years, and 20% were 15-17 years. 254
  • The occupational statuses of the study population were domestic helper (or officeattendants), 50.5%; security guards, hairdressers, taxi drivers, machine operators, andcosmetologists, 29.7%; labourers, construction workers or farmers, 9.8%; managers, assistantmanagers, and entrepreneurs 1.0%; supervisors and accountants, 3.0%; teachers, police officers,nurses or nurse technicians, 3.0%; and no response, 3.0%. Almost 4% of the men were engaged in homosexual relationships, 0% bisexual and 96%heterosexual relationship. Among the females, 11.4% were lesbians, 4.5% were bisexual and84.1% were in heterosexual unions. Substantially more men were in heterosexual unions thanfemales, and more females in homosexual relationships compared to females and this was alsothe case in bisexual unions (χ2 = 155.9, P < 0.0001). A cross tabulation between educational status and gender of respondents showed nostatistical association (χ2 = 1.8, P = 0.41). All the HIV-positive cases were reported by young males. Of those who were HIV-positive, 60% stated that they had no chance of contracting the virus and 40% indicated that theyhad a little chance. And all the respondents had sexual intercourse in the last 30 days. Table 10.2shows information on HIV status, commercial sex workers, sexually assaulted individuals,condom usage, chance of contracting HIV, STI and employment status by sex of respondents.The findings revealed that young adult females were 2.4 times more likely to reported havinghad a STI than males. Figure 10.1 shows the number of sexual partners of the study population over differenttime periods. Moreover, there are young adults who have had sexual intercourse with more than15 individuals in the last 12 months (3.6%), 3 months, 1.2%, and 0.4% in 12+ months. 255
  • Figure 10.2 shows individual who are having sexual intercourse with most recent, nextmost recent and second next most recent partner by gender and total. Almost 48% of the sampleindicated having sexual relations with most recent partner, 37.2% with the next most recentpartner and 37.6% with the second next most recent partner. There were no significant statisticalassociation between having sex with recent partner and gender of respondents (χ2 = 0.29, P =0.593) and having it with the second next most recent partner and gender (χ2 = 1.17, P = 0.280).However, there existed a significant statistical association between having sex with the next mostrecent partner and gender of respondents (χ2 = 6.2, P = 0.013). Furthermore, statistically morefemales were having sexual intercourse with their next most recent partner (53.3%) compared tomales (33.5%). Males were significantly more likely to indicate consistent condom usage (77.3%) thanfemales (61.7%; χ2 = 4.8, P = 0.028). On the other hand, no statistical association existedbetween an individual reporting that his/her partner has other partner(s) and gender ofrespondents (males, 55.2%; females, 58.8%; χ2 = 0.15, P = 0.700). When the aforementionedwas disaggregated by frequency of condom usage, 54.6% of males who indicated that theirsexual partner(s) had consistently used a condom compared to 52.2% of females (χ2 = 0.04, P =0.880). Cross tabulations between condom usages last time had sexual intercourse withfrequency of condom usage, and condom usage first time had sexual intercourse with currentpartner by frequency of condom usage showed statistical associations. Ninety-three percentagesof those who indicated consistent condom usage, used one the last time they had sexualintercourse compared to 58.9% who reported inconsistent condom usage (χ2 = 42.4, P < 0.0001).Likewise 89% of those who indicated consistent condom usage used one the first time with their 256
  • current partner compared to 15.9% of those who stated inconsistent condom usage (χ2 = 119.0, P< 0.0001). An examination between frequency of condom usage (i.e. consistent and inconsistentusage) by age cohorts of respondents revealed no statistical association (χ2 = 5.2, P = 0.160).However, 78.8% of individuals aged 15-17 years consistently used a condom compared to 79.8%of those 18-20 years; 70.0% of those aged 21-23 years and 63.6% of those aged 24 years. Of those who had sexual intercourse with their most recent partner, 42.5% of themconsistently use a condom compared to 32.8% of those who had sexual relations with their nextmost recent partner and 33.1% with their second most recent partner. Furthermore, Figure 3shows consistent condom usage by particular typology of sexual relationship controlled forgender of respondents. Of those who consistently used a condom with their most recent partner,41.4% were females compared to 42.8% males. Figure 10.4 presents information on occasion with which an individual indicating havingsexual relations at particular time, with a typology of partner by gender of respondents. Thefindings revealed that condom usage declines over time with any typology of relationships.Furthermore, condom usage falls more substantially for females among the typology of partnerand occasion of sexual activity compared to that of males (Figure 4). Table 10.3 presents information on positive HIV test results, commercial sex encounter,sexual violence, consistent condom usage, ever had STIs, employment status and risk ofcontracting HIV by age cohort controlled for by gender of respondents. Using logistic regression analyses, only one variable emerged as statistically significantexplanation of consistent condom usage with respondents’ current partners (Table 10.4): age ofrespondents (OR = 0.80, 95% CI = 0.68 – 0.94; Model chi-square = 23.2, P = 0.039). The model 257
  • had statistically significant predictive power (Hosmer and Lemeshow goodness of fit test, χ2 =4.4, P = 0.819), and correctly classified 78.0% of the sample. Table 10.5 presents information on the explanatory factors which account for number ofsexual partners of an individual with multiple concurrent sexual partners.DiscussionThe findings revealed that 74.3% of the sample consistently used a condom, and that this wasgreater among males (77.3%) compared to females (61.7%). However, consistency in condomusage was lower with having sexual intercourse with most recent partner (42.5%), next mostrecent partner (32.8%) and second next most recent partner (33.1%) compared to current partner.Consistent condom usage was only greater for females having sexual relations with their nextmost recent partner (60.7%) than males in the other partnership typology. Four and 3-tenth timesmore young males indicated having 2+ sexual partners compared to females. Of the studypopulation, 22% had done a HIV test in the last 12 months. Two percentage of the sample hadpositive HIV results, which represents 9.3% of those who were test for the virus. Only 9.1% ofyoung adults with multiple sexual partners indicated having been engaged in commercial sexualencounters. Twenty-two out of every 100 of the respondents had done a HIV test, and only10.2% of those tested had positive HIV test results (i.e. 2% of the sample). HIV is the second leading cause of mortality in the world [7-9] and one group of scholarsopined that it was the first in the Caribbean among 15-49 year olds [10]. With the currentfindings revealing 1 in every 50 young adults aged 15-24 years had positive HIV results, whichis equally comparable that for the Caribbean [4] and for the adult population in Jamaica [29],young adult promiscuity is, therefore, a public health challenge. Statistics from the Jamaican 258
  • Ministry of Health showed that 19.8% of Jamaicans aged 10-29 years have been infected withthe HIV virus compared to 33.4% of those aged 30-39 years, 22.6% of those aged 40-49 years,which are greater than that for this sample. Unlike the Jamaican Ministry of Health publishedstatistics on HIV-positive individuals, the present work disaggregated ages 15-24 years andrevealed that 20% of the HIV-positive individuals were 15-17 years. It should be elaborated herethat 60% of HIV-positive young adults had stated that they had no chance of contracting thevirus, while none of the high risk individuals reported having the virus. There are a plethora ofreasons; including sexual naivety, consequence of inconsistent condom usage, a single sexualencounter with an exposed individual without a condom and correctness of condom usage, thatare factors which can account for the high HIV-positive cases among those who thought they hada no-to-low chance of contracting the virus. Although positive HIV results are low among promiscuous young adults aged 15-24years, with mean age of first sexual intercourse being 13.3 years (SD = 2.7 years), which concurswith the literature that early sexual initiation commences during adolescence [25, 26, 30], andthe fact that early sexual relation is positively associated with a high probability of contractingSTIs [31,32], it follows that the risky behaviour will eventually result in an increase in teenagepregnancies, STIs, HIV/AIDS and other public health problems will abound if age of first sexualintercourse is not increased and condom usage is not consistently used among this cohort. WhileYan et al’s work showed that age of coitus commenced in the later adolescence years amonguniversity students in China (18.7 years) and that 5.3% were engaged in multiple sexualrelationships [25], this study revealed that Jamaican adolescents began having sex 5.4 years earlyand 2.6 times more likely to be involved in polygamous relationship. However, multiple sexualrelationships were about the same among young adult Jamaicans and US adolescents [24]. 259
  • Another disparity between undergraduate Chinese students and young adult Jamaicans aged 15-24 years was that the former reported a greater inconsistent condom usage (38.6%) [25]compared to the latter (25.7%). Based on the aforementioned findings, there are evidences tosupport a present public health problem as 10.2% of those who have had a HIV test in this studyhad a positive test result compared to 3.6% of the adult Jamaican population according to theJamaican Ministry of Health [29]. Clearly this work reinforces and highlights the traditional masculinity ideology which isaccepted as the natural state of affairs in many Caribbean societies. It is this masculine ideologywhich accounts for even male youths more likely to have multiple concurrent sexualrelationships than females, based on disparity in social construction of gender roles. Within thisculture, young males who become engaged in multiple sexual relationships are lauded for theirsexual prowess, but this is not the same for their female counterparts. A part of the justificationof this promiscuity among males is embodied in them seeking to prove their manhood, coming ofage, and these account for the risk taking behaviour that they will become involved in onlybecause of the constructions of masculinity in the society. The risk taking behaviours whichemerged from the present work are the multiple sexual partners, inconsistent condom usage, andtransactional sex. More young adult males used a condom than their female counterparts as wellas a greater percentage of them reported consistent condom usage among most typology ofsexual partnerships. The care with which the males are engaged is demonstrated in fewer of themreporting having had STI (12.2%) compared to 29.8% of females. However, all the HIV-positivecases were reported by young males, supporting the strong association between promiscuity andcontracting the AIDS or HIV virus. 260
  • Males’ promiscuity is more guarded away from contracting a STI, but not HIV comparedto females. Unlike their young male counterparts, young females who are economicallydisadvantaged are engaged in sexual-economic exchange, this is rarely defined as prostitution,sex work or commercial sex activities. The sexual-economic exchange with which these youngfemales are engaged means that their sexual partners determine choice of family planning, use ofmethod of contraception and consistency of usage in exchange for material, luxurious, othergoods (including “basic” items such as groceries, housing, electricity, and clothes as well aseducational expenses, et cetera), and security (i.e. social status). The evidence unequivocally states that young males are involved in multiple sexualrelationships than young females; females in this study are less economically independentcompared to males, which reduces their sexual autonomy. The findings highlighted that 6.4 timesmore young males had full-time employment than females and that 1.8 times more young maleswere employed on a part-time basis compared to females. Clearly being employed provides somelevel of economic independency which is more a case for the males, and therefore the femalesmust leave the vetoing power of reproductive health matters to their males partners, which givespower to the males in this sample compared to their female counterparts. Herein is a subtle maleauthorization of family planning measures which reside with males, while its removal willincrease contraception usage as was observed in Ethiopia [33], such a reality is unlikely withouteconomic independency, and higher level of education. On average, young males begin theirsexual debut about 2 years earlier than young females, but because of economic independencythey are able to stipulate condom usage which is reduced among females. Thus, the health risk ofyoung males is greater even though they have a high consistent condom usage, and so traditional 261
  • masculine ideology of having many children, male dominance and prowess are responsible forthis high HIV prevalence among than young females. Young males are not necessarily more knowledgeable about reproductive health matters,less sexually active or more conscious on sexually transmitted infections than young females, soto argue for the introduction of a campaign to promote responsible sexual behaviour [34] will notalleviate, abate or reduced the high prevalence of STIs among young females compared to males.The reality is they (males) are having sexual intercourse at an early age, consistently usingcondoms more than their females’ counterparts, which means that any behavioural modificationamong young females must to tied to education as this has been found to positive reduce fertilityamong women [35]. This brings into question, access to methods of contraception for minors anda change in attitude of health practitioners in providing them with family planning choices as aresult of the reality of these findings. The realities are 29.8% of young females aged 15-24 yearshave had a STI compare to 11.0% of females aged 15-74 years [6], and that 12.2% of youngmales (ages 15-24 years) indicated having had STI compared to 18.2% of males aged 15-74years [6]. Interestingly 14.3% of the study population had been sexually assaulted, 23.0% werefemales and 12.2% were males, indicating the vulnerability of young males to sexual violenceand particular health outcome which emerged from the present findings. Another fact which wasunearthed in this research is the vast disparity between those who consistently and inconsistentlyuse a condom and those having had a STI. Almost 2 times more young adults who inconsistentlyuse a condom reported having had a STI compared to those who consistently use one, and thesewere mostly economically deprived young females who are unemployed, and social vulnerable. In Jamaica, public health intervention programmes are primarily responsible for thedrastic reduction in total fertility rates from 6.0 children per women in 1960, 5.5 children per 262
  • women in 1970, 3.5 children per women in 1983 to 2.5 children per women in 2006 [12, 29, 36,37]. Undoubtedly the contributions of the Jamaican Ministry of Health and the JamaicanNational Family Planning Board are paramount to the aforementioned lifestyle practicemodifications, and increases in method of contraception usage that are the crux of decline infertility. The present findings revealed that 35 out of every 100 young adults with multiple sexualpartners begin having sex before 13 years, and that more young males (15-24 years) reportedhaving STI compared to men (15-74 years). Interestingly what emerged from this work is that 99.8% of the study population has hadat least secondary level education, all respondents indicated being knowledge of HIV and AIDS,yet these individuals practice risky behaviour. All this time, public health interventions seem tohave done very little towards the continuous lowering of the age of sexual debut, and increases inSTIs, particularly HIV among Jamaican youths. It is an undeniable fact that there are someeconomically vulnerable groups such as children, elderly, orphans in the society as well as vasteconomic disparity between the sexes [38, 39]; the evidence supports a very limited success forpublic health intervention programme as it relates to aforementioned findings. Like Forrester[40], the researcher wonders whether the evidences are not (something missing) in thatdemonstrate the need for public health practitioners to change their modus operandi asindividuals may not like the strategies used, want the product offerings, dislike how programmesare implemented, and that the strategies are bi-dimensional, regardless of the glowing benefits. A finding which cannot be understated here which emerged in this work is the negativeassociation between being in a stable union and number of multiple concurrent partners. It can beextrapolated from this finding that young people are searching for stability in a sexual union, andso short term relationship (visiting) is not finality, therefore the individuals continue to be 263
  • engaged in many sexual relationships before a stable union is attained. Marriage has many socio-economic securities and with women entering into it earlier than men [41,42], the price of thissecurity is reduced sexual autonomy, family planning choices and men being given the vetoingpower over reproductive health matters. The men, on the other hand, are allowed the choices ofnumber of fertility, condom usage, less multiple concurrent sexual relationships by their partnersand a domesticated woman. The gendered-(socio-economic)-asymmetric position of young females in Jamaica meansthat they are in a weaker negotiation state than males in a sexual relationship. This unmatchedeconomic situation allows the males to dictate many issues including reproductive health mattersin relationship, which are adhered to by the young females as they seek to satisfy needs, desiresand security. Despite the gendered-(socio-economic) disparity and the reduced sexual rightsowing to the inequalities, it does not hold true that young females totally subscribed to themasculine ideology or their weakened position make them submissive to the dictates of themales. The positive association between one partner having other partner and the individualhaving multiple sexual partners is an indication that females are departing from the masculineideology and seeking other avenues to supply their needs, desire and independency. The realityhere is that multiple sexual relationships are begetting other such encounters, which is a make forthe furtherance of not only promiscuity, but also STIs, particularly HIV/AIDS.ConclusionThe evidences are in on the sexual behaviour of young adults who have multiple sexual partners.The findings provide a comprehensive understanding of the risky behaviour and choices ofyoung people, and the results can be used to change young people’s engagement in multiple 264
  • sexual encounters and reproductive health matters. Understanding the behaviour of theseindividuals is the first defense in the way forward, and how intervention strategies should becoalesce with the present realities in order to effectively address the public health challenge thatemerged from this work. With regard to the sexual behaviour and reproductive health matters of young adults aged15-24 years in Jamaica, these individuals have developed an elaborate set of ideas aboutsexuality and their sexual roles long before the adolescence years. The culture is responsible forthe masculinity ideology and sexual script that are given and followed by young adults. Thus thecontinuous lowering of age of sexual debut is simply a bi-product of the glorification of sex andintimacy. The young adult is forwarded with dual messages as to sex, infertility, abstinence, anda macho ideology which embodies promiscuity, fertility, risk taking and the social disabilitybiases against homosexuality. Young males do not want to be seen as homosexuals, whichdictate their promiscuity with females, fertility, and inconsistent condom usage. The next side tothis reality, they are expected to abstain from sexual activity, consistently use a condom, and nothave children. While the society condemns high fertility and promiscuity among females, there isa paradox in that multiple sexual relationships are looked down upon for females; yet youngwomen and men are subtly pressured psychological to have more than one child and adopt thesexual script that is laid out for them. The findings are astounding and must be used by public health policy practitioners.Merely using social marketing programmes in the media on reproductive health matters toaddress risky sexual behaviour, and consequences of inconsistent condom usage are wellexpounded upon, economically vulnerable young females will always leave reproductive healthmatters to their males’ partners because of financial inadequacies. The gender economic- 265
  • differential, thus, is resulting in risky sexual behaviour as young vulnerable females as well asmales are expected to follow the script of morality during food, material and social deprivation.The masculinity ideology forms the platform for the sexual script used by young men, and thesemust be incorporated into any intervention strategies. In summary, the culture is the backdrop that fashions sexuality, sexual behaviour,reproductive health and risky behaviour among young adults who are engaged in multiple sexualrelationships. Clearly, sexual naivety and perception about risk factors are accounting for thehigh prevalence of HIV virus in young adults who have multiple sexual partners. Economics isimportant to women, which means that young adult females are trapped by economic deprivationand this justifies their higher inconsistent condom usage than young males. Public health needsto coalesce economics, educational advancement, and the findings that emerged from this studyin order to adequately change the exhibited behaviours. As young adult Jamaicans are fueling theHIV/AIDS epidemic, reducing the multiple concurrent sexual relationship, premarital sexualactivities, and increasing consistency of condom usage as well as educating them on sexualpractices, proper usage of the method of contraception, and counseling them about HIV testingare the realities on moving forward. There is a need to oppose, revamp and modernize themasculine ideology that encourage multiple concurrent sexual relationship as this as well aseconomic deprivation is account for the public health challenge of increased HIV/AIDS, otherSTIs, increased health budget and mortality in developing countries’ population. Genderedimbalance in power must be brought into the strategies to address HIV, promiscuity and sexual-economic exchanges among young people in Jamaica.Disclaimer 266
  • The researcher would like to note that while this study used secondary data from the JamaicanMinistry of Health (KABP Survey), none of the errors in this paper should be ascribed to theMinistry of Health and/or Hope Enterprise Limited, but to the researcher. 267
  • References 1. 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. 2. Murray D. Positively limited: Gender, sexuality and HIV and AIDS discourses in Barbados. In: Barrow C, de Bruin M, Carr R. eds. Sexuality, social exclusion and human rights: Vulnerability in the context of HIV. Kingston: Ian Randle; 2009. 3. Barrow C. Caribbean Gender Ideologies: Introduction and Overview. In: Barrow C. Ed. Caribbean Portraits: essays on Gender Ideologies and Identities, Kingston, Jamaica: Ian Randle Publishers; 1998. pp.xi-xxxviii. 4. Douglas DL. Perspectives on HIV/AIDS in the Caribbean. In: Morgan O. ed. Health issues in the Caribbean. Kingston: Ian Randle; 2005:pp. xv-xxi. 5. Barnett T, Whiteside A. AIDS in the twenty-first century: Disease and globalization. London: Palgrave MacMillan; 2002: p.11. 6. 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. 7. Population Action International. A Measure of Survival. Calculating Women’s Sexual and Reproductive Risk. Washington DC: Population Action International; 2007 8. World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009. 9. Rawlins J, Crawford T. Women’s Health in the English-Speaking Caribbean: The Case of Trinidad and Tobago. Journal of Social and Economic Studies; 2006; 55:1-31. 10. Camera B, Lee R, Gatwood J, et al. The Caribbean HIV/AIDS epidemic epidemiological status: Success stories—a summary. CAREC Surveillance Report (CSR), 2003; 23:1–16. 11. Eversley RB, Newstetter A. AIDS risk among women with multiple sexual partners: HIV risk screening data from a family planning population. Int Conf AIDS 1989; 5:750. 12. Statistical Institute of Jamaica (STATIN). Demographic statistics, 2007. Kingston; 2008. 13. Duncan J, Gebre Y, Grant Y, et al. HIV prevalence and related behaviors among sex workers in Jamaica. Sexually Transmitted Diseases 2010; 37:306-310. 14. Kishore J, Joshi TK. Health status and health seeking behaviour of male workers in Delhi. Indian J Community Med 2001; 26:192-917. 15. Elmore-Meegan M, Conroy RM, Agala CB. Sex workers in Kenya, numbers of clients and associated risks: An exploratory survey. Reproductive Health Matters 2004; 12:50- 57. 16. George C, Alary M, Otis J. Correlates of sexual activity and inconsistent condom use among high-school girls in Dominica. West India Med J 2007; 56:433-438. 17. Coker AL, Richter DL, Valois RF, et al. Correlates and consequences of early initiation of sexual intercourse. J Sch Health 1994; 64:372-377. 18. 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. 19. Shelton JD. Why multiple sexual partners? Lancet2009; 374:367-369. 20. Santelli JS, Brener ND, Lowry R, et al. Multiple sexual partners among U.S. adolescents and young adults. Fam Planning Perspective 1998; 30:271-275. 21. Norman L, Figueroa JP, Wedderburn M, et al. Trends in HIV risk perception, condom use and sexual history among Jamaican youth, 1996-2004. International Journal of Adolescent Medicine and Health 2007; 19: 199-207. 268
  • 22. Hendriksen ES, Hlubinka D, Chariyalert S, et al. Keep talking about it: HIV/AIDS- related communication and prior HIV testing in Tanzania, Zimbabwe, South Africa, and Thailand. AIDS and Behavior 2009; 13: 1213-1221.23. Jamaica, National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston; NFPB: 2004.24. Santelli JS, Brener ND, Lowry R, et al. Multiple sexual partners among US adolescents. Fam Planning Perspect 1998; 30:271-275.25. 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; 9:305.26. Shelton JD. Why multiple sexual partners. Lancet 2009; 374:367-369.27. Hope Enterprise Limited. HIV/AIDS Knowledge, Attitudes and Behaviour Survey, 2008. Kingston: Jamaica, Ministry of Health, National HIV/STI Programme; 2008.28. Bourne PA, Charles CAD, Crawford TV, et al. Current use of contraceptive method among women in a middle-income developing country. Open Access J Contraception 2010; 1:39-49.29. Jamaica, Ministry of Health (MoHJ). Annual report, 2006. Kingston; MoHJ: 2007.30. Resnick M, Bearman P, Blum R, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. JAMA 1997; 278:823-832.31. Andersson-Ellstrom A, Forssman L, Milsom I. Age of sexual debut related to life-style and reproductive health factors in a group of Swedish teenage girls. Acta Obstet Gynecol Scand 1996; 75:484-489.32. Coker AL, Richter DL, Valois RF, et al. Correlates and consequences of early initiation of sexual intercourse. J Sch Health 1994; 64:372-377.33. Cook RJ, Maine D. Spousal veto over family planning services. Am J Public Health 1987; 77:339-343?34. Hernandez-Giron CA, Cruz-Valdez A, Quiterio-Trenado M, et al. Factors associated with condom use in the male population of Mexico City. Int J STD AIDS 1999; 10:112-117.35. Martin TC, Juarez F. The impact of women’s education on fertility in Latin America: Searching for explanations. Int Fam Planning Perspect 1995; 21:52-57.36. Statistical Institute of Jamaica (STATIN). Statistical Digest 1960-1992. Kingston; STATIN: 1961-1993.37. Statistical Institute of Jamaica (STATIN). Demographic statistics, 1970-2006. Kingston; STATIN: 1971-2007.38. Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 1989-2007. Kingston; PIOJ, STATIN: 1989-2008.39. Planning Institute of Jamaica (PIOJ). Social and Economic Survey of Jamaica, 1980- 2008. Kingston; PIOJ: 1981-2009.40. Forrester C. Marketing public health: Can you hear me? In: Bacallao J, Pena M, Kidd E, et al. eds. Proceedings of the 8th International Conference on Diabetes and Obesity. UDOP/PAHO, Ochi Rios, Jamaica. 7 March 2002; pp 50-60.41. Cremin I, Mustati P, Hallett T, et al. Measuring trends in age at first sex and age at marriage in Manicaland, Zimbabwe. Sex Tranm Infect 2009; 85:i34-i40.42. Bourdillon MFC. Where are the ancestors: Changing culture in Zimbabwe. Harare: University of Zimbabwe; 1993. 269
  • Table 10.1: Demographic characteristics of study population, n = 247Characteristic n %Sex of respondents Male 200 81.0 Female 47 19.0Educational level Primary or below 2 0.8 Secondary 225 91.1 Tertiary 20 8.1Union status Married or common law 21 8.5 Visiting 183 74.1 Single 43 17.4Commercial sex worker Yes 22 9.1 No 219 90.9Current partner has other partner(s) Yes 114 55.9 No 90 44.1Sexually assaulted (ever) Yes 29 14.2 No 175 85.8Ever had sexually transmitted infections (STIs) Yes 38 15.5 No 206 84.4Ever done a HIV test Yes 54 22.0 No 192 78.0Positive HIV test result of those tested Yes 5 9.3 No 44 81.4 Did not respond 5 9.3Condom usage (with current partner) Inconsistent usage 182 25.7 Consistent usage 63 74.3Was HIV testing done in last 12 months Yes 35 64.8 No 19 35.2Age of respondents mean (SD) 20.0 years (2.8 years)Age of first sexual debut mean (SD) 13.3 years (2.7 years) 270
  • Table 10.2: Particular socio-demographic and reproductive health variables by sex of respondents, n = 247Characteristic Male Female P value 2Positive HIV test results n (%) n (%) χ = 2.7, P = 0.100 No 28 (84.8) 16 (100.0) Yes 5 (15.2) 0 (0.0)Commercial sex encounter (or worker) χ2 = 0.53, P = 0.468 No 175 (90.2) 44 (93.6) Yes 19 (9.8) 3 (6.4)Sexually assaulted (ever) χ2 = 3.9, P = 0.049 No 173 (87.8) 36 (76.6) Yes 24 (12.2) 11 (23.4)Forced someone to have sexual intercourse (ever) χ2 = 5.3, P = 0.021 No 156 (79.2) 44 (93.6) Yes 41 (20.8) 3 (6.4)Used a condom the first time with most recent partner χ2 = 6.6, P = 0.013 No 55 (27.6) 19 (40.4) Yes 144 (72.4) 28 (59.6)Little chance of contracting HIV χ2 = 4.6, P = 0.033 No 132 (71.4) 21 (53.8) Yes 53 (28.6) 18 (46.2)Ever had STI χ2 = 8.9, P = 0.003 No 173 (87.8) 33 (70.2) Yes 24 (12.2) 14 (29.8)Employment status Employed: χ2 = 20.1, P = 0.001 Full-time 55 (27.5) 2 (4.3) Part-time 39 (19.5) 5 (10.6) Unemployed 57 (28.5) 27 (57.4) Student 49 (24.5) 13 (27.7)Age at first sexual intercourse mean (SD) 13.0 years (2.8 years) 14.7 years (1.8 years) t-test = -5.1, P < 0.0001 271
  • Table 10.3: Particular socio-demographic and reproductive health variables by sex of respondents, n = 247Characteristic Age group (in years) Age group (in years) 15-17 18-20 21-23 24 15-17 18-20 21-23 24Positive HIV test results Male (in %) Female (in %) Yes 20.0 18.2 0.0 33.3 0.0 0.0 0.0 0.0Commercial sex encounter (or worker) Yes 4.8 4.2 19.0 15.8 0.0 0.0 12.5 20.0Sexually assaulted (ever) Yes 7.0 16.9 8.9 13.2 11.1 35.3 13.8 20.0Consistent condom usage Yes 79.1 83.3 77.3 64.1 77.8 64.7 50.0 60.0Used a condom on last sexual intercourse Yes 81.4 72.2 73.3 61.5 88.9 64.7 43.8 40.0Low chance of contracting HIV Yes 29.3 30.3 20.0 34.3 37.7 53.3 38.5 66.7High chance of contracting HIV Yes 9.8 1.5 25.6 28.6 12.5 13.3 23.1 0.0Ever had STI Yes 2.3 8.5 20.0 21.1 0.0 47.1 25.0 40.0Employment status Employed: Full-time 2.3 15.1 48.9 53.8 0.0 0.0 6.3 20.0 Part-time 2.3 23.3 22.2 28.2 0.0 11.8 6.3 40.0 Unemployed 14.0 45.2 24.4 17.9 11.1 64.7 81.3 40.0 Student 81.0 16.4 4.4 0.0 88.9 23.5 6.3 0.0 272
  • Table 10.4: Logistic regression analysis: Possible variable(s) which account for consistentcondom usage with current partner Variable Coefficient Std. error Odds ratio CI (95%) Age at sexual debut 0.02 0.08 1.02 0.87 - 1.19 Age of respondents -0.22 0.08 0.80* 0.68 - 0.94 Gender (1=males) 0.61 0.53 1.85 0.66 - 5.17 Ever had STI (1=yes) -0.47 0.69 0.62 0.16 - 2.41 Commercial sex worker (1=yes) 0.51 0.80 1.67 0.35 - 7.92 Partner have other partner (1=yes) 0.22 0.44 1.25 0.53 - 2.97 Religiosity (1=attend religious service at least once 0.63 0.46 1.88 0.76 - 4.64 per week) Married -1.01 0.96 0.36 0.06 - 2.36 visiting -0.80 0.69 0.45 0.12 - 1.71 Single 1.00 Tertiary -19.05 40192.98 0.00 0.00 – 0.00 Secondary -19.27 40192.98 0.00 0.00 – 0.00 Primary 1.00 Moderate chance of contracting HIV 0.29 0.91 1.34 0.22 - 8.06 High chance of contracting HIV -0.45 0.58 0.64 0.21 - 2.01 Low chance of contracting HIV 1.00*P < 0.05Model chi-square = 23.2, P = 0.039-2 Log likelihood = 144.4Nagelkerke r-squared = 0.213Hosmer and Lemeshow test, χ2 = 4.4, P = 0.819Overall correct classification = 78.0%Correct classification of cases of frequent condom usage with current sexual partner = 96.5%Correct classification of cases of non-frequent condom usage with current sexual partner = 21.6% 273
  • Table 10.5: Multiple linear regression: Explanatory factors of respondents of logged number of concurrent sexual partners in last 3months Unstandardized B Standard R2 changeExplanatory variable error CI (95%) Constant 0.59 0.13 0.32 - 0.85 Gender (1=males) 0.58 0.13 0.32 - 0.84 0.116 Partner having other partner(s) (1=yes) 0.39 0.11 0.18 - 0.59 0.079 Good chance of contracting the HIV virus 0.60 0.16 0.30 - 0.91 0.056 No chance of contracting the HIV virus (reference) Commercial sex worker 0.57 0.19 0.20 - 0.95 0.045 Married -0.41 0.20 -0.80 - -0.02 0.020 Single (reference)R-squared = 0.316F-statistic = 13.212, P < 0.0001 274
  • Figure 10.1: Number of sexual partners over different time periods (in %) 275
  • Figure 10.2: Having sexual intercourse with most recent, next most recent and second next most recent partner bygender and total. 276
  • Figure 10.3: Consistent condom usage with most recent, next most recent and second next most recent partner bygender and total. 277
  • Figure 10.4: Occasion having sexual intercourse with typology of partners and by gender of respondents 278
  • Chapter 11 Psychosocial correlates of condom usage in a developing countryPaul A. Bourne, Christopher A.D. Charles, Cynthia G. Francis, Maxwell S. Williams, Neva South-Bourne, Samuel McDanielIntroductionThis study examines the use of condoms among Jamaicans. In the 1960s, the total fertility rate inJamaica was 6.2 children per woman.1 During the 1970s, the introduction of family planning andcontraceptive methods in Latin America and the Caribbean saw a reduction in the generalfertility rate in Jamaica to 4.3 children per women. By 1999 it was 2.8 children per woman, andin 2007, the figure further declined to 2.4.1-3 Jamaica is not atypical in the reduction of its totalfertility rate as this is also the case in the Caribbean and the rest of the world.4,5 Globally,although the total fertility rate has been falling, the data revealed that it is averaging 5.2 childrenper woman in the least developed countries, and in excess of 5.5 children per woman in Eastern,Western and Middle Africa.5 Contraceptive methods such as the condom, pills, and injections areresponsible for the exponential decline in total fertility in Jamaica,1-3 Latin America and theCaribbean6-10 and internationally.11 Family planning and contraceptive methods, coupled withimprovements in sanitary and public health intervention, are also responsible for thedemographic transition towards the ageing of many societies in the developing world. InJamaica, contraceptive prevalence has increased from 38% between 1975-76 to 64% in 1997, 279
  • and 69% in 2007.2, 12 In spite of the wide access to contraceptive methods such as the condom,developing countries, in particular Africa and the Caribbean, have seen widespread increases inHIV, AIDS and/or STI infections, as well as adolescent pregnancy,12-15 all of which highlightinfrequency in condom usage in these societies. In response to public health concern about adolescents’ sexual behaviour, increased HIVamong this cohort, high promiscuity and fertility, some societies have used an abstinencecampaign on radio in the face of the current premarital sexuality. There is a topical debate whichlooks at whether adolescents should be provided with condoms and other forms of contraceptionor not. While the discourse sometimes takes a moral trajectory, the designers and debaters areolder than the cohort who are engaged in the various sexual acts, and have missed the sexualreality of the adolescents.16, 17 Hence, withholding methods of contraception from adolescents ormaking them feel embarrassed asking about or purchasing contraceptives will not make themcease their premarital sexual behaviour, reduce unwanted pregnancy, decrease STIs includingHIV and/or AIDs, and will definitely not influence them to get married and abstain from sexbased on the morals of the older generations. One study highlights the socio-sexual reality ofcontemporary society. The author found that in Jamaica “…the birth of a child decreases theprobability of a transition to more stable unions and at the same time decreases the probability ofa partnership terminating for women whose first union was a visiting one”.18 This findingemphasizes that some sexually active adolescents will use neither a traditional contraceptivemethod nor a modern one.19 HIV and AIDS infections mostly occur through sexual transmission,20 which meansinfrequent condom usage during sexual relations. Therefore, if people do not like condoms, thereis a high probability that they will forego regular condom use, despite the risk of sexually 280
  • transmitted infections. Research evidence shows that latex condoms are highly protective againstcontracting HIV.21,22 These findings suggest that the increase in HIV, AIDS and other sexuallytransmitted infections in developing nations is supported by low condom usage, infrequentcondom usage, or improper usage of the condom. It should be noted that the unwillingness to selladolescents condoms and other contraceptives is only exacerbating the high prevalence of STIs,unwanted pregnancies, and deaths as a result of STIs. Condom usage therefore is an importantmeasure in preventing the spread of HIV, AIDS, and other STIs.23 The foregoing means that thesuitability of condoms24-28 must be widely accepted, if public health intervention is to beeffective in increasing the proper usage of condoms during sexual intercourse. The proper use of a condom is based on fit, preference and knowledge. These factors alsoinfluence whether or not men use a condom at all during sexual intercourse. Within the contextof patriarchy, the male partner is able to dictate the determination of a method of contraception,and this decision-making power29 is among the reasons for the increase in STIs (including HIVand AIDS) in spite of the increasing use of contraceptives since the 1970s. Therefore, in orderfor public health programmes to foster an increase in the use of modern contraceptive methods, amultifaceted intervention is needed, that will include access to youth-friendly services andeducation on the use of contraceptives, life skills, and information in a cultural context that meetspeople’s needs. Clearly there is evidence to support the fact that condom usage is inconsistently utilizedin many nations among different groups. In the current study, using 2004 data, we found that54.4% of Jamaicans between the ages of 15-49 years always use a condom, compared to 23.8%in Dominica based on 2007 data.30 George et al.30 found in his sample of high school girls inDominica (controlling for age), that sexual coercion and parents owning a vehicle were 281
  • statistically correlated with inconsistent condom use. Another study, in Western Nigeria,31 foundthat gender, age, monthly family income, age at first act of sexual intercourse and non-acceptingattitudes towards recreational sex were correlates of the inconsistent use of condoms. Norman32found in his data from Kenya, Tanzania, and Trinidad and Tobago, that only 19% of theparticipants reported that they consistently used a condom. In addition, the factors associatedwith consistent condom use were most recent sex partner, gender, study site, perceived difficultyin requesting condom use, and requesting that a condom be used. Another study in Mexico33found that age, educational level, socioeconomic status, and type of sexual partners (occasionaland regular) were statistically significantly related to condom use. Nnedu et al.34 in a study with a sample of 212 respondents from clinics in Montego Bay(Jamaica), who had sexually transmitted infections, found that 43% reported that they used acondom during their last sexual intercourse. It was also found that employment status, greaterknowledge of STIs, multiple sexual partners, and belonging to a religious organization weresignificantly correlated with last condom usage. A review of the literature on condom use hasprovided a plethora of factors which are associated with consistent, inconsistent and generalcondom use. However, all the studies used gender as an independent variable, and none of thestudies examined the psychosocial variables that influenced the use of condoms among malesand females, and the factors which account for the frequent use of condoms. Therefore, theobjectives of the current study are to investigate: (1) psychosocial factors which explain condomusage during the last sexual episode for males, (2) psychosocial factors explaining condom usageduring the last sexual intercourse for females, (3) psychosocial factors regarding condom usageduring the last sexual episode for the population (ages 15-49 years), and (4) psychosocial factorswhich account for frequency in the use of condoms. 282
  • MethodsSampleThe study population comprised people aged 15–49 years who resided in Jamaica at the time ofthe survey in 2004 (May-August). The population data for this research were collected by HopeEnterprises Limited on behalf of the Jamaican Ministry of Health.35 A multi-staged samplingdesign was used to collect the data. Each of the 14 parishes in Jamaica was stratified intoconstituencies, with each constituency stratified into three sections – rural areas, parish capitals(urban areas) and main towns (semi-urban areas). The areas which comprised a constituencywere then stratified into primary sampling units (PSUs) or enumeration districts (EDs). A random sample of each PSU was then selected based on probability proportional tosize (PPS). Seventy-two EDs were selected for the study – 23 EDs in urban areas, 25EDs insemi-urban areas, and 24 EDs in rural areas. Twenty-five households were systematically chosenfrom each ED, and cluster sampling was carried out with all the people living in the household ofthe designated ages being interviewed for the survey.Data sourcesA questionnaire was used to collect the data from respondents. Face-to-face interviews,conducted by trained interviewers, were used to collect the information. The training took 5days, of which 2 days were devoted to field practices. Interviewers were assigned to a teamcomposed of two females, two males and a supervisor. Oral consent was sought and givenbefore the actual interview commenced. Interviewees were informed of confidentiality and theirright to stop the interview at any time. No names, addresses or other items of personalinformation were collected from respondents in order to ensure anonymity and confidentiality.The instrument employed in the survey utilized indicator measures and definitions consistentwith UNAIDS and the USAID Priority Prevention Indicator. 283
  • Statistical analysesData were entered, stored and retrieved using SPSS for Windows, Version 16.0 SPSS Inc;Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographiccharacteristics of the sample. Multivariate logistic regressions were fitted using one outcomemeasure: self-reported, confirmed positive HIV test results. We examined correlation matrices todetermine multicollinearity. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the final modelconstruction.35 To derive accurate tests of statistical significance, we used SUDDAN statisticalsoftware (Research Triangle Institute, Research Triangle Park, NC), and this was adjusted for thesurvey’s complex sampling design. A p-value < 0.05 (two-tailed) was used to establish statisticalsignificance.Analytic ModelFor this study, the analytic models used accommodated multiple independent variables on asingle binary dependent variable – (1) condom usage during the last sexual episode for male, (2)condom usage the last time female had sexual intercourse, (3) condom usage the last time thegeneral population had sexual intercourse. Using logistic regression,34 this paper tested variablesidentified in the literature, as well as adding some new ones. The current work will test condomusage the last time male had sexual intercourse, Equation [1.1]; condom usage the last timefemale had sexual intercourse, Equation [2.1]; condom usage the last time the general populationhad sexual intercourse, Equation [3.1], and Equation [4.1] examines frequency of condom usage:Cmi(t+1) = f(Ai, EDi, Ei, MSi, Cti, SIi, Ni, ASi, Li, CUi, Ki, Wi, Fi, Pi, Ti,STIi, Ri, Qi)….…Eqn [1.1]Cfi(t+1) = f(Ai, EDi, Ei, MSi, Cti, SIi, Ni, ASi, Li, CUi, Ki, Wi,Fi, Pi, Ti,STIi, Ri, Qi)………Eqn [2.1]C(t+1)i = f(Ai, Xi, EDi, Ei, MSi, Cti, SLi, Ni, ASi, Li, CUi, Ki, Wi,Fi, Pi, Ti,STIi, Ri, Qi)..…Eqn [3.1] 284
  • Ci = f(Ai, Xi, EDi, Ei, MSi, Cti, SLi, Ni, ASi, Li, CUi, Ki, Wi,Fi, Pi, Ti,STIi, Ri, Qi)..…….Eqn [4.1] where Cmi(t+1) denotes the male having used a condom the last time he had sexualintercourse with current partner, Cfi(t+1) represents the female partner using a condom the lasttime she had sexual intercourse with current partner, C(t+1)i denotes having used a condom thelast time individual i had sexual intercourse with current partner, Ci is frequency of condom usein the last 12 months for individual i with current sexual partner, Ai is age of individual i, EDirepresents educational level of individual i, Ui, means occupation of individual i, ASi is havingsex with a commercial sex worker for individual i, ARi indicates area of residence of individuali, Pi denotes currently having sexual relations with a commercial sex worker for individual i, MSiis marital status of individual i, Xi is gender of respondent i, Cti means having used a condom thefirst time with the current sexual partner for individual i, SLi is age of first sexual intercourse ofindividual i, Si means that individual i indicated that his/her sexual partner has other sexualpartner(s), Ni is number of sexual partners of individual i in the last 12 months, Ri denotesactively practicing religion of individual i, Ki is individual i having had a STI, Wi representsself-efficacy of individual i, Qi denotes individual’s i chance of contracting HIV, and theparameter εi is the model’s error term. Using logistic regression to test the hypotheses, the data showed that the following areexplanatory variables which account for each dependent variable – these are written as equations[1.2], [2.2], [3.2], and [4.2].Cmi(t+1) = f(MSi, Cti, Si, Ni, Wi)…………………………………………………….……Eqn [1.2]Cfi(t+1) = f(MSi, Cti, Si, Wi)………………………………………………………………Eqn [2.2]C(t+1)i = f(MSi, Cti, Si, Ni, Wi)…………………………………….………………..……Eqn [3.2]Ci = f (Cti, Si, Wi, ASi, MSi, Xi)……....…………………………….……………………Eqn [4.2] 285
  • MeasuresProfessionals were classified into three groups: (1) upper professionals (CEOs, lawyers, doctorsand architects etc.); (2) middle professionals (nurses, teachers, police officers, secretaries,accountants, etc); and (3) lower occupations (labourers, taxi operators, machine operators,domestic workers, cosmetologists etc.).Self-efficacy denotes measures which are instituted by an individual to protect himself/herselffrom danger, threat or harm. This variable was measured using the following questions: (1) whatdid you do to avoid pregnancy? (2) The last time you had sex, did you or [your] partner doanything to delay or avoid pregnancy? (3) Whose idea was it to use a condom? With the choices– myself = 1 or other = 0; (4) Do you think your partner would be upset if he/she found that youhad a condom available? (5) Do you do anything to protect yourself from contracting HIV?Contraceptive method comes from the question “Are you and your partner currently using amethod of contraception? …”, and if the answer is yes “Which method of contraception do youuse?”Condom use is measured from the question “Did you use a condom the last time or the first timeyou had sexual intercourse with your partner?” (1 = Yes, 0 = no).Marital status is measured from the following question “Are you legally married now?”, “Areyou living with a common-law partner now?” (that is, are you living as man and wife now with apartner to whom you are not legally married?), “Do you have a visiting partner, that is, a more orless steady partner with whom you have sexual relations?”, and “Are you currently single?”Subjective social class is measured from “In which class do you belong?” The options are lower,middle or upper social hierarchy.Results 286
  • Demographic characteristic of sample Table 11.1 presents the sociodemographic characteristics of the sample. The sampleconsisted of 1,800 participants (males, 48.8%). Sixty-nine percent of the participants indicated that they had used a condom in the past.However, only 31% reported that they always used a condom with their recent partner (in the last12 months) compared to 16.5% who said most times, 21.4% mentioned sometimes and 31%stated never. Comparatively, 47.5% mentioned that they always used a condom with their partnerjust before the most recent one (in the last 12 months), 14.0% said most times and 11.5%indicated sometimes. With respect to the third most recent partner (in the past 12 months), 54.4%said that they always use a condom, 12.9% indicated most times, 9.2% reported sometimes and23.5% mentioned never. Almost 18% of the participants have had STIs (males, 22.7%; females, 12.3%; χ2 =29.635, P < 0.0001), and only 13.3% have done an HIV test (males, 15.1%; females, 12.3% - χ2= 0.900, P = 0.366). Seventy-eight percent of the participants indicated that they were willing todo an HIV test in the future (males, 79.3%; females, 76.4% - χ2 = 1.349, P = 0.245). The mean age for first sexual relations for the sample was 15.4 years (SD = 3.2 years):Age at first sexual intercourse was 16.7 years (SD = 2.7) for females and 14.1 years (SD = 3.2)for males – Student’s t-test = 16.4, P < 0.0001. When the participants were asked “What is your chance of catching HIV?”, 52.8%indicated no chance, 33.8% mentioned little chance, 6.9% said moderate chance, 6.4% remarkeda good chance and 0.1% said they already had the virus.Multivariate analyses 287
  • Table 11.2 presents information on possible factors which account for using a condom the lasttime one had sexual intercourse with a partner based on gender and population. Using logisticregression analyses, five variables emerged as statistically significant factors of the last timemales used a condom (Chi-square (14) = 128.76, P < 0.001), four variables for females (Chi-square (13) = 75.45, P < 0.001), and five variables emerged as statistically significant factors ofthe last time the general population used a condom (Chi-square (14) = 200.84, P < 0.001). The general model (population) had statistically significant predictive power (Model χ2 =200.84; P < 0.0001; Hosmer and Lemeshow goodness of fit χ2 = 5.428, P = 0.711) and correctlyclassified 79.1% of the sample. The explanatory variables (condom usage at first sexualintercourse of individual i, sexual partner having other sexual partner(s) of individual i, self-efficacy of individual i, number of sexual partners of individual i in last 12 months, and maritalstatus of individual i) account for 49.8% of the condom usage the last time the participants hadsexual intercourse with their current partner (Table 11.2). The male model had statistically significant predictive power (model χ2 = 128.76, P <0.001; Hosmer and Lemeshow goodness of fit test, χ2 = 4.35, P = 0.83), and correctly classified76.8% of the sample. The explanatory variables (condom usage the first time the participants hadsexual intercourse with current partner; partner having other sexual partner(s) for male i; self-efficacy of male i; number of sexual partners male i had in the last 12 months; marital status ofmale i) account for 50.3% of the condom usage of male the last time he had sexual intercourse(Table 11.2). The female model had statistically significant predictive power (model χ2 = 75.45, P <0.001; Hosmer and Lemeshow goodness of fit test, χ2 = 2.95, P = 0.937), and correctly classified79.3% of the sample. The explanatory variables (condom usage the first time the participants had 288
  • sexual intercourse with current partner; partner having other sexual partner(s) for male i; self-efficacy of male i; marital status of male i) account for 51.4% of the condom usage of male thelast time he had sexual intercourse (Table 11.2). Using logistic regression analyses, six variables emerged as statistically significantpredictors of frequency of condom usage in the last 12 months with current partner (Table 11.3):self efficacy, partner with partner, first time condom usage with current partner, commercial sexworker, marital status and gender of participants. The model (frequency of condom usage in the last 12 months with current partner) hadstatistically significant predictive power (model χ2 = 115.34, P < 0.001; Hosmer and Lemeshowgoodness of fit test, χ2 = 5.348, P = 0.720), and correctly classified 78.2% of the sample.Furthermore, the three most significant factors correlating with frequency of condom usage inthe last 12 months with current partner in descending order are condom usage during the firstsexual encounter with current partner, self efficacy and marital status (married) (Table 11.3).Jamaicans between the ages of 15 and 49 years who are married are 66% less likely to frequentlyuse a condom with their current partners (most times-to-always).DiscussionThe current study investigated the reasons for the use of condoms among Jamaicans. Thefindings indicated that 31 out of every 100 Jamaicans between the ages of 15-49 yearsconsistently used a condom, 69 out of every 100 inconsistently used a condom, 31 out of every100 had never used a condom, 58 out of every 100 used a condom the first time with theircurrent sexual partner, and 40 out of every 100 used a condom the last time with their currentpartner. 289
  • The findings suggest that a large number of Jamaicans do not use a condom or are inconsistent intheir use of condoms during sexual intercourse. This revelation must be a cause for concernamong public health officials, given the thrust to reduce HIV infections in Jamaica in particular,and the Caribbean in general. Most of the factors which account for why males used a condomthe last time during sexual intercourse were the same for females, with the exception of thenumber of sexual partners. The findings revealed that self efficacy, one partner having otherpartners and condom use the first time the participants had sexual intercourse with currentpartner emerged as the principal factors which account for condom use the last time anindividual had sexual relations, as well as the frequency of condom use. Males were 2.4 times more likely to use a condom consistently than females, and marriedJamaicans between the ages of 15-49 years were 64% less likely to use a condom consistentlycompared to those who were never married, and married males were more likely to use acondom the last time than married females with their spouses. One of the findings which wasconsistent across the different cohorts was that using a condom the first time with one’s partnerwas the most significant predictor of condom use the last time an individual had sexualintercourse with the current partner. Males were primarily the ones who were having sexualrelations with commercial sex workers, but condom use became significant with the frequency ofsexual intercourse with these workers, and not merely having sexual relations with them. Thefact that condoms are being used with commercial sex workers is an important finding, sincethese workers face the greatest risk of contracting HIV and other STIs and transmitting them,because they earn their living by having sex with many people. The targeting of commercial sexworkers is a critically important strategy to reduce HIV infection and transmission. However, thefact that it was the frequency of sexual intercourse with commercial sex workers rather than just 290
  • having sex, which determined condom use, means that the men who have sex infrequently or onan impromptu basis with commercial sex workers do not wear a condom. The literature identified age, educational level, socioeconomic level, income and age atfirst sexual intercourse as being significant factors which account for condom use,30-33 but this isnot the case in the current study. None of the afore-mentioned variables explained condom usethe last time for males, females, and the population of Jamaica. These findings point to commonfactors that cut across age, level of education, socio-economic status and income, which suggestcultural influences of condom use. The current work also concurs with Norman30 that consistentcondom use (always) was based on gender, and self efficacy. This paper went further thanNorman’s work30 as it shows that marital status, sexual intercourse with a commercial sexworker, and whether one’s sexual partner had other partners, determined consistent condom use.This work also added to the literature by showing the magnitude of each determinant ofconsistent condom use. Unlike other studies which used a piecemeal approach in the examinationof condom use, the current study provided in, a single research project, information on condomuse the last time one had sexual intercourse, in the case of males, females and the generalpopulation and the consistency of condom use. Clearly, condom use “all the time” or “mosttimes” in sexual intercourse is determined primarily by the same factor (condom use the firsttime with the current partner) as is the case for condom use the last time one had sexual relationswith his/her current partner. Embedded in this work therefore is an explanation of whyinconsistent condom use the first time is highly correlated with low use thereafter, and how withthe stability of a sexual union, inconsistent condom use increases. It is possible that theparticipants believe that having not caught STIs after the first act of sexual intercourse withoutusing a condom, it was safe to continue having unprotected sex with this partner. In addition, it is 291
  • possible that the participants also believe that the establishment of a steady union does notrequire safe sexual practices, since it is expected that one’s partner remains faithful to the union.However, if these explanations are correct, there is cause for concern because some of theparticipants reported having multiple sexual partners. People’s desire to live accounts for their willingness to protect themselves, whichjustifies the critical role that self efficacy plays in condom use and consistent condom use inJamaica. Within the context of the preservation of life, a crucial question is: What accounts forthe gender differences in consistent condom use? Males in this study were twice as consistent inusing a condom than females, which concurs with the literature.31 The answer lies in the vetopowers that males have over family planning, contraceptive methods and condom use,29 becauseof the economic supremacy they have over women in the relationship. Another explanation isembodied in the socio-cultural and gender roles, and the sexual behaviours which are taught tosexes before adulthood.36-38 It is this reality that public health specialists must be cognizant of inunderstanding sexual behaviour and the behaviour of youths, adolescents, and females.Therefore, it is not sufficient to educate the population about the use and importance of usingcondoms, but also how patriarchy, the subordination of women, gender roles and socializationpractices influence the spread of STIs. Public health specialists must seek answers in theJamaican culture if they want to succeed in their efforts. The lower rate of condom use among females partly explains the elevated number ofunwanted pregnancies, STIs (including HIV and/or AIDS virus), unsafe sex, and the high levelof school drop-outs among this cohort in developing nations, and in particular Jamaica. Anotheraspect which cannot be omitted from this discourse is the cultural underpinning that condom useindicates a lack of love between partners, and this extends beyond Jamaica.39 It is this 292
  • misrepresentation of information contained in the culture that accounts for the risky sexualpractices of many teenagers. The current study shows that age at first sexual intercourse was 15.4years for Jamaicans, and this speaks to the need to make available contraceptives to adolescents,as they are having unprotected sexual relations. Young people in Jamaica are not atypical intheir engaging in unprotected and premarital sexual relationships, as this is also found in 40,41Thailand, Indonesia,16 the wider Caribbean, 7-9, 15, 42 Uganda, Kenya, Zimbabwe and otherAfrican nations,12-14,43,44 as well as some Latin American countries.45 According to Crawford etal.,46 80% of pregnancies among adolescents were unwanted and 40% of women in Jamaica werepregnant before their 20th birthday. These findings point to the need to distribute condoms inschools. This controversial suggestion should be taken seriously because it is not the availabilityof condoms that makes adolescents have sex, but their psycho-biological drives, and the culturalvalues and boundaries that they have internalized about sex. Wilks et al. in their 2007 study using a sample of 2,848 Jamaicans between the ages of 15-74years, found that 60% of students indicated that they had had sexual intercourse.47Disaggregating condom use by age cohort, they found that 52% of Jamaicans aged 15-24 yearsused a condom (males, 66%; females, 37%).47 Furthermore, Wilks et al.’s study showed that44.3% of students had one or more sexual partners, with 24.6% having 2 or more sexual partners,and that 46% had engaged in sexual intercourse in the last 4 weeks. Another study,48 which useda sample of 7,168 Jamaicans ages 15-49 years, found that 45.9% had sexual intercourse before19 years of age, and 76.9% had sexual relations before age 20. Studies exist about Nigeria, whereeven young people in higher learning institutes are involved in risky sexual behaviour.49-51 Thesefindings mean that the use of condoms among people in developing countries is similar.Therefore, without international consultations, collaborations and the sharing of best practices 293
  • dealing with improving condom use, and other modern contraceptive methods for young people,there will be a greater increase than we are now experiencing globally, in the transmission ofSTIs. Embedded in the current work are some similarities and dissimilarities among males,females and the general population in regard to condom use (the last time one had sexualintercourse) in Jamaica. Condom use (the first time one had sexual relations) with partner, one’spartner having another partner/other partners, self-efficacy, and being married were statisticallysignificant factors for condom use (the last time one had sexual relations) across the sexes. Self-efficacy, therefore, had a stronger association with condom use (the last time one had sexualintercourse) for females than males. This suggests that females who had greater self-desire toprotect themselves from HIV, AIDS, pregnancy and STIs in general were significantly morelikely to have their partners use a condom than males. However, males were more likely to use acondom than their female counterparts, indicating that material supremacy for males gives themvetoing powers over condom usage compared to females, and this accounts for some of thecondom usage differences between the sexes. It is the economic supremacy that justifies the malepartner’s ability to dictate the determination of a method of contraception, as economicallydisadvantaged females will say that the males are the bread winners, and so embodied in realityis their relinquishing of contraception decisions to their partners.29 It is this fact that accounts formales opining that they are likely to use a condom, more than females, who are cognizant thattheir partners have another partner/other partners, indicating that even in the face of a sexuallyrisky environment, economically vulnerable females will be unable to stipulate that their malepartner use a condom, unlike males in similar social milieus. 294
  • The afore-mentioned issue is further reinforced by the finding which revealed that maleswho have multiple partners are more likely to use a condom, and the same was not found amongfemales. Money, therefore, makes a difference in the health status of a population, as for anindividual it accounts for nutritional intake, a particular socio-physical milieu, water and foodquality, as well as choices.52 In 2007, statistics for Jamaica showed that 59 out of every 100persons in the poorest 20% indicated having an illness compared with 54 out of every 100 ofthose in the wealthiest 20%.53 It is this same income inequality between the sexes that accountsfor the choices, especially condom use, or non-use, for males and females in Jamaica. Again thepoint is made, but it is reinforced in the findings which reveal that males who are involved invisiting unions are more likely to have used a condom the last time, while this is not the same forfemales in such sexual unions. One of the ironies embedded in the current work is the similarity in condom usage (lasttime) between married males and females in Jamaica. This requires further study in order toprovide pertinent information that can be used by policy makers in framing intervention oncondom use for the population, and in particular to different demographic characteristics. The current research highlights the inverse statistical association between stable unionsand condom use in Jamaica. Clearly, as people become older, they desire stability in a sexualunion, children and family, which explains the lowered condom use among married peoplecompared to non-married Jamaicans. The findings revealed that there is inconsistent condom use, and infidelity amongJamaicans. Despite knowledge about how HIV/AIDS is contracted, more people contract thevirus from sexual intercourse than via other media. Yet consistent condom use is stillproblematic in the developing world, and in particular Jamaica. HIV is among the 10th leading 295
  • causes of mortality in Jamaica,54 and although Africa has the highest HIV infection rate in theworld,55 with the Caribbean having the highest incidence rate of HIV/AIDS in the Americas,56,57people in many developed nations, and in particular Jamaica, continue to practice infidelity,infrequent condom use and low condom usage in certain marital unions. While infidelity can be traced back to our ancestors in Africa, and offers some culturalunderpinning in explaining the phenomenon in contemporary Jamaica, its practice is stillwidespread, and it is propelled by economic hardship, income inequality between the sexes, theeconomic misfortunes of females, low education, and the high dependency on males foreconomic livelihood. A study conducted in Antigua and Barbuda, Haiti, Guyana, Trinidad andTobago and the Dominican Republic found that one in every six women between the ages of 15and 24 became sexually active before the age of 15 years58, suggesting not only a high level ofpremarital sexual intercourse among young adults, but also offering an understanding ofinfidelity in the region. A study by Chevannes,59 using five Caribbean states, opined that learning to be a man, inparticular Caribbean societies, can be explained by social learning theory. Young Caribbeanmales imitate the social role that they see being exhibited by older men. Young males aresocialized to be strong, masculine, and brave. Infidelity is embedded in Caribbean socialrealities. A study by Crawford and colleagues noted that 38% of female adolescents (ages 15-17)were having sexual intercourse, compared to 64% of males of the same age.46 It can beextrapolated from the Crawford and colleagues’ work that premarital sexual activities amongyoung adolescent males is significantly greater than that of their female counterparts, and thatinfidelity among adolescent males is embedded in the culture. One scholar postulated that “earlysexual activity and early childbearing are solid features of the adolescent landscape in the 296
  • region.”60 Another scholar argued that Caribbean societies do not ‘frown’ upon premarital sexualactivities,61 explaining Crawford and colleagues’ findings that 28% of male adolescentsinconsistently used a method of contraception, compared to 25% of adolescent females, and that39% of the former consistently used a contraceptive method compared to 8% of the latter.46 In the afore-mentioned discussion, we have omitted condom fit and knowledge of propercontraceptive use in explaining the low level of contraception use, large numbers of unplannedpregnancies and increased STIs. A study conducted by Nnedu et al.34 found that greaterknowledge regarding STIs was associated with an increased likelihood of condom use during thelast sexual episode, and again “Does it fit okay?”24 is still left outside of the explanatory powers.Crosby and colleagues found that men who reported ill-fitting condoms were more likely toreport breakage, slippage, and difficulty reaching an orgasm for themselves and their femalepartners. “Does it fit okay?”46 was omitted from the current work. But, clearly, it provides someexplanation for the inconsistent condom use among the sexes, and especially young adults whoseek a good experience in their sexual encounters.ConclusionWhile most of the factors which predict condom use during the last sexual episode were the sameacross the genders and the population, as well as consistent condom use, there are dissimilaritieswhich are imperative and must be taken into consideration when formulating interventions toaddress fertility, family planning, STIs, HIV, AIDS, unwanted pregnancies, teenage drop-outsdue to pregnancy, and the culture. Denying access to contraceptive methods, therefore, will onlyfurther exacerbate the current crisis of sexual behaviour and STIs identified in the developingnations. 297
  • In summary, the use of condoms and the consistency of such use are not based on thelevel of education of Jamaicans, the probability of contracting HIV, occupational type, religiouspractices, age of respondents or age at first sexual intercourse. The foregoing points tocommonalities which are cultural factors that permeate these domains. Therefore, interventionmeasures which address these variables, based on the literature, can explain the irresponsivenessof young people to public health intervention programmes. Currently, public health interventionprogrammes need to use a multifaceted domain approach to sexual and reproductive health inJamaica, and by extension the wider Caribbean and other developing nations. A critical issuewhich must be addressed by the intervention programmes is the spousal authorization of malesand husbands in family planning, as studies show that the removal of this veto power over theuse of contraceptives increases family planning efficiency.RecommendationThere has never been a study in Jamaica or the Caribbean which has examined the associationbetween men’s self-reports of ill-fitting condoms and problems with consistent condom use.Thus, the lack of information makes it difficult for intervention programmes to effectivelyaddress condom use, if we do not first understand this critical issue, which explains theinconsistency in condom use. We are recommending that research be done to investigate theassociation between men’s self-reports of ill-fitting condoms and condom use in general, as thiswill provide knowledge about how programmes can be tailored to address this reality. Based on the research findings, there should be an ongoing national dialogue with thecritical stakeholders including the youth, service clubs, non-governmental organizations, healthpractitioners, the Ministry of Health, schools, colleges, universities and religious institutionsamong others, about the use of condoms and other contraceptives. Some of the popular dancehall 298
  • DJs should be co-opted to disseminate the information, backed by a campaign that uses not onlythe print electronic media including billboards, but also networking sites like facebook andtwitter, among others. The information should also be incorporated in the relevant high school,college and university curricula. The distribution of condoms should be carried out ineducational institutions and prisons, and be widely available in health centres. The governmentshould withhold funding from schools which refuse to distribute condoms to students, and a sexeducation quiz competition similar to the schools challenge quiz for high schools should bedeveloped.DisclosuresThe authors report not conflict of interest with this work.DisclaimerThe researchers would like to note that while this study used secondary data from the JamaicanMinistry of Health (MoHJ), none of the errors in this paper should be ascribed to the MoHJ, butto the researchers.AcknowledgementThe authors would like to extend their appreciation to the Jamaican Ministry of Health thatcommissioned the data collection, Hope Enterprise Limited that collected the data and the SirAuthor Lewis Institute which made it available to us for use.Paul A. Bourne1*, Christopher A.D. Charles2, Cynthia G. Francis1, Maxwell S. Williams3,Neva South-Bourne, Samuel McDaniel31 Department of Community Health and Psychiatry, Faculty of Medical Sciences, The Universityof the West Indies, Mona, Kingston, Jamaica2 King Graduate School, Monroe College, 2375 Jerome Avenue, Bronx, New York 10468 andCenter for Victim Support, Harlem Hospital Center, New York3 Department of Mathematics, Faculty of Pure and Applied Sciences, The University of the WestIndies, Mona, Kingston, Jamaica 299
  • References1. Statistical Institute of Jamaica (STATIN). Demographic statistics, 1960-2008. Kingston:STATIN; 1961-2009.2. National Family Planning Board (NFPB). Reproductive Health Survey, 2008. Kingston:NFPB;2009.3. Planning Institute of Jamaica (PIOJ). Economic and Social Survey Jamaica, 1980-2008.Kingston: PIOJ; 1981-2009.4. Domenach H, Guengant J. Infant mortality and fertility in the Caribbean basin. Cah Orstom(Sci Hum) 1984;20(2):265-72.5. Department of Economic and Social Affairs, Population Division. United Nations. Worldpopulation ageing 1950-2050. New York: UN;2002.6. Cummins GTM, Lovell HG, Standard KL. Population control in Barbados. Am J of PublicHealth 1965;55(10):1600-1608.7. Omran AR, Solis JA. Family planning for health in the Americas. In: Omran AR, Yunes J,Solis JA, Lopez G. Reproductive health in the Americas. Washington D.C.: Pan AmericanHealth Organization; 1992: pp. 55-74.8. Munitz M, Silber T. Adolescent pregnancy in Latin America: A clinical-epidemiologicalapproach. In: Omran AR, Yunes J, Solis JA, Lopez G. Reproductive health in the Americas.Washington D.C.: Pan American Health Organization; 1992: pp. 89-119.9. Morris L. Contraceptive use and reported levels of unplanned pregnancies in Latin America.In: Omran AR, Yunes J, Solis JA, Lopez G. Reproductive health in the Americas. WashingtonD.C.: Pan American Health Organization; 1992: pp. 166-185.10. Jamaica Ministry of Health (MoH). Strategic framework for reproductive health within thefamily health programme, 2000-2005. Kingston: MoH; 2000.11. Department of Reproductive Health and Research. World Health Organization (WHO).Sexual and reproductive health – laying the foundation for a more just world through researchand action. Biennial Report, 2004-2005. Geneva; WHO:2006.12. Aka Dago-Akribi H, Adjoua M-C C. Psychosexual development among HIV-Positiveadolescents in Abidjan, Côte d’Ivoire. Reproductive Health Matters 2004;12(23):19-28.13. Cohen S. Beyond slogans: Lessons from Uganda’s experience with ABC and HIV/AIDs.Reproductive Health Matters 2004;12(23):132-135.14. Hallett TB, Aberle-Grasse J, Bello G, et al. Decline in HIV prevalence can be associated withchanging sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti. Sex TransmInfect 2006;82(Suppl 1):i1-i8.15. Barker ML, Saint-Victor R. Adolescent pregnancy the experience in the English-SpeakingCaribbean. In: Omran AR, Yunes J, Solis JA, Lopez G. Reproductive health in the Americas.Washington D.C.: Pan American Health Organization; 1992: pp. 145-165.16. Hull TH, Hasmi E, Widyantoro N. “Peer initiatives for adolescent reproductive healthprojects in Indonesia. Reproductive Health Matters 2004;12(23):29-39.17. Sychareun V. Meeting the contraceptive needs of unmarried young people: Attitudes offormal and informal sector providers in Vietiane Municipality, Lao PDR. Reproductive HealthMatters 2004; 12(23):155-165.18. Wright RE. The impact of fertility on sexual union transitions in Jamaica: An event historyanalysis. J of Marriage and Family 1989; 51(2):353-361. 300
  • 19. Hart GJ. Limits to modern contraceptive use among young women in developing countries: asystematic review of qualitative research. Reproductive Health 2009; 6:3.20. Goldberg HI, Lee NC, Orberle MW, Peterson HB. Knowledge about condoms and their usein less developed countries during a period of rising AIDS prevalence. Bulletin of the WorldHealth Organization 1989; 67(1): 85-91.21. Conant M, et al. Condoms prevents transmission of AIDS-associated retrovirus. J of theAmerican Association 1986; 255:1706.22. Van de Perre P, et al. The latex condom: An efficient barrier against sexual transmission ofAIDS-related viruses. 1987; 1:49-52.23. Feldblum PJ, Fortney JA. Condoms, spermicides, and the transmission of human immune-deficiency virus: A review of the literature. Am J of Public Health 1988; 78:52-53.24. Crosby RA, Yarber WL, Graham CA, et al. Does it fit okay: Problems with condom use a afunction of self-reported poor fit. Sex Transm Infect 2010; 86:36-38.25. Crosby RA, Yarber WL, Sander SA, et al. Men with broken condoms: Who and why? SexTransm Infect 2007; 83:71-75.26. Crosby RA, Yarber WL, Sanders SA, et al. Condom discomfort and associated problemswith their use among university students. Am J College Health 2005; 54:143-148.27. Reece M, Dodge Herbenick D, et al. Experiences of condom fit and feel among AfricanAmerican men who have sex with men. Sex Transm Dis 2007; 73:454-457.28. Reece M, Herbenick D, Sanders SA, et al. Breakage slippage and acceptability outcomes of acondom fitted to penile dimension. Sex Transm Infect 2008; 80:306-309.29. Cook RJ, Maine D. Spousal veto over family planning services. Am J of Public Health 1987;77(3):339-344.30. George C, Alary M, Otis J. Correlates of sexual activity and inconsistent condom use amonghigh-school girls in Dominica. West Indian Med J 2007; 56(5):433-438.31. So F, Vo O, Po A, et al. Sexual risk behaviours among university students in South WesternNigeria. J of Youth and Adolescence 1995; 24(4):419-438.32. Norman LR. Predictors of consistent condom use: A hierarchical analysis of adults fromKenya, Tanzania and Trinidad. Int J of STD & AIDS. 2003; 14:584-590.33. Hernandex-Giron CA, Cruz-Valdez A, Quiterio-Trenado M, Uribe-Salas F, Peruga A,Hernandez-Avila M. Factors associated with condom use in the male population of Mexico City.Int J STD & AIDS 1999; 10:112-117.34. Nnedu ON, McCorvey S, Campbell-Forrester S, et al. Factors influencing condom useamong sexually transmitted infection clinic patients in Montego Bay, Jamaica. The OpenReproductive Science J 2008; 1:45-50.35. Jamaica Ministry of Health. [Computer file]. Kingston, Jamaica: Jamaica Ministry of Health[producer], 2004. Kingston, Jamaica: Jamaica Ministry of Health and Derek Gordon Databank,University of the West Indies [distributors]; 2004.36. Murray NJ, Zabin LS, Toledo-Dreves V, Luengo-Charath X. Gender differences in factorsinfluencing first intercourse among urban students in Chile. Int Family Planning Perspectives1998; 24:139-144.37. Agha S. Sexual activity and condom use in Lusaka, Zambia. Int Family Planning Perspctives1998; 24:32-37.38. Eggleston E, Jackson J, Hardee K. Sexual attitudes and behaviour among young adolescentsin Jamaica. Int Family Planning Perspectives 1999; 25:78-84. 301
  • 39. Amazigo U, Silva N, Kaufman J, Obikeze DS. Sexual activity and contraceptive knowledgeand use among in-school adolescents in Nigeria. Int Family Planning Perspectives 1997; 23:28-33.40. Nelson KE, Eiumtrakol S, Celentano DD, et al. HIV infection in young men in northernThailand, 1991-1998: Increasing role of injection drug use. J Acquir Immue Defic Syndr 2002;29(1):62-68.41. Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior and a decline inHIV infection among young Thai men in Thailand. N Engl J Med 1996; 335(5):297-303.42. Yeboah DA. Strategies adopted by Caribbean family planning associations to addressdeclining international funding. Int. Family Planning Perspectives 2005; 28(2):1-13.43. Cleland J, Ali MM. Sexual abstinence, contraception, and condom use by African women: Asecondary analysis of survey data. Lancet 2006; 368:1788-1793.44. Maharaj P, Cleland J. Condoms become the norm in sexual culture of college students inDurban, South Africa. Reprod Health Matters 2006; 14:104-112.45. Ali MM, Cleland J. Sexual and reproductive behaviour among single women aged 15-24years in eight Latin American countries: A comparative analysis. Soc Sci Med 2005; 60:1175-1185.46. Crawford TV, McGrowder DA, Crawford A. Access to contraception by minors in Jamaica:a public health concern. North Am J of Med Sci 2009; 1(5):247-255.47. Wilks R, Younger N, Tulloch-Reid M, and McFarlane S, Francis D: Jamaica health andlifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the WestIndies, Mona; 2008.48. National Family Planning Board (NFPB). Reproductive Health Survey, 2002. Kingston:NFPB; 2005.49. Okonofua FE. Factors associated with adolescent pregnancy in rural Nigeria. J of Youth andAdolescence 1995; 24(4):419-438.50. Feyisetan B, Pebley AR. Premarital sexuality in urban Nigeria. Studies in Family Planning1989; 20(6):343-354.51. Orubuloye IO, Caldwell JC, Caldwell P. Sexual networking in Ekiti district of Nigeria.Studies in Family Planning 1991; 22(2):61-73.52. Marmot M. The influence of Income on Health: Views of an Epidemiologist. Does moneyreally matter? Or is it a marker for something else? Health Affairs 2002; 21: 31-46.53. Planning Institute of Jamaica, Statistical Institute of Jamaica. Jamaica Survey of LivingConditions, 1989-2007. Kingston: PIOJ and STATIN; 1988-2008.54. Statistical Institute of Jamaica (STATIN). Demographic statistics, 2007. Kingston: STATIN;2008.55. McGrath N, Nyirenda M, Hosegood V, Newell M-L. Age at first sex in rural South Africa.Sex Tansm Infect 2009; 85(suppl 1):49-55.56. Gebre Y. National HIV/STD prevention and control facts and figures, Jamaica. AIDS report,2004. Kingston, Jamaica: Epidemiology Unit, Ministry of Health, 2005.57. Norman LR. HIV testing practices in Jamaica. HIV Medicine 2006; 7:231-242.58. Rawlins J. Teenage Pregnancy: A study in three communities in Trinidad and Tobago. Paperpresented at the Caribbean Health Research Conference 2007, Jamaica.59. Chevannes B. Learning to be a man: Culture, socialization and gender identity in fiveCaribbean communities. Kingston, Jamaica: The Univer. of the West Indies Press; 2001. 302
  • 60. Jagdeo T. The dynamics of adolescent fertility in the Caribbean. St. John’s, Antigua:Caribbean Family Planning Affiliation; 1992.61. Drayton VLC. Contraceptive use among Jamaican teenage mothers. Pan Am J Public Health2002;11(3):150-157. 303
  • Table 11.1. Sociodemographic characteristics of sample, n= 1 800Characteristic n (%)Sex Male 878 (48.8) Female 920 (51.2)Education Primary or below 51 (2.8) Secondary 1546 (85.9) Tertiary 203 (11.3)Employment status Employed: Full time 626 (34.8) Part time 201 (11.1) Unemployed 563 (31.3) Student 410 (22.8)Union status Married/common-law 561 (31.2) Visiting 619 (34.4) Single 619 (34.4)Ever had sexual relations Vaginal 1543 (85.7) Anal 1 (0.1) Both 14 (0.8) No 242 (13.5)Number of sexual partners in Last 4 weeks median (range) 1 (0,17) Last 3 months median (range) 1 (0,30) Last 12 months median (range) 1 (0,100) More than 12 months median (range) 1 (0,24)Condom usage on first sexual relations (with current partner) Yes 1042 (57.9) No 454 (25.2) Non-response 304 (16.9)Condom usage (during the last sexual episode) Yes 718 (39.9) No 792 (44.0) Non-response 290 (16.1)Sexual relations with a commercial partner (ever had) Yes 89 (5.6) No 1498 (94.4)Length of time living in community median (range) 7.5 years (0, 40)Age mean (SD) 28.3 years (11.1 years)Age of first sexual relations mean (SD) 15.4 years (3.2 years) 304
  • Table 11.2. Logistic regression analyses of variables for condom usage during the last sexual episode for male, females and the populationCharacteristic Male1 Female2 Population3 OR CI (95%) OR CI (95%) OR CI (95%)Condom usage – first time had sex 4.27*** 1.76 – 10.40 3.61** 1.31 – 9.97 4.19*** 2.17 – 8.07Partner having other partner 6.36*** 2.51 – 16.14 5.22*** 1.93 – 14.08 5.35*** 2.81 – 10.20Self efficacy 26.53*** 7.13 – 98.68 33.64*** 4.20 – 269.62 26.84*** 9.11 – 79.04Chance of contracting HIV Little chance 1.01 0.51 – 2.00 0.58 0.21 – 1.63 0.93 0.54 – 1.62 Moderate chance 1.04 0.32 – 3.36 1.23 0.25 – 6.16 1.15 0.46 – 2.89 Good change 0.65 0.18 – 2.36 0.40 0.06 – 2.88 0.70 0.25 – 1.99 No change (reference group) 1.00 1.00 1.00Upper professionals 0.35 0.06 – 1.96 1.93 0.18 – 20.96 0.66 0.17 – 2.64Middle professionals 0.85 0.44 – 1.62 0.88 0.48 – 1.63 0.73 0.48 – 1.13Lower professional (reference group) 1.00 1.00 1.00Age of respondents 1.00 0.96 – 1.04 0.98 0.93 – 1.03 0.99 0.96 – 1.02Age at first sexual intercourse 0.91 0.82 – 1.02 1.14 0.94 – 1.37 0.97 0.88 – 1.06Male 1.70 0.88 – 3.21No. of persons had sex with (in last 12 1.05* 1.01– 1.09 1.20 0.82 – 1.76 1.10* 1.04 – 1.15months)Actively practicing religion (1=yes) 1.41 0.74 – 2.71 1.80 0.68 – 4.75 1.41 0.84 – 2.38Had STI 0.73 0.37 – 1.44 0.75 0.18 – 3.10 0.77 0.43 – 1.39Sex with commercial worker 1.54 1.32 – 5.26 4.88 0.51 – 47.12 1.58 0.61 – 4.08Union status Visiting relationship 2.63** 1.81 – 3.56 1.54 0.55 – 4.34 2.05* 1.18 – 3.56 Married 0.21*** 0.15 – 0.29 0.20*** 0.14 – 0.28*** 0.20*** 0.14 – 0.28 Single (reference group) 1.00 1.00 1.00Tertiary education 2.39 0.68 – 8.45 2.22 0.51 – 9.64 2.48 0.70 – 8.73Secondary education 1.84 0.62 – 5.60 1.46 0.39 – 5.62 1.92 0.64 – 5.74Primary education (reference group) 1.00 1.00 1.00 1 Model chi-square (14) = 128.76, P < 0.001 -2 Log likelihood = 244.75 Nagelkerke r-squared = 0.503 Hosmer and Lemeshow test, χ2 = 4.35, P = 0.83 Overall correct classification = 76.8% Correct classification of cases of condom usage at first sexual intercourse = 71.7% Correct classification of cases of not using condom at first sexual intercourse = 80.4% *P < 0.05, **P < 0.01, ***P < 0.001 2 Model chi-square (13) = 75.45, P < 0.001 -2 Log likelihood = 128.07 Nagelkerke r-squared = 0.514 Hosmer and Lemeshow test, χ2 = 2.95, P = 0.937 Overall correct classification = 79.3% Correct classification of cases of condom usage at first sexual intercourse = 55.1% Correct classification of cases of not using condom at first sexual intercourse = 89.2% *P < 0.05, **P < 0.01, ***P < 0.001 3 Model chi-square (14) = 200.84, P < 0.001 -2 Log likelihood = 381.84 Nagelkerke r-squared = 0.498 Hosmer and Lemeshow test, χ2 = 3.94, P = 0.86 Overall correct classification = 77.9% Correct classification of cases of condom usage at first sexual intercourse = 67.3% Correct classification of cases of not using condom at first sexual intercourse = 84.0% 305
  • Table 11.3. Binary logistic regression analyses of frequency of condom usage in last 12 monthswith current partner Wald Variable β Coefficient statistic Odds ratio CI (95%) Self efficacy 1.26 10.22 3.53*** 1.63 - 7.66 Partner having other partner 0.79 5.08 2.20* 1.11 - 4.38 Condom usage – first time had sex 1.88 20.11 6.57*** 2.89 - 14.97 Age at first sexual intercourse 0.08 1.65 1.08 0.96 - 1.21 Age of respondents -0.03 1.73 0.98 0.94 - 1.01 No. of persons had sex with (in last 12 months) 0.01 0.04 1.01 0.91 - 1.12 Male 0.87 5.50 2.39* 1.15 - 4.95 Had STI (in the past) -0.05 0.02 0.95 0.43 - 2.09 Actively practicing religion (1=yes) 0.31 0.92 1.37 0.72 -2.58 Sex with commercial sex worker (1=yes) 2.28 3.99 9.73* 1.04 - 90.61 HIV (1=yes) -0.14 0.11 0.87 0.37 - 2.06 Tertiary -1.73 1.53 0.18 0.01 - 2.74 Secondary -2.18 2.54 0.11 0.01 - 1.65 Primary or below (reference group) 1.00 Visiting union 0.01 0.00 1.01 0.41 - 2.47 Married -1.07 4.66 0.34* 0.13 - 0.91 Single (reference group) 1.00 Little chance of contracting HIV 0.22 0.41 1.25 0.64 - 2.43 Moderate chance of contracting HIV -0.18 0.07 0.84 0.23 - 3.02 Good chance of contracting HIV 0.93 2.47 2.53 0.79 - 8.08 No chance (reference group) 1.00Model chi-square = 115.34, P < 0.001-2 Log likelihood = 277.19Nagelkerke r-squared = 0.441Hosmer and Lemeshow test, χ2 = 5.348, P = 0.72Overall correct classification = 78.2%Correct classification of cases of frequent condom usage with current sexual partner = 67.8%Correct classification of cases of non-frequent condom usage with current sexual partner = 84.8%*P < 0.05, **P < 0.01, ***P < 0.001 306
  • Chapter 12 Current use of contraceptive method among women in a middle-income developing country Paul A. Bourne, Christopher A.D. Charles, Tazhmoye V. Crawford, Maureen D. Kerr- Campbell, Cynthia G. FrancisIntroductionThis article aims to explore the use of contraceptives among women in Jamaica in order tocorrect a paucity of information in the academic literature, and to provide information for policy-makers, public health practitioners and educators. The rationales which influence this researchare (1) the lack of a comprehensive study on contraceptive use, and (2) the public healthconcerns which have arisen in the past decade. The mean age of first sexual intercourse has beenfalling since 1997 and this is coupled with (1) increased contraceptive use, (3) increased teenagepregnancy, (3) increased premarital sexual relations, and (4) increased HIV in the young adultpopulation, as well as (5) the piecemeal approach to the study of contraceptive use in Jamaica. Itshould be noted that some adolescent and young adult females who engaged in unplanned sexualintercourse underestimated the risk of pregnancy and did not use contraceptives consistently. Theprevention of pregnancy was deemed to be the responsibility of the women. Their decision-making was strongly influenced by friends, family and social norms. The most important formsof support these females received were from partners and parents1. College women having theirfirst experience of sexual intercourse did so at an older age than men. Some 61% of the womenused an unreliable method or no contraceptive at all. The most frequent reason reported by these 307
  • women for non-use of contraceptives in their first sexual intercourse was that it was unplanned.The lack of knowledge and inaccessible sources of contraception also influenced the women’suse of contraceptives.2 The use of contraceptives is also related to the length of birth intervals. A review of theliterature connecting the length of birth intervals to the use of contraceptives reveals mixedfindings. However, the use of contraceptives is a protective factor against short birth intervals.3The variables of the theories of planned behaviour, coupled with family planning self efficacy,accounted for 65% of the outcome for intent to use oral contraceptives, and 27% of the variancein behaviour among women.4 A study of women’s views on family planning services suggeststhat they find several factors important. These are, the providers showing empathy andrespecting the women’s autonomy, the provision of personalized care and comfort of the women,the information provided, the technical quality of care and the organization of the service.Another important factor is the provider’s ability and willingness to communicate in thelanguage of the women5. Moving from the clinic to their homes, the views of these womensometimes have little influence, even with the encouragement of their female friends. Theencouragement wives receive from their social networks about the use of contraceptives does notinfluence the use of contraceptives by their husbands.6 However, some women who wereexperiencing domestic violence in their relationship with men stated that violence was not animportant factor influencing their use of contraception.7 Illness also influences women’s use of contraceptives. Women with bipolar disorder usecontraception sub-optimally.8 Similarly, women who are depressed are more likely to choose anineffective method of contraception. These women need contraceptive counselling which istailored to improve their decision-making and choice of contraception.9 A review of the studies 308
  • dealing with oral contraceptives and multiple sclerosis (MS) suggests that the use of oralcontraceptives does not increase the risk of MS. On the contrary, it may delay the onset of thedisease.10 Although knowledge of contraception is high among HIV sero-discordant couples, theuse of contraceptives is low. Gender difference is an important factor, because many womenengage in the clandestine use of contraceptives.11 The use of contraceptives among women is notonly related to illness but also to religious factors. Religions differ in their dictates aboutcontraception, which influence its use among religious people shaped by the history and politicsof their particular religion.12 Given the range of factors outlined above, dealing with women’s use of contraceptives,the promotion of reproductive health by the international donor community sometimes does notwork. This failure occurs because the donor and the policy-makers of the target country definereproductive health differently. The priorities and values of the donors and policy-makers are atodds, because cultural factors drive contraceptive use away from the expected outcome of thedonors13. The purpose of this article is to understand the methods of contraception used byJamaican women, and some of the factors that influence them to use these methods ofcontraception. The data collection method used in the current study is outlined below.MethodsSince 1997, the National Family Planning Board (NFPB) has been collecting information onwomen (ages 15-49 years) in Jamaica regarding contraception usage and/or reproductive health.In 2002, the Reproductive Health Survey (RHS) collected data on women ages 15-49 years andmen 15-24 years. The current study extracted the sample of only women (ages 15-49 years)given the nature of the research. The sample was 7,168 women, representing a response rate of91.8%. 309
  • Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration districts, EDs). This was calculated based on probability proportion to size. Jamaicais classified into four health regions. Region 1 consists of Kingston, St. Andrew, St. Thomas andSt. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up ofTrelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchesterand Clarendon. The 2001 Census showed that region 1 comprised 46.5% of Jamaica, comparedto Region 2, 14.1%; Region 3, 17.6% and Region 4, 21.8%. 14 Stage 2 saw the clustering of households into primary sampling units (PSUs), with eachPSU constituting an ED, which in turn consisted of 80 households. The previous sampling framewas in need of updating, and so this was carried out between January 2002 and May 2002. Thenew sampling frame formed the basis upon which the sampling size was computed for theinterviewers to use. Stage 3 was the final selection of one eligible female this was done by theinterviewer 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 interviewersadministered a 35-page questionnaire. The data collection began on Saturday, October 26, 2002and was completed on May 9, 2003. The data was weighted in order to represent the populationof women ages 15 to 49 years in the nation.14Statistical methodsWe used the Statistical Packages for the Social Sciences (SPSS) for Windows, Version 16.0(SPSS Inc; Chicago, IL, USA). Frequencies and means were computed on the basis of 310
  • sociodemographic characteristics, health conditions, pregnancy, Pap smears, gynaecologicalexaminations and reasons for choices. We also performed χ2 tests to compare associations, inparticular sociodemographic variables, contraception, pregnancy, and gynaecologicalexamination. Stepwise multiple logistic regressions were used to analyze factors that explainedgynaecological examinations undergone in the last 12-month period, and Pap smear tests doneduring the same period. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the final modelconstruction.15 To derive accurate tests of statistical significance, we used SUDDAN statisticalsoftware (Research Triangle Institute, Research Triangle Park, NC), and this was adjusted for thesurvey’s complex sampling design.MeasureCrowding is the total number of persons in a dwelling (excluding kitchen, bathroom andverandah). 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 amethod of contraception? …”, and if the answer is yes “Which method of contraception do youuse?” Age at which began using contraception was taken from “How old were you when youfirst used contraception? Area of residence is measured from “In which area do you reside?” Theoptions were rural, semi-urban and urban. Currently having sex is measured from “Have you hadsexual intercourse in the last 30 days?” Education is measured from the question “How manyyears did you attend school?” Marital status is measured from the following question “Are youlegally married now?”, “Are you living with a common-law partner now? (that is, are you livingas man and wife now with a partner to whom you are not legally married?)”, “Do you have avisiting partner, that is, a more or less steady partner with whom you have sexual relations?”, and 311
  • “Are you currently single?” Age at first sexual intercourse is measured from “At what age didyou have your first intercourse?” Gynaecological examination is taken from “Have you ever hada gynaecological examination?” Pregnancy was assessed by “Are you pregnant now?”Religiosity was evaluated from the question “With what frequency do you attend religiousservices?” The options range from at least once per week to only on special occasions (such asweddings, funerals, christenings et cetera). Subjective social class is measured from “In whichclass do you belong?” The options are lower, middle or upper social hierarchy.Analytic ModelUsing logistic regression, this study seeks to examine factors associated with the method ofcontraception usage among women in Jamaica. Different social factors influence women’schoices and their decision to use a method of contraception, and this study used Grossman’smodel16 which established the use of econometric analysis to determine the use of healthdemand. Grossman’s model has been modified and used by many scholars to examine health,health outcome and other health-related issues.The current research will use the theoretical framework of Grossman’s econometric analysis toexamine factors associated with the method of contraception usage among women ages 15-49years in Jamaica. The variables used in this econometric model are based on the literature as wellas the dataset. We will test the hypothesis that the methods of contraception usage among womenages 15-49 years are determined by particular sociodemographic variables (Equation [1]). Cwi = f(Ai, EDi, Ui, SSi, ARi, Pi, Fi, GNi, ASi, Si, Ni, Ri, Ki, Mi, Wi, Ti εi) Eqn [1] where Cwi denotes method of conception usage among women i, Ai is age of woman i,EDi represents educational level of woman i, Ui, means employment status of woman i, SSi issocial class of woman i, ARi indicates area of residence of woman i, Pi denotes current 312
  • pregnancy status of woman i, Fi is forced to have sex (woman i), GNi means gynaecologicalexamination in the last 12 months, woman i, ASi is age of first sexual intercourse of woman i, Sirepresents currently having sex (woman i), Ni is number of sexual partners of woman i, Ridenotes religiosity of woman i, Ki woman is currently in a sexual union i, Mi denotes age of firstmenstruation of woman i, Wi represents crowding in household of woman i, Ti denotes age atwhich contraceptive use for woman began i, and the parameter εi is the model’s error term. Using the data to test the hypothesis (Equation [1]), from the logistic regression analyses,we can write equation [2] to represent the function that explains the method of contraception forwomen ages 15-49 years in Jamaica. Cwi = f(Ai, SSi, ARi, Pi, Ki, Wi, Ni, Si, Ti, εi) Eqn [2] To make more sense of the function (Equation [2]), we can rewrite it into an equation(Equation [3]):Log (P/1-P) = α + β1Ai + β2SSi + β3ARi + β4Pi + β5Ki + β6Wi + β7Ni + β8 + β9Si + β10Ti + εiEqn [3] Where P denotes the probability of currently using a method of contraception and 1- P isthe probability of currently not using a method of contraception, α represents the constant, β1-10means the coefficient of each variable from 1 to 10. The predictive power of the model was tested using the ‘omnibus test of model’ andHosmer and Lemeshow’s17 technique was used to examine the model’s goodness of fit.ResultTable 12.1 presents sociodemographic information on the sample. The sample was 7,168 womenages 15 to 49 years, and most of them were currently using a method of contraception (64%).Currently, 4.4% of the sample was pregnant and 84.3% had previously been pregnant. Almost 313
  • 16% had at least one miscarriage, 2.2% at least one abortion and 5.4% at least one stillbirth. Themean age of the sample was 31.0 years (SD = 9.3 years). A detailed description of the age cohortof the sample revealed that 13.8% of the women were 15-19 years; ages 20-24 years, 13.1%;ages 25-29 years, 16.4%; 30-34 years, 18.3%; 35-39 years, 16.2%; ages 40-44 years, 12.8% andages 45-49 years, 9.4%. Half of the sample began using a method of contraception at 19 years(range = 33 years: 11, 44), and 4.5% indicated that they desired to be pregnant sometime in thefuture. Almost 62% of the respondents indicated that they had asked their partners to use acondom, 20.1% of the women reported that they refused to do so. On the other hand, 5% ofwomen said that they insisted that their partners did not use a condom during sexual intercourse.Twenty-three percent of the respondents indicated that they had had multiple partners. Of thosewith non-steady partners, 24% provided information on the frequency of use of condoms withthis/these person/s: Forty-nine percent of them indicated that they always used a condom, 26.1%claimed most times, 0.7% said seldom and 23.9% remarked never. Regarding women with asteady partner, 44.4% indicated that they always used a condom with their partners, 48%remarked most times, 6.0% said seldom and 0.2% reported that they had never done so. Only2.4% of the women in the sample were sex workers (being paid for sex – money or goods inexchange for sex), and 9.1% said that they had done this more than two times in their lives.Twenty-six percent of the sex workers indicated that they began while they were in school, and57% said they commenced after leaving school. When the respondents were asked “Are you and your partner currently using a method ofcontraception or doing something to prevent pregnancy”, 63.8% indicated yes. Of those whoresponded to the method of contraception, it was revealed that most respondents used a condom 314
  • (62%) followed by the pill (14.4%), female tubal ligation (10.4%), and injection (10%). Thisquestion was followed by “Are you and your partner also using a second method ofcontraception”, and to this 14.6% indicated yes. The methods were withdrawal (65.3%), rhythm,calendar or Billings, 26.5%, pill (2.1%), diaphragm (4.1%) and other (2.0%). When the samplewas asked “Are you and your partner also using a second method at the same time for eithersexually transmitted disease prevention or contraception”, 14.6% indicated yes. The methodswere withdrawal (65.3%), condom (7.5%), and other.Table 12.2 presents information on particular demographic characteristics of the sample by agegroup.Table 12.3 presents information on frequency of condom use (with a non-steady partner) by agegroup.Table 12.4 presents information on frequency of condom use (with a steady partner) by agegroup.Multivariate analysesTable 12.5 provides information on factors that explain the method of contraception usage ofwomen ages 15 to 49 years. Using stepwise logistic regression analyses, eight variables emergedas statistically significant variables of women ages 15-49 years who are currently using a methodof contraception. Women (ages 15-49) who are in the upper class are 17% less likely to use amethod of contraception in reference to those in the lower class (OR = 0.83, (95% CI: 0.73-0.95). The older the women become, they are 2% less likely to use a method of contraception(OR = 0.98, 95% CI: 0.98 – 0.99), and if they are pregnant they are 99% less likely to use amethod of contraception. The model had statistically significant predictive power (model χ2 (df =9) = 1684.75, P-value < 0.0001; Hosmer and Lemeshow goodness of fit χ2 = 2.87, P = 0.94), andcorrectly classified 78.5% of the sample (Table 12.5).Limitations of the studyOne of the fundamental limitations of this study is the cross-sectional nature of the datacollection. A cross-sectional study cannot be used to establish causality or predictability, and the 315
  • results can change with time. Hence, although social policy formulation relies on this researchdesign, policy-makers should be cognizant of the aforementioned issues in designinginterventions and strategic frameworks. Despite those limitations, cross-sectional data design isstill a good way to collect social science data on a population.DiscussionThe current study found that although 64% of the sample indicated that they or their partner useda method of contraception, consistency of use among those with a steady partner was relativelylow (always, 44.4%; most times, 48.0%) and 73.9% of the respondents indicated that they hadnever had a non-steady partner. Of those who had a non-steady partner, 49.3% consistently useda condom and 23.9% indicated that they had never used a condom. Almost 60% of therespondents indicated that they had had sex in the last 30 days, and 58% were primarilyfinancially supported by their partner(s). Some 5% of the respondents stated that they desired tobecome pregnant. Current methods of contraception used by the female or her partner wereexplained by age of respondent, subjective social class, whether or not in a sexual union, area ofresidence, currently pregnant, currently having sex (in the last 30 days), number of sexualpartners, age at which individual began using contraception and crowding. In 1997, statistics revealed that the prevalence of women currently using contraceptives 21in Jamaica was 50.3% and this increased to 64% in 2007. The majority of women reportedusing a contraceptive, which is a very high rate of usage for a developing country. Using datafrom Kenya, Tanzania, and Trinidad and Tobago, Norman [22] found that only 19% reportedconsistently using a condom. In another research, using a sample of 212 respondents from clinicsin Montego Bay (Jamaica) who had sexually transmitted infections, the study [23] found that43% reported using a condom the last time they had sexual intercourse. The current study 316
  • revealed a higher consistency prevalence of condom usage than the aforementioned studies, andshowed that almost 92.4% of Jamaican women used a condom most times with their currentpartner, and 75.4% did so with non-steady partner. The current work provides information which shows that 21.4% of young women (ages15-19 years) were forced into having sexual relations, 7.4% of adolescents (ages 15-19 years)desired to become pregnant, 51.4% had sexual intercourse, some of them were having it twice amonth, and on average they were having sex with 6.6 men in 90 days. Although the mean age ofthe first sexual intercourse was 15.2 years of age, the mean age of the first sexual intercourse forwomen between the ages of 15-19 years was 7.7 years of age. Furthermore, 35.7% of womenbetween the ages of 15-19 years had been pregnant in the past. The present work showed that 1in every 2 Jamaican woman between the ages of 15-19 years had sexual intercourse in the last 30days, and that 8 out of every 10 had been pregnant. Some 21.5% of these women experienced a miscarriage and stillbirth, with only 2.2 % ofthem having at least one abortion. This low rate of abortion reported is consistent with therelatively high use of contraceptives reported by the women, and the 62% of the respondentswho declared that they asked their partner to use a condom. Taking the possibility of under-reporting into account, the reported low use of abortion as a method of contraception contradictsrecent media reports of widespread abortion in Jamaica, and the fierce activism of the churchlobby against legalizing abortion. The assertiveness of the women in asking their men to use acondom is something that should be further encouraged within the national family planningstrategy, rather than joining the moral panic against abortion that sometimes infuses nationaldiscussions of family planning. The reality which emerged from the current research is that alittle over 50% of women are mostly supported financially by their partners, which means that 317
  • the males are still able to determine, or veto, contraceptive usage. This is not peculiar to Jamaicaas it was also found to be the case in Sub-Saharan Africa, and the removal of spousalauthorization (male) was associated with increased contraceptive usage.24 Despite the relatively high use of contraceptives among the women, what emerged fromthe current work gives rise to many public health and other concerns. Women as young as 7years of age are having sexual intercourse, and 21 out of every 100 adolescents between the agesof 15-19 years are forced into sexual activities. It does not cease there, as 36 out of every 100young women (ages 15-19 years) have been pregnant, which means that there would be a highfertility rate or prevalence of adoption among these individuals. A number of young adultwomen in Jamaica were not only having premarital sexual relations, but they were having sexualintercourse with multiple partners. There is currently a public health problem as adolescents(ages 15-19 years) had more multiple sexual partners in the last 3 months than other women,with some young women engaging in promiscuity. This concurs with the literature which showshigh promiscuity, premarital sexual activity and high fertility among young adults.25-27 Less than 50% of the women with multiple partners who responded to the question aboutcondom use indicated that they always used a condom. More than half of these participants donot use a condom with multiple partners, which increases their risk of contracting sexuallytransmitted infections (STIs). However, since only 24% of the women with multiple partnersprovided information about condom use, further research is required to explore this criticallyimportant health issue. Regarding women with one steady partner, only 44.4% stated that theyalways used a condom, which leaves them vulnerable to STIs if their male partner is unfaithful.Therefore, although the overall use of contraceptives among the women was relatively high(64%), and 62% of the women asserted that their men used a condom, the breakdown of the data 318
  • between women with steady and unsteady partners indicated that inconsistent condom use ishigh among Jamaican women. It is this inconsistent contraceptive usage, in particular condomutilization, that explains the HIV/AIDs epidemic in Jamaica and other developing countries.28-33 Only 56.1% of the sample stated their choice of contraceptives, among those who arecurrently using a method of contraception. Overall, the data suggests that among the womenwho responded about the method of contraception used, there is a greater concern for preventingan unwanted pregnancy than for contracting STIs. Only 32 % of these women used a condom,with the remaining 68% using, in descending order of importance, the pill, injection, tuballigation, the withdrawal method, IUD, the rhythm method, emergency contraceptives, implantsand other methods. More women ages 15-19 years used a method of contraception to avoid beingpregnant (64%) than to prevent STIs (14.6%), indicating that contraception is more aboutpreventing pregnancy then STIs. Embedded in this finding is the disconnect between awareness,knowledge and practice. Failure to consistently use a condom exposes one to HIV and/or STIs. It is clear from thecurrent findings that women are exposing themselves to STIs by premarital sexual relations,promiscuity, and inconsistent condom usage. Young women having sex as early as 7 years, andbecoming pregnant between 15-19 years, exposes many of these individuals to an HIV positivepartner. HIV serodiscordant couples is a reality, as was noted by USAID and other scholars.34-37Economic challenges, and men’s economic supremacy, are among the reasons why women’sreproductive health issues can be vetoed by males. Embedded in these findings is an explanationof why condom usage and other contraceptive methods are inconsistently used by both womenand men, as this is often based on the decision of the male partner. Henry-Lee38 opined that 34%of pregnancies in Jamaica are planned, and that poverty retards information on contraceptives 319
  • and their usage. Another study found that 80% of adolescent pregnancies39 were unplanned,which reemphasizes the heavy involvement of this age cohort in premarital sexual activities andsometimes promiscuity. The lack of material power and economic independence means thatsome women will find it extremely difficult to dictate, insisting that their male partners have anHIV test, and that a condom is consistently used in sexual intercourse. Warren et al. opined that 40% of all females aged 14-24 years and 61% of those who aresexually experienced have been pregnant.40 Warren and his colleagues’ work was in 1988 andthe current research found that 56% of women of the same age had already been pregnant.Disaggregating the age cohort (15-24 years), this work found that 67.1% of women ages 20-24years, and 35.7% of those 15-19 years have already been pregnant. Despite the difference inyears between 1988 and now, with increased knowledge, wider access to contraception andincreased public health education campaigns, the number of young adult-women who are stillhaving unplanned pregnancies is still higher than in 1988. The public health concern is not onlywith increased pregnancies among young women, but promiscuity, the increased incidence ofHIV28, the problems of inconsistent condom usage, and the disparity between the widespreadknowledge of HIV and continued inconsistent condom usage.23, 41 Women who are involved in a relationship are more likely to use a method ofcontraception. It is possible that these women are not ready to get pregnant or they believe theirpartner may not be ideal for them. Women in urban areas are more likely to use a method ofcontraception than rural women. It is possible that rural women may have a lower level ofeducation, and there are not enough professional women in the rural areas compared to urbanareas, or rural women may be influenced by the culture of having a lot of children to help withagricultural work, and children may be seen as retirement planning, given the higher level of 320
  • poverty in rural areas.18-20 Women currently having sex and those with multiple partners tend touse a method of contraception. It is possible that these women are not ready to have children.Similarly, there is a positive relationship between crowding and use of contraceptives. However,the younger the age at which the women start to use a method of contraception, the more likely itis that they are using one currently. Clearly, Jamaica has been struggling with premarital sexual relations and adolescentpregnancy for many decades42 and this continues unabated. In contemporary Jamaica, the issuesare old, but there are also some new ones. Added to the old issues are increased HIV prevalenceamong young adults,43 early sexual relations of women ages 15-19 years, promiscuity amongwomen ages 15-19 years, the prevalence of young women who are forced to have sexualrelations, frequency of sexual relations in a 30-day period and the percentage of women ages 15-39 years who want to become pregnant. Douglas43 opined that the major cause of mortalityamong women of 15-44 years in the Caribbean is AIDS, and that 1 in every 50 Caribbeannationals was infected with HIV/AIDS. There is no denying that inconsistent condom use accounts for high fertility, pregnanciesand HIV/AIDS infections in the Caribbean and sub-Saharan African nations. Therefore, it isuseful to encourage the early use of contraceptives, in particular the condom, as a second methodamong young women. In 2000, the Jamaican Ministry of Health used the Jamaica ReproductiveHealth Survey for 1997, among other data sources, to write a ‘Strategic Framework forReproductive Health Programme for 2000-2005’.44 New data indicate that the issues are morediverse than in 1997 and therefore a new policy framework is needed for 2005 and beyond. It isan absolute that consistent condom usage can stem the rise in teenage pregnancies, HIV/AIDS45and abortions, and reduce sexually transmitted infections46 and the risk of transmission among 321
  • young women and men in developing countries. Wilks et al.’s findings revealed that 97% ofthose in the lower social hierarchy have had sexual intercourse, compared to 96% of the middleclass and 95% of the upper social hierarchy, 60% of Jamaican students (ages 15+ years) havehad sexual relations, as have 99% of those with primary or lower education level (secondary,93%; post-secondary, 94%).47 In addition to the aforementioned, the new findings should be usedto effectively frame policies to address the new realities. A multifaceted approach must be takento address the new realities in Jamaica, and this must include (1) an intervention programme toaddress the information needs of adolescents, and to make reproductive health services moreyoung people friendly (2) post-intervention surveys to assess the effectiveness of implementedmeasures, (3) a sensitization campaign against male supremacy in vetoing reproductive healthchoices of females, (4) identifying new areas for contraception inquiry, (5) formulation of anintact condom usage campaign, and (6) designing a programme to financially empower those inthe lower class, the disadvantaged, orphans and young people, as well as to provide the samegroup with educational empowerment. A study conducted in Mexico City on a group of youngfemales who had unplanned pregnancies emphasized the rationale of financial empowerment incontraceptive decision-making. The respondents indicated that they left contraceptive decisionsto their partner as “he looks after me”,48 indicating the males’ vetoing power in reproductivehealth decisions, and the justification for their involvement in women’s reproductive healthmatters.ConclusionThe majority of participants used some method of contraception. The most popular method ofcontraception among the women was condoms. Despite the relatively high use of contraceptivesamong the women, a breakdown of the data on women in a steady relationship and women with 322
  • multiple partners, suggests that 44% of the women used a condom in the former group and 49%used a condom in the latter group. These findings have implications for the spread of STIs. Thereare several explanatory variables for contraceptive use among the women. These explanatoryfactors are age, social class, being in a relationship, the rural-urban dichotomy, being currentlypregnant, currently having sex, the number of partners, the age at which the women began usinga contraceptive, and crowding.Conflict of interestThe authors have no conflict of interest to report.DisclaimerThe researchers would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researchers.AcknowledgementThe 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 (Jamaica Survey ofLiving Conditions, 2002) available for use in this study, and the National Family Planning Boardfor commissioning the survey.Paul A. Bourne1*, Christopher A.D. Charles2, Tazhmoye V. Crawford3, Maureen D. Kerr-Campbell4, Cynthia G. Francis11 Department of Community Health and Psychiatry, 3Basic Medical Sciences, Faculty of MedicalSciences, The University of the West Indies, Mona, Kingston, Jamaica2 King Graduate School, Monroe College, 2375 Jerome Avenue, Bronx, New York 10468 andCenter for Victim Support, Harlem Hospital Center, New York4Systems Development Unit, Main Library, Faculty of Humanities and Education, TheUniversity of the West Indies, Mona, JamaicaReferences[1] Ekstrand M, Tyden T, Darj E, Larsson M. An illusion of power: Qualitative perspectives on abortion decision-making among teenage women in Sweden. Perspectives on Sexual and Reproductive Health 2009; 41(3): 173-180.[2] Needle RH. The relationship between first sexual intercourse and ways of handling contraception among college students. Journal of the American College Health Association 1975; 24(2):106-111. 323
  • [3] Yeakey MP, Ramachandran DV, Myint Y, Creanga AA, Tsui AO. How contraceptive useaffects birth intervals: results of a literature review. Studies in Family Planning 2009; 40(3): 205-214.[4] Peyman N, Oakley D. Effective contraceptive use: An exploration of theory-based influences. Health Education Research 2009; 24(4): 575-585.[5] Becker D, KLassen AC, Koenig MA, LaVeist TA, Sonenstein FL, Tsui AO. Women’s perspectives on family planning service quality: An exploration of difference by race, ethnicity and language. Perspectives on Sexual and Reproductive Health 2009; 41 93): 158- 165.[6] Avogno W, Agadjanian V. Men’s social networks and contraception in Ghana. Journal of Biosocial Science 2008; 40(3):413-429.[7] Ogunjuyiqbe Po, Akinlo A, Oni GO. Violence against women as a factor in unmet need for contraception in Southwest Nigeria. Journal of Family Violence 2010; 25(2): 123-130.[8] da Silva Magalhaes PV, Kapczinski F, Kauer-Sant’Anna M. Use of contraceptive methods among women treated for bipolar disorder. Archives of Women’s Mental Health 2009; 12(3):183-185.[9] Garbers S, Correa N, Tobier N, Blust S, Chiasson MA. Association between symptoms of depression and contraceptive method choices among low income women at urban reproductive health centers. Maternal and Child Health Journal 2010; 14910:102-109.[10] Alonso A, Clark CJ. Oral contraceptives and the risk of multiple sclerosis: A review of Epidemiologic evidence. Journal of the Nuerological Sciences 2009; 286 (1): 73-75.[11] Grabbe K, Stephenson R, Vwalika B, Ahmed Y, Vwalika C, Chomba E, Karita E, Kayitenkore K, Tichacek A, Allen S. Knowledge, use, and concerns about contraceptive Methods among sero-discordant couples Rwanda and Zambia. Journal of Women’s Health, 2009; 18 (9):1449-1456.[12] Agadjanian V, Yabiku ST, Fawcett L. History, community milieu, and Christian-Muslim Differentials in contraceptive use in Sub-Saharan Africa. Journal of the Scientific Study of Religion 2009; 48(3): 462-479.[13] Waller KA. Understanding policymakers’ perspectives. Dissertation Abstracts International: Section B: The Sciences and Engineering 2009; 69 (12B):7452.[14] National Family Planning Board. Reproductive Health Survey, 2002 (Jamaica). Kingston: NFPB; 2005.[15] Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton & Lange Publisher, 1996. [16] Grossman M. The demand for health - a theoretical and empirical investigation. New York:National Bureau of Economic Research, 1972.[17] Homer D, Lemeshow S. Applied Logistic Regression, 2nd edn. John Wiley & Sons Inc.,New York, 2000.[18] Planning Institute of Jamaica, (PIOJ), Statistical Institute of Jamaica, (STATIN). JamaicaSurvey of Living Conditions, 1989-2007. Kingston: PIOJ, STATIN; 1989-2008.[19] Statistical Institute of Jamaica (STATIN). Demographic Statistics, 1988-2007. Kingston;STATIN; 1989-2008.[20] Planning Institute of Jamaica (PIOJ). Economic and social survey of Jamaica, 1990-2007.Kingston: PIOJ;1991-2008. 324
  • [21] National Family Planning Board (NFPB). Reproductive Health Survey 2002. Kingston:NFPB;2005.[22] Norman LR. Predictors of consistent condom use: A hierarchical analysis of adults fromKenya, Tanzania and Trinidad. Int J of STD & AIDS. 2003;14:584-590.[23] Nnedu ON, McCorvey S, Campbell-Forrester S, et al. Factors influencing condom useamong sexually transmitted infection clinic patients in Montego Bay, Jamaica. The OpenReproductive Science J 2008;1:45-50.[24] Cook RJ, Maine D. Spousal veto over family planning services. Am J of Public Health1987;77(3):339-344.[25] Feyisetan B, Pebley AR. Premarital sexuality in urban Nigeria. Studies in Family Planning1989;20(6):343-354.[26] Hull TH, Hasmi E, Widyantoro N. “Peer initiatives for adolescent reproductive healthprojects in Indonesia. Reproductive Health Matters 2004;12(23):29-39.[27] Sychareun V. Meeting the contraceptive needs of unmarried young people: Attitudes offormal and informal sector providers in Vietiane Municipality, Lao PDR. Reproductive HealthMatters 2004;12(23):155-165.[28] Pan American Health Organization (PAHO). Health in the Americas, 2007 volume II-Countries. Washington, D.C: PAHO;2007. pp.448-464.[29] Population Action International (2007). A Measure of Survival. Calculating Women’sSexual and Reproductive Risk. Washington DC: Population Action International.[30] World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009.[31] Rawlins, Joan and Crawford, Tazhmoye (2006). Women’s Health in the English-SpeakingCaribbean: The Case of Trinidad and Tobago. Journal of Social and Economic Studies; 55(4),2006:1-31.[32] Camara, B., Lee, R., Garweed, J., Wagner, H., Cazal-Gamelisky, R., and Boisson, E.(2003); in Rawlins, Joan and Crawford, Tazhmoye (2006). Women’s Health in the English-Speaking Caribbean: The Case of Trinidad and Tobago. Journal of Social and Economic Studies;55(4), 2006:1-31.[33] Thomas, Tara (2006). Youth Reproductive and Sexual Health in Jamaica. Washington DC.,Advocates for Youth.[34] USAID. HIV prevention knowledge base: Emerging areas. HIV prevention forserodiscordant couples. New York: USAID; 2009. www.aidstar-one.com/prevention/knowledgebase.[35]. Bunnel R, Opio A, Musinguzi J, et al. HIV transmission risk behavior among HIV-infectedadults in Uganda: Results of nationally representative survey. AIDS 2008;22(5:617-24.[36] Bunnel R, Nassozi J, Marum E, et al. Living with discordance: Knowledge, challenges, andprevention strategies of HIV-discordant couples in Uganda. AIDS Care 2005;17(8):999-1002.[37] Dunkle K, Stephenson R, Karita E, et al. New heterosexually transmitted HIV infections inmarried or cohabiting couples in urban Zambia and Rwanda: An analysis of survey and clinicaldata. The Lancet 2008;37:2183-91.[38] Henry-Lee A. Women’s reasons for discontinuing contraceptive use within 12 months:Jamaica. Reproductive Health Matters 2001;9(17):213-220.[39] Crawford TV, McGrowder DA, Crawford A. Access to contraception by minors in Jamaica:a public health concern. North Am J of Med Scie 2009;1(5):247-255. 325
  • [40] Warren DP, Morris L, Jackson J, Hamilton P. Fertility and family planning among youngadults in Jamaica. Int Family Planning Perspectives 1988;14 (4):137-141.[41] Duncan J, Gebre Y, Grant Y, et al. HIV prevalence and related behaviors among sexworkers in Jamaica. Sexually Transmitted Disease 2010.[42]. Drayton VLC. Contraceptive use among Jamaican teenage mothers. Rev Panam SaludPublica 2002;11(3):150-157.[43] Douglas DL. Perspectives on HIV/AIDS in the Caribbean. In: Morgan O (ed). Health issuesin the Caribbean. Kingston: Ian Randle; 2005:pp. xv-xxi.[44] Jamaican Ministry of Health (MoH). Strategic framework for reproductive health within theFamily Health programme 2000-2005. Kingston: MoH; 2000.[45] Steiner MJ, Cates W. Are condoms the answer to rising rates of non-HIV sexuallytransmitted infections? Yes. BMJ 2008;336(7637):184.[46] Carey RF, Lytle CD, Cyr WH. Implications of laboratory tests of condom integrity. SexTransm Dis 1999;26:216-20.[47] Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. Jamaica health and lifestylesurvey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies,Mona; 2008.[48] World Health Organization (WHO). Reproductive health research at WHO: a newbeginning. Biennial Report 1998-1999. Geneva: WHO;2000: p.31. 326
  • Table 12.1. Sociodemographic characteristic of sample, n = 7,168Characteristic n %Religiosity At least once a week 2707 37.8 At least once a month 1368 19.1 Less than once a month 861 12.0 Only on special occasions (weddings, funerals, 1631 22.7christening) Does not attend at all 524 7.3 No response 77 1.1Marital status Legally married 1542 21.5 Common-law 1733 24.2 Visiting 1959 27.3 Not currently in union 1934 27.0Currently pregnant Yes 288 4.4 No 6219 94.6Ever been pregnant Yes 5301 84.3 No 985 15.7Forced to have sex Yes 747 11.6 No 5707 88.4Currently having sex (in the last 30 days) Yes 4289 59.8 No 2879 40.2Currently using a method of contraception Yes 4027 63.8 No 2282 36.2Employment status Unemployed 4143 57.8 Employed 3025 42.2Are of residence Urban 1144 16.0 Semi-urban 2079 29.0 Rural 3945 55.0Socioeconomic class Lower 1705 23.8 Middle 3079 43.0 Upper 2384 33.2No. of pregnancies that resulted in live births median 2.0 (0, 14)(range)Years of schooling mean (SD) 13.0 years (3.0 years)Age mean (SD) 31.3 years (9.3 years)Age of first sexual intercourse median (range) 17.0 (15,49), mean =15.2 yrs (SD =5.8) 327
  • Table 12.2. Particular demographic characteristics by age group of respondents, n= 7,126 Age group PCharacteristic 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40-44 yrs 45-49 yrs % % % % % % %Currently pregnant Yes 9.3 5.7 6.6 5.4 3.3 0.1 0.1 χ2 = 111.5, P < 0.001Ever been pregnant Yes 35.7 67.1 83.5 91.8 93.6 96.1 95.4 χ2 = 1289.8, P < 0.001Forced to have sex Yes 21.4 23.8 19.0 21.0 19.1 18.8 18.9 χ2 = 11.6, P = 0.071Currently having sex (in the last 30days) Yes 51.8 66.3 71.2 69.1 64.9 66.9 56.2 χ2 = 92.8, P < 0.001Currently using a method ofcontraception Yes 62.9 67.4 64.5 66.7 64.6 61.9 53.9 χ2 = 37.7, P < 0.001Want to be pregnant Yes 7.4 21.9 31.0 35.6 36.8 18.2 11.6 χ2 = 75.6, P < 0.001Ever had sexual intercourse Yes 51.4 94.8 97.4 98.8 99.0 100.0 99.7 χ2 = 2497.1, P < 0.001Age at first sexual intercourse mean 7.7 (7.7) 15.3 (4.2) 16.4 (4.3) 16.9 (4.2) 17.0 (3.7) 17.2 (3.2) 15.1 (5.8) F = 11416.7, P <0.0001(SD) in yearsFrequency of sexual intercourse in 2.0 (9.3) 1.5 (6.2) 1.8 (8.0) 1.5 (6.5) 1.5 (6.4) 1.9 (8.6) 1.5 (6.3) F = 0.5, P <0.0001last 30 days Mean (SD)No. of men had sexual intercourse 6.6 (21.4) 2.7 (11.9) 2.7 (11.9) 3.2 (13.4) 3.1 (13.4) 3.2 (13.7) 2.1 (9.9) F = 5.1, P <0.0001with (in last 3 months)Age at first contraceptive use (in 15.9 (1.4) 17.8 (2.2) 19.2 (3.0) 20.0 (3.9) 20.7 (4.5) 21.8 (5.6) 22.6 (4.3) F = 198.6, P <0.0001years) 328
  • Table 12.3: Frequency of condom use (with non-steady partner) by age group, n = 1,748 Age group 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40-44 yrs 45-49 yrs TotalFrequency of condom usage % % % % % % %Always 11.8 13.6 14.9 14.2 10.5 12.0 9.4 12.9 Most of the time 7.0 9.6 6.5 5.3 4.9 6.9 8.2 6.8 Seldom 0.0 0.3 0.0 0.6 0.0 0.0 0.0 0.2 Never 3.9 6.3 5.9 6.5 7.9 6.3 7.1 6.2 77.3 70.2 72.8 73.4 76.7 74.9 75.3 73.9Never had non-steady partnerTotal, n 229 332 323 338 266 175 85 1748χ2 = 20.9, P = 0.644 329
  • Table 12.4: Table 3: Frequency of condom use (with steady partner) by age group, n = 1,767 Age group 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40-44 yrs 45-49 yrs TotalFrequency of condom use % % % % % % % %Always 49.4 38.9 41.5 42.0 43.2 54.2 55.8 44.4Most of the time 43.7 54.2 49.5 48.7 50.9 38.5 38.4 48.0Seldom 2.6 5.7 8.7 8.5 5.1 6.7 5.8 6.4 Never 0.0 0.3 0.0 0.3 0.4 0.0 0.0 0.2Never no steady partner 4.3 0.9 0.3 0.6 0.4 0.6 0.0 1.0Total, n 231 332 323 343 273 179 86 1767χ2 = 63.6, P < 0.0001 330
  • Table 12.5. Logistic regression: Explanatory variables on method of contraception usage ofwomen (ages 15 – 49 years) in Jamaica, n = 6,043 R2 Explanatory variable Odds ratio CI (95%) Age 0.98*** 0.98 - 0.99 0.006 Lower class (reference group) 1.00 Upper class 0.83** 0.73 - 0.95 0.002 In union 3.35*** 2.80 - 4.02 0.158 Urban (reference group) 1.00 Rural 1.16* 1.02 - 1.32 0.001 Currently pregnant 0.01*** 0.00 - 0.02 0.114 Currently having sex 2.29*** 1.95 - 2.70 0.034 Number of partners 1.85*** 1.57 - 2.17 0.036 Age at which began using contraception 0.99** 0.98 - 1.00 0.002 Crowding 1.4*** 1.21 – 1.60 0.0052Log likelihood = 5588.0R2 = 0.358Model χ2 (df = 9) = 1684.75P-value < 0.0001Overall correct classification = 78.5%Correct classification of cases that currently use a method of contraception = 91.8%Correct classification of cases that are not currently using a method of contraception = 54.2%*P < 0.05, **P < 0.01, ***P < 0.001 331
  • Chapter 13Young adult men and their reproductive health issues in a developing country Paul A. Bourne, Christopher A.D. CharlesIntroductionThe purpose of this article is to understand the use of contraceptive methods by males 15-24years of age in Jamaica. Jamaica is a Third World country with an ever-increasing population,and public resource constraints to address development imperatives, one of which is reproductivehealth. There is a dearth of published research on the reproductive health of Jamaican males, sothis article is a modest effort to address the issue. Among some low-income men, familyplanning is viewed as fathering the number of children a man can provide for. Although most ofthe men had poor and misconceived knowledge, they were nonetheless aware of the traditionaland modern methods of birth control. The men believed that the use of these modern methodsdiscouraged family planning and led to side effects. The family planning methods were not usedbecause children are considered a source of wealth.1 One study showed that the use of contraceptives by wives was a function of theencouragement their husbands received from social networks, which triggers communicationbetween the partners about reproductive health.2 Whenever partners engage in mutual decision-making about the use of contraceptives and sexual activities, men are construed as the initiatorsof sexual intercourse, and women are more likely to suggest that they use a condom.3 However,religious influence can be disruptive in mutual decision-making about reproductive health. Onestudy found that 63% of men did not use condoms for religious reasons, and did not want theirwomen to use contraceptives.4 Similarly, masculine identity influences reproductive health 332
  • decision-making in intimate partner relationships. Some men keep the decision about the use ofcontraceptives under their control when they are negotiating their masculine identity duringsexual intercourse.5 College men who had sexual intercourse in the last 30 days for the first time were youngerthan a similar cohort of college women. More often than not these men had their first encounterwith someone to whom they were not emotionally attached. Some 60% of the men did not use amethod of contraception, or the method they used was unreliable. The most frequent reasonreported by the men for not using a contraceptive was that the encounter was unplanned. Thenon-use of contraceptives was also influenced by the men’s inaccessibility to sources ofcontraceptives and their lack of knowledge. Some 21.9% of the men said they did not use acontraceptive because it was inconvenient.6 Despite the availability of the pill, the rate ofunwanted pregnancies among adolescents has grown significantly. Therefore, increasing men’sinvolvement in contraception can make a difference to the trend of unwanted pregnancies.7 Men’s involvement is indeed relevant, because among mature men perceived behaviouralcontrol and belief about condom use are important in reproductive health. An online survey ofmen’s attitudes and beliefs towards male hormonal contraceptives (MHC) suggests that ingeneral perceived behavioural control was the most significant predictor of their intention to tryMHC. The men’s belief about condom use was the most significant predictor of the use of MHCalong with condoms. Some 56% of the men stated that MHC would reduce their use ofcondoms.8 Targeting men when they are watching sports is of critical importance. Reproductivehealth information disseminated during football games, and the presentation of other sport-related images, are particularly useful in reaching men about the long-term use of moderncontraceptives.9 333
  • The purpose of this article is to understand the reproductive health of males 15-24 yearsof age in Jamaica. Reproductive health is an issue of critical importance in this developingcountry because it affects development targets in general, and the health system in particular,through population growth. Below is the method of data collection used in the study.MethodsSample: This descriptive cross-sectional study used a secondary dataset from the NationalFamily Planning Board. There are two sets of inclusion criteria, which are males and ages. Theeligibility criterion for age was 15 to 24 years at last birthday. Since 1997, the National FamilyPlanning Board (NFPB) has been collecting information on men (ages 15-24 years) and women(ages 15-49 years) in Jamaica regarding contraception usage and/or reproductive health. In2002, the Reproductive Health Survey (RHS) collected data on Jamaican men ages 15-24 yearsand women 15-49 years. The current study, using 2,437 men, extracted the sample of men (ages15-24 years). Stratified random sampling was used to design the sampling frame from which thesample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage samplingdesign was used. Stage 1 was the use of a selection frame of 659 enumeration areas (orenumeration 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 madeup 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 Jamaicacompared to Region 2, at 14.1%; Region 3 at 17.6% and Region 4 at 21.8% [10] 334
  • In stage 2 the households were clustered into primary sampling units (PSUs), and eachPSU constituted an ED, which in turn was comprised of 80 households. The previous samplingframe was in need of updating, and so this was performed between January and May 2002. Oncompletion of the exercise, the total number of households visited was 15,950 of which 17.5% ofthe inhabitants dwelled in urban areas, 27.7% resided in semi-urban zones and 54.8% lived inrural areas. Almost 18% of the households had eligible men (ages 15-24 years old, n = 2,795men). Sixteen percent of the eligible men resided in urban areas, 27.7% lived in semi-urban areasand 56.4% dwelled in rural areas. The new sampling frame formed the basis upon which thesampling size was computed for the interviewers to use. The sample represents a response rate of87.2%: 88.3% of eligible urban men, 88.0% of semi-urban and 86.7% of eligible ruralrespondents. Stage 3 was the final selection of one eligible male from each sampled household and thiswas 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 instrumentadministered 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-testingof the instrument was conducted between March 16 and 20, 2002. A total of 175 instrumentswere 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 wasweighted in order to represent the population of men ages 15 to 24 years in the nation.Statistical methods 335
  • We used the Statistical Packages for the Social Sciences (SPSS) for Windows, Version 16.0(SPSS Inc; Chicago, IL, USA). Frequencies and means were computed on the sociodemographiccharacteristics. We also performed χ2 tests and F-tests to evaluate associations and differencesamong mean scores. Stepwise multiple logistic regressions were used to analyze factors thatexplain the current usage of a contraceptive method. Odds ratios were determined from the useof a binary logistic regression model. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the finalconstruction of the model.11 To derive accurate tests of statistical significance, we usedSUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), andthis was adjusted for the survey’s complex sampling design. A P-value < 0.05 (two-tailed) wasused to determine statistical significance.MeasureCrowding is the total number of persons in a dwelling (excluding kitchen, bathroom andverandah).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. Thesemethods include tubal ligation, vasectomy, implant (norplant), injection, emergencycontraceptive protection, pill, condom, foaming tablets, creams, jellies, diaphragm, abstinence,withdrawal, the rhythm method, calendar or Billings. The dependent variable for this study was acontraceptive method which was coded as a binary variable from those who indicated yes to anyof the afore-mentioned methods of contraception. 336
  • Non-steady sexual partner denotes casual sexual relations with someone with whom theindividual is not having a common-law sexual relationship, visiting relationship or to whom theindividual is legally married.Education is taken from the question, ‘How many years did you attend school?’ This is coded asprimary or below (0 – 9 years), secondary (10-12 years) and tertiary (13+ years).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.Number of sexual partners is taken from the question, ‘How many “baby mothers” (includingwives) have you had?ModelUsing logistic regression, this study seeks to examine factors associated with the methods ofcontraceptive used among men in Jamaica. Different social factors influence men’s choices, andtheir decision to use a method of contraception, and this study used Grossman’s model, whichestablished a connection between the use of econometric analysis and the use of health demand.Grossman’s model has been modified and used by many scholars to examine health, healthoutcome and other health-related issues. The current research will use the theoretical framework of Grossman’s econometricanalysis to examine factors that are associated with the method of contraception usage amongmen ages 15-24 years in Jamaica. The variables used in this econometric model are based on theliterature as well as the dataset. We will test the hypothesis that the method of contraceptionusage among men ages 15-24 years is determined by particular sociodemographic variables. Based on the literature, the following variables were examined using logistic regression:Dependent - method of conceptive used. Independent - age of respondents; educational level; 337
  • employment status of young adult man; social class of young adult man; area of residence;someone currently pregnant for respondent; forced to have sex (young adult man i); sharedsanitary convenience with non-household members; age of first sexual relations; currently hadsexual intercourse in the last 30 days; number of sexual partners; religiosity; currently in a sexualunion; hearing family planning message; crowding in household; age at which began usingcontraceptive method; involvement in family planning programme and having had sexualintercourse in the last 30 days with a non-steady partner.ResultsTable 13.1 presents information on the sociodemographic characteristics of the sample. Almost59% of the sample had their first sexual encounter between 15-19 years and 41% between ages20-24 years. When respondents were asked “Which is your preferred source of information aboutfamily life or sex education topics?” marginally more indicated teacher (25.4%) thanparent/guardian (22.5%), peers/friends (20.6%), sibling (13.5%), telephone counselor (13.5%)and lastly by radio (1.2%). None of the respondents indicated television, audiovisual materialsand printed materials. When the respondents were asked ‘What is the method of contraception that was used bythemselves or their partners that last time they had sexual relations?’ 60.5% indicated a malecondom, 3.4% said the pill, 0.1% claimed the emergency contraceptive protection, 1.0% statedthe rhythm or calendar method, and 32.9% did not respond to the question. Sixty-three percent ofthe sample indicated that they have had sex with a non-steady partner. Of those who have hadsex with a non-steady partner, 72.4% indicated that they have always used a condom, 22.7% said 338
  • they used a condom most of the time, 1.7% said they have never used a condom, and 3.2%claimed that they seldom used a condom. A significant statistical association existed between frequent church attendance and areaof residence (χ2 = 45.9, P-value < 0.0001). Almost 25% of urban respondents attended church atleast once a week, compared to 23% of those who dwelled in semi-urban zones and 21% in ruralareas. Figures 13.1 and 13.2 present information on contraceptive methods, having had sex inthe last 30 days, and having never had sexual intercourse, by age group of respondents. Table 13.2 provides information on source of family life or sex education by age group ofrespondents. Using logistic regression analyses, three variables emerged as statistically significantdeterminants of the current contraceptive methods of the participants (Table 133).Discussion This study examined the method of contraception used by Jamaican males and the factors thatinfluenced their decisions. The overwhelming majority of men (81%) have had sex, but only53% had sexual intercourse in the last 30 days. However, only 24% among the currently sexuallyactive males always used a condom. The most prevalent method of contraception used by themen is condoms (60.5%) with pills, emergency contraceptives and the rhythm methodaccounting for 4.5% of the other methods, based on the descending order of use. A largeproportion of the men (63%) had sex with a non-steady partner, with 72.4 % of this groupdeclaring that they always used a condom. This finding means that just under 30% of the menwho were sleeping with multiple partners did not always use a condom, which increased theirrisk of sexually transmitted infections (STIs). Hence when studies reveal the method of 339
  • contraception usage among people of a particular gender, socioeconomic status or otherdemographic characteristics12-14 without providing information on the frequency of the usage ofthe contraceptive method, it does not give a true picture of their reproductive practices. Thecurrent study found that 83% of young males were currently using a contraceptive method, butthat only 24% always used a condom and 28% remarked most times, which means that theprevalence of 83% contraceptive usage would be excellent, and speaks volumes about theseemingly healthy lifestyle practices of young males. However, this becomes farther from thetruth when the data are examined using frequency of contraceptive method usage. This research,therefore, provides a better understanding of young men’s reproductive attitudes, and theirinvolvement in risky sexual practices, and not merely the usage prevalence of a male method ofcontraception. The findings which emerged from this study also support other studies that haveexamined men’s health and men’s reproductive attitudes and practices.15-17 Despite their awareness of the probability of contracting HIV or AIDS owing to unsafesexual practices, there are still many men who do not frequently use a condom. It may appeardifficult to understand that there is not an increase in frequent condom usage or condom usageamong men in different geopolitical regions, as is the case in this study,18-22 but a part of this isembedded in the culture which ties masculinity to fertility. A Caribbean anthropologist, in aCaribbean research, found that young males are socialized to be strong, eschew weakness, havemany women and children as well as avoid health care utilization, because this is interpreted asweakness.23 Embedded in Chevannes’ findings23 is a sociological explanation as to why youngCaribbean males would be reluctant to frequently use a condom. Maleness or manhood,according to Chevannes23 means taking risks. Sexual risk-taking is among many risks that mentake, and so reluctance towards condom usage is one more risk that young males would be more 340
  • likely to take, in comparison to older men who have material resources, family and have hadmany of the experiences that young males are involved in. Some 53% of the men indicated that they did not use a method of contraception whenthey had sexual intercourse for the first time. The majority of these men (54.8%) had their firstsexual intercourse with a woman to whom they were not emotionally attached in a relationship.These findings corroborate those of the study done by Needle,6 that the majority of men incollege who had their first sexual intercourse did so without a contraceptive and with a woman towhom they were not emotionally attached. There are other similarities between the findings ofthe study done by Needle and the findings of the current study. The first sexual intercourse wasunplanned for 38% of the men in the current study, 16% did not have access to a contraceptive atthe time of their first sexual intercourse, and 30% displayed a lack of knowledge about methodsof contraception. Despite these findings, the majority of the men (60.8%) used a condom in theirlast sexual intercourse to prevent pregnancy and STIs. However, the foregoing finding meansthat 15% of the men who recently had sex and used a condom used it only for preventing STIs orpregnancy, because 25% of the men stated that they did not know why they used a condom. It ispossible that their female partner asked these men to use a condom. Nevertheless, these menneed to be educated to understand that the use of condoms prevents not only pregnancy but alsoSTIs. This education is of the utmost importance, given the negative impact that unwantedpregnancies and STIs have on reproductive health. The low prevalence of males using acontraceptive method at first, or in repeated sexual relations in Jamaica, is also the case in SouthAsia, particularly Nepal,24 which denotes that there are attitudes and practices among males thatextend beyond the Caribbean. 341
  • The majority of the men (53%) stated that they were responsible for supplying themethod of contraception. These men may be negotiating their masculine identity during sexualintercourse by taking control over the use of the method of contraception.5 Pharmacies are themajor outlets for the methods of contraception used, because 69% of the men get theircontraceptives from pharmacies, compared to 16.1% who get them from health centres andhospitals. The use of the pharmacies suggests a cost to these men. Therefore, the reproductivehealth policy, which influences the transmission of STIs as well as population growth, shouldmake condoms more readily available in the public health system. The greater availability ofcondoms free of cost to these men should push the use of condoms beyond the 60.8% of thosewho reported that they used a condom during their last sexual intercourse. The men received information on sex education or family life education from severalinstitutional sources. These institutional sources, in descending order of importance, are teachers,parents and peers/friends. The fact that radio, television and printed material were not reportedby the men as sources of information about sex and family may be due to the ascendancy of theinternet and the attendant social networking sites as sources of information. Therefore, anyeducation campaign component of a reproductive health policy should use the internet and socialnetworking sites to disseminate information. The three significant explanatory factors for the current contraceptive methods used bythe men are having someone pregnant, sharing sanitary facilities with a non-household memberand having had sexual intercourse in the last 30 days with a non-stable partner. The men wereless likely to use a method of contraception when their partner was pregnant. One possiblereason for this finding is that some men generally prefer to have sex without condoms, and theirpartners being pregnant provides the opportunity for them to have sex with their pregnant partner 342
  • without using a condom. The likelihood of the men using a condom decreases when they sharesanitary facilities with persons who are not a part of their household. This may occur becauseusing shared sanitary facilities with non-household members provides opportunities for the mento have unplanned and so unprotected sex with women with whom they do not have arelationship. The men are more likely to use a method of contraceptive when they have hadsexual intercourse in the last 30 days with a non-stable partner. It is possible that these men use acondom because they are not sure of the STI status of the woman, since she is not their steadypartner and maybe had sexual intercourse in the last 30 days with other men. It is also possiblethat these men may not want to father a child with their non-stable partner. Other studies have shown that the low use of male-based methods has been attributed tolack of awareness of different methods, opposition by husbands, lack of method satisfaction, fearof side effects and poor access to family planning services.25-29 However, in the current researchwe found something of a difference. We found that high contraceptive usage (male-basedmethod) was owing to having had sexual intercourse in the last 30 days with a non-stablepartner. However, the low contraceptive method usage was owing to (1) being in a relationshipwith a woman who is currently pregnant and (2) shared sanitary conveniences. The issue of fearof side effects and lack of a method of satisfaction do not account for the low male-method usedby young males in Jamaica as there is an embedded belief that condom usage should be moreused with a stranger than a stable partner, which opens the individual to the risk of his partner’slifestyle. Hence, the opposition of females or wives to the use of condoms is also embedded inthis study, as they would question the practices of the male partner or their fidelity in therelationship. Therefore policies that are geared towards male reproductive attitudes cannot cease 343
  • with increased condom usage, as is evident in this study as well as others,30-34 because clearly thecurrent reproductive health programmes are not reaching all the men of Jamaica. A part of the rationale for why the current reproductive health intervention gearedtowards males is not reaching them, is embedded in the fact that most of the family planningprogrammes are designed primarily to serve women.35,36 It is evident that there many options inmethods of contraception for women, compared to those for males. Males are limited to coitus-dependent ones such as the condom or withdrawal, or permanent choices such as vasectomy orhormonal contraceptives. Young males would not be willing to use the latter method, whichsubstantially limits their choices. This limited choice in contraceptive methods for males isfuelling the low usage among them, and it is difficult for family planning methods to effectivelyreach men of all ages in the world, which is equally the case in Jamaica. Males are boxed in to alimited choice of methods of male-contraception, and if they refuse to use either choice, it meansthat they are exposing themselves to risky sexual behaviour.ConclusionThe majority of men currently had sexual intercourse in the last 30 days. Church attendance andage influenced the men’s involvement in sexual intercourse, because men who attended churchfrequently and were younger were more likely to abstain from sexual intercourse. The men usedseveral methods of contraception such as the pill, the rhythm method and condoms, with themajority using the latter contraceptive. The majority of the men had engaged in sexualintercourse in the last 30 days with a non-steady partner, and a significant minority of these mendid not always use a condom, thereby increasing the risk of STIs. The majority of the menclaimed responsibility for making the decision about the use of contraceptives, and pharmacieswere the most popular outlet from which contraceptives were purchased. The three significant 344
  • factors that explain the current method of contraception used by the men were having had sexualintercourse in the last 30 days with a non-steady partner, sharing sanitary facilities with a non-household member and a woman being pregnant for them. A national reproductive health policyis needed to take into account the type of contraceptives used, the institutional sources of sexeducation, the sources of contraceptives, the risk of STIs and the three explanatory factors for themethods of contraception used.DisclosuresThe authors report not conflict of interest with this work.References[1] Wambui T, Ek AC, Alehagen S. Perceptions of family planning among low income men in Western Kenya. International Nursing Review 2009; 56(3):340-345.[2] Avogo W, Agadjanian V. Men’s social networks and contraception in Ghana. Journal of Biosocial Science 2008; 40(3): 413-429.[3] Harvey SM, Beckman LJ, Browner CH, Sherman CA. Relationship power, decision making, and sexual relations: An exploratory study with couples of Mexican Origin. Journal of Sex Research 2002; 39 (4):284-291.[4] Degni F, Mazengo C, Vaskilampi T, Essen B. Religious beliefs among Somali men living in Finland regarding the use of the condom by men and that of other forms of contraception by Women. The European Journal of Contraception and Reproductive Health Care 2008; 13(3): 298-303.[5] Castro-Vasquez G, Kishi I. Silence, condoms, and masculinity: Heterosexual Japanese males negotiating contraception. Men and Masculinities 2007; 10(2):153-177.[6] Needle RH. The relationship between first and sexual intercourse and ways of handling Contraception among college students. Journal of the American College Health Association 1975; 24(2):106-111.[7] Chng CL. The male role in contraception: Implications for health education. Journal of School Health 1983; 53(3): 197-201.[8] Thompson MM. Males and male hormonal contraception. Dissertation Abstracts International Section A: Humanities and Social Sciences 2008; 68(12-A):4994.[9]. Mi Kim Y. Stimulating men’s support for long-term contraception: A campaign in Zimbabwe. Journal of Health Communication 1997; 2(4):271-297.[10] National Family Planning Board. Reproductive Health Survey, 2002 (Jamaica). Kingston: NFPB; 2005.[11] Grossman M. The demand for health- a theoretical and empirical investigation. New York: National Bureau of Economic Research, 1972. 345
  • [12] Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D: Jamaica health and lifestylesurvey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies,Mona; 2008.[13] Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States,1994 and 2001. Perspectives on Sexual Reproductive Health 2006;38:90-96.[14] Mosher WD, Martinez GM, Chandra A, Abma JC, Willson SJ. Use of contraception and useof family planning services in the United States, 1982-2002. Advance data from vital and healthstatus; no. 350. Hyattsville, Maryland: National Center for Health Statistics; 2004.[15] International Conference on Population and Development, Programme of Action, NewYork: United Nations (UN), 1994.[16] Drennan M, Reproductive health: new perspectives on mens participation, PopulationReports, 1998, Series J, No. 46.[17]. Masson OK and Herbert LS, Husbands versus wives fertility goals and use ofcontraception: the influence of gender context in five Asian countries, Demography, 2000,37:299–311.[18] The Alan Guttmacher Institute (AGI), In Their Own Right: Addressing the Sexual andReproductive Health Needs of Men, New York: AGI, 2003.[19] Ezeh AC, Seroussi M and Raggers H, Mens Fertility, Contraceptive Use, and ReproductivePreferences, Calverton, MD, USA: Macro International, Inc., 1996.[20] Salem R, Mens surveys: new findings, Population Reports, 2004, Series M, No. 18.[21]. U.S. Agency for International Development Interagency Gender Working Group, ReachingMen to Improve Reproductive Health for All: Resource Guide, Washington, DC: PopulationReference Bureau, 2003.[22]. Hulton L and Falkingham J, Male contraceptive knowledge and practice: what do weknow? Reproductive Health Matters, 1996, 4(7):90–100.[23] Chevannes B. Learning to be a man: Culture, socialization and gender identity in fiveCaribbean communities. Kingston, Jamaica: The Univer. of the West Indies Press; 2001.[24] UN, World contraceptive use 2005 wall chart, New York: Department of Economic andSocial Affairs, Population Division, UN, 2005.[25] Casterline JB, Zaba AS and Manhaj MH, Obstacles to contraceptive use in Pakistan: a studyin Punjab, Studies in Family Planning, 2001, 32(2):95–110.[26]. Casterline JB and Sinding SW, Unmet need for family planning in developing countriesand implications for population policy, Population and Development Review, 2000, 26(4):691–723. 346
  • [27]. Bongaarts J and Bruce J, The causes of unmet need for contraception and the social contentof services, Studies in Family Planning, 1995, 26(2):57–75.[28]. Bankole A, Desired fertility and fertility behaviour among the Yoruba of Nigeria: a studyof couples preferences and subsequent fertility, Population Studies, 1995, 49(2):317–328.[29]. Shrestha A, Stoeckel J and Tuladhar JM, The KAP gap in Nepal: reasons for non-use ofcontraception among couples with unmet need for family planning, Asia-Pacific PopulationJournal, 1991, 6(1):25–38.[30] Dahal GP, Padmadas SS, Hinde PRA. Fertility-Limiting Behavior and Contraceptive ChoiceAmong Men in Nepal. International Family Planning Perspectives, 2008, 34(1):6–14[31] The Alan Guttmacher Institute (AGI). In Their Own Right: Addressing the Sexual andReproductive Health Needs of Men, New York: AGI; 2003.[32]. Feyisetan B and Casterline JB. Fertility preferences and contraceptive change in developingcountries, International Family Planning Perspectives, 2000, 26(3):100–109.[33]. Ezeh AC, Seroussi M, Raggers H. Mens Fertility, Contraceptive Use, and ReproductivePreferences, Calverton, MD, USA: Macro International, Inc.; 1996.[34]. Roudi F, Ashford L. Men and Family Planning in Africa, Washington, DC: PopulationReference Bureau; 1996.[35] Ringheim K. Factors that determine prevalence of use of contraceptive methods for men.Stud Fam Plann 1993; 24:87-99.[36] Ringheim K. Whither methods for men? Emerging gender issues in contraception.Reproductive Health Matters 1996;4: 79-89. 347
  • Figure 13.1: Attitude and practices on reproductive health issues by age group 348
  • Figure 13.2: Frequency of condom usage by age group 349
  • Figure 13.3: Method of contraception used by respondent or respondent’s partner by age group 350
  • Table 13.1. Demographic characteristic of sample, n = 2,437Characteristic %Educational level Junior high or below 9.3 Secondary 42.9 Tertiary 47.8Marital status Legally married 3.9 Common-law 40.3 Visiting 17.1 Not currently in union 38.7Had sex in the past Yes 81.3 No 18.7Currently had sexual intercourse in the last 4-week (in the last 30 days) Yes 53.2 No 46.8Currently using a method of contraception Yes 82.7 No 17.3Employment status Employed 34.1 Unemployed 65.9Area of residence Urban 16.2 Semi-urban 27.9 Rural 55.9Shared facilities (sanitary convenience or water) Shared 13.8 Not shared 84.8 Not stated 1.4Someone currently pregnant for you Yes 2.1 No 97.9Frequency of condom usage Always 23.9 Most times 28.1 Sometimes 9.7 Never 2.1 Have no steady partner 11.6 Refused to answer 24.6Age mean (SD) 19.0 years (2.8 years)Age of first sexual relations mean (SD) 14.9 years (3.1) 351
  • Table 13.2: How helpful have you found the following sources? by age group, n = 2,437Characteristic Age group 15 – 19 yrs. 20 – 24 yrs. P-value % %Helpful of sourcesParents/guardians χ2 = 9.772, P = 0.021 Very helpful 56.6 50.8 Somewhat helpful 21.7 22.9 Not helpful 12 15.3 Not a source 9.7 11Sibling χ2 = 0.733, P = 0.866 Very helpful 23 23.1 Somewhat helpful 22.3 23.7 Not helpful 21.5 21.3 Not a source 33.2 32Telephone counselor χ2 = 4.008, P = 0.261 Very helpful 4.5 4.4 Somewhat helpful 7.6 9 Not helpful 16.7 14.1 Not a source 71.3 72.5Teacher χ2 = 11.961, P = 0.008 Very helpful 64.9 59.3 Somewhat helpful 22.2 25.8 Not helpful 4.4 6.7 Not a source 8.5 8.2Peer χ2 = 10.748, P = 0.013 Very helpful 39.5 43.5 Somewhat helpful 36.2 37.7 Not helpful 14 11.1 Not a source 10.4 7.8Radio χ2 = 8.717, P = 0.033 Very helpful 35.1 38.7 Somewhat helpful 37.3 38.4 Not helpful 11.2 10.2 Not a source 16.4 12.6Television χ2 = 3.117, P = 0.374 Very helpful 42.7 46.3 Somewhat helpful 33.1 31 Not helpful 9.9 9.3 Not a source 14.3 13.4 352
  • Table 13.3. Logistic regression: Explanatory variables of respondents who currently usecontraceptive methods, n = 2, 059 Explanatory variable Odd ratio CI (95%) Woman pregnant for respondent (1= yes) 0.08*** 0.04 - 0.16 Shared sanitary facility (1 = yes) 0.62* 0.42 - 0.94 Had sexual intercourse in the last 30 days with non-stable partner (1 = yes) 2.00*** 1.40 - 2.86 Constant 4.99-2Log likelihood = 1032.9R2 = 0.103Model χ2 (df = 3) = 65.2P-value < 0.0001Overall correct classification = 87.8%Correct classification of cases that currently use a contraceptive method = 98.8%Correct classification of cases that did not currently use a contraceptive method = 72.3%*P < 0.05, **P < 0.01, ***P < 0.001 353
  • Chapter 14Sexual behavior and attitude towards HIV testing among non-HIV testers in a developing nation: A public health concern Paul A. Bourne, Christopher A.D. CharlesIntroduction There are several studies dealing with sexual behavior, people’s attitude towards HIV/AIDsand HIV testing [1-4]. In Zimbabwe, one study found that the prevalence of HIV amongmonogamous women was 21.8% [1]. Several factors increase the risk of HIV infection. Thesefactors are the husbands having children with other women, more than five years age differencewithin couples, the woman’s age, and the likelihood of the woman discussing monogamy withher husband in the next three months [1] as well as economic disparities between the sexes. InZambia there is a sizable group of HIV positive neurology patients who suffer from myelopathy,neuropathy/radiculopathy, cerebrovascular diseases and infectious diseases [2]. A multi-countrystudy including Thailand, South Africa, Tanzania and Zimbabwe, which used a sample of 14,818in 48 communities, found that frequent discussions about HIV significantly influenced prior HIVtesting [3]. A study in Vietnam, dealing with HIV risk behavior and the determinants amongpeople living with HIV/AIDS, found that 82% of the participants were sexually active [4]. Some20% of the participants reported having sex with multiple partners, and only one third of theparticipants consistently used a condom. Jamaica manifests some of these problems relating to HIV/AIDS, HIV testing, anddeterminants of risky behaviors seen in other developing countries. Sexual risk taking behavioramong working class women were influenced by being in a relationship with a physically violent 354
  • intimate partner, attitudes towards children as resources, having multiple sexual partners, beingeconomically vulnerable, the perception about men being providers [5] and the vetoing power ofmales on women’s reproductive health matters. Choices and the lack of economic dependencyare accounting for increasing HIV/AIDS/STDs in developing countries. The risk of contracting HIV also affects the incarcerated where the rate of HIV infectionamong prisoners is higher than the incidence in the general population [6]. HIV/AIDS is viewedby some Jamaicans as a homosexual disease. The negative stigma of homosexuality and AIDSinfluences low levels of HIV testing [7]. There is nuanced sympathy for people living withHIV/AIDS. A majority of university students stated that they had no avoidance intentionstowards their relatives and friends living with HIV/AIDS [8]. However, less than one-half of thestudents were sympathetic to gay and lesbians living with HIV/AIDS who were not theirrelatives or friends [9]. It is important to understand the cultural factors at the societal, family and individuallevels that influence HIV risk among Jamaican youth [10]. In 2004, from a survey of Jamaicanyouth, males reported greater condom use (67.9%) during their last sexual intercourse with theirmost recent and regular partner compared to 57% in 1996 [11]. There was no change in the useof condoms among adolescent females for the same period. The youth perceived that they wereat a greater risk for HIV infection in 2004 compared 1996 [11]. Despite the aforementioned fact,there are still many youths who are inconsistently using a condom, indicating the divide betweenknowledge and practice. Public health effort to improve the case management of sexuallytransmitted diseases now includes the private sector. Private medical practitioners are nowreceiving continuing medical education [12] to address the HIV/AIDS epidemic and youths’reproductive health matters. 355
  • Despite the increased risk of contracting HIV owing to inconsistent and impropercondom usage [8-11], many Jamaicans do not want to know their HIV status. A person knowinghis or her HIV status allows the person to get the appropriate medical treatment if they arepositive and prevent the spread of the virus through safe sexual practices. Douglas opined thatthe major cause of mortality among women of 15-44 years in the Caribbean is AIDS, and that 1in every 50 Caribbean national was infected with HIV/AIDS [13], suggesting that there are somepremature mortality arising owing to not being cognizant of one’s HIV status. Sexual relation is primarily the medium through which most people contract HIV/AIDS[14]. In 2007/2008, Wilks et al. conducted a study of some 2,848 Jamaicans between the ages of15-74 years; they found that 3.4% of females reported having been infected with a STI in thestudied period compared to 1.3% of males [15]. Although the prevalence of males having hadSTI is greater than that of females, which is concurred by Wilks et al study (males, 18.1%;females, 11.0%) [15], with the context that more males (having multiple partners in last 12months, 41%) are promiscuous than females (8.4%) [15], there is a pending public healthproblem that is underlying the females allowing males to have vetoing power over theirreproductive health issues and having male partners inconsistently using condoms. This realityrequires immediate public health intervention. An extensive research of the literature found nostudy which has examined the attitude of non-HIV testers towards future HIV testing as well astheir current attitude and sexual behaviour. Within this context, the objectives of this paper are to(1) investigate the sexual behavior of non-HIV testers in Jamaicans, and (2) their attitudestowards future HIV testing.MethodSample 356
  • The current study extracted a sample of 1,192 participants, from a nationally representativesurvey, who indicated that they had never had an HIV test done up to 2004. The HIV/AIDS/STDNational KABP Survey comprised 1,800 participants 15-49 years of age who resided in Jamaicaat the time of the survey (May-August, 2004) [16]. The data was collected by Hope EnterprisesLimited on the behalf of the Ministry of Health [16]. A multi-staged sampling design was used tocollect the data. Each of the 14 parishes in the country is stratified into electoral constituencies,with each constituency stratified into three areas – rural areas, parish capitals (urban areas) andmain towns (semi-urban areas). The areas which comprised a constituency were then stratifiedinto primary sampling units (PSUs) or electoral enumeration districts (EDs). A random sample of each PSU was then selected based on probability proportional to size(PPS). Seventy-two EDs were selected for the study – 23 EDs in the urban areas, 25 EDs in thesemi-urban areas, and 24 EDs in the rural areas. Twenty-five households were systematicallychosen from each ED, and cluster sampling was carried out with all the people living in thehousehold of the designated ages interviewed for the survey.Data sources A questionnaire was used to collect the data from the participants. Trained interviewers usedface-to-face interviews to collect the data. The interviewers were trained for a 5-day period, ofwhich 2 days were devoted to field practices. Interviewers were assigned to a team comprisingtwo females, two males and a supervisor. Verbal consent was sought and given before theinterviews commenced. The participants were informed of their right to confidentiality and theirright to stop the interview at any time. No names, addresses or other personal information wascollected from the participants to ensure anonymity. The instrument used in the survey utilized 357
  • indicator measures and definitions consistent with UNAIDS and the USAID Priority PreventionIndicator.Statistical analyses Data were entered, stored and retrieved using SPSS for Windows, Version 16.0 SPSS Inc;Chicago, IL, USA). Descriptive statistics were generated for the socio-demographic variables.Multivariate logistic regressions were fitted using one outcome measure: self-reported confirmedpositive HIV test results. We looked at correlation matrices in order to examine multicollinearity.Where collinearity existed (r > 0.7), variables were entered independently into the model todetermine those that should be retained during the final model construction. A p-value < 0.05(two-tailed) was used to establish statistical significance.Results Table 14.1 presents the demographic characteristics of sample. Of the sample (n=1192participants), 54.4% was males, 42.9% were employed, and the majority had secondary leveleducation. Of those who had never done a HIV test ( n=1192), 78.0% indicated that they would bewilling to do this in the future; 16.3% have STI; 55.2% are currently and actively practicing areligion; 14.9% are laborers; 38.8% are household helpers and office attendants; 31.1% aresecurity guards, hairdressers, taxi operators, machine operators and cosmetologist, 3.6%teachers, police officers, nurses and technicians; 6.8% clerks, 2.2% manager, assistant managersand heads of small businesses, 0.2% business executives, and 0.4% professionals (doctors,lawyers, architects, etc.). When the participants were asked “What is the chance of [you] catching HIV?” 57.7%indicated none, 30.2% said little, 6.3% reported moderate and 5.8% remarked a good chance. 358
  • However, 20.5% had sex with at least two partners in the last 4 weeks. Seventy-two percent hadsexual relations with one partner. Only 53.4% used a condom the first time with their currentpartners, and 36.1% indicated that their current partner has other partner(s). Fewer than 70% ofthe sample indicated that their next most recent partner had other sexual partner(s). A statistical difference was found between the mean number of sexual partners males hadin the last 12 months (2.6, SD = 4.0) and females (existed between the mean age of sexual debutfor males (14.2 years, SD = 3.2 years) and that of females (16.5 years, SD = 2.8 years) – t-test = -11.443, P < 0.0001. Table 14.2 shows information on the reasons the participants gave for not using acondom by current, next recent and next most recent partner. The findings reveal that between10% and 15% of the participants do not like using condoms with current, next recent or nextmost recent sexual partner(s), and between 3 to 5% of the participants stated that their partnerobjected to using a condom. Table 14.3 provides condom usage (ever) and precautions taken to avoid pregnancy bycurrent, next recent and next most recent partner. The percentage of participants who are using acondom with their current partner(s) is less (68%) compared to the next recent partner (89%) andthe next most recent partner (91%). Different reasons were given for the moderate-to-good chance of contracting the HIVvirus. The reasons were; have different partners, 13.6%; spouse has many partners, 4.1%; do notuse a condom, 7.6%; had blood transfusion, 1.3%; never too careful, 14.5%; and condom canburst, 8.0%. When the participants were asked why they had not done a HIV test, 59.7% indicated thatthey do not want to know their status, 15.4% said they are not sexually active, 10.0% reported 359
  • that they know that they do not have HIV, 5.0% reported that they are not interested, 0.5%remarked that they always practice safe sexual relations. Eight percent of the participants stated that they were forced to have sexual relations, 7.0%indicated that they had forced someone to have sexual intercourse and 1.7% remarked thatphysical force was used in the process. Significantly more males (12.5%) had forced someonecompared to 2.5% of females (χ2 = 32.946, P < 0.0001). However, 35.9% of females indicatedthat physical force was used in the process of forced sexual relations compared to 6.7% of males(χ2 = 17.485, P < 0.0001). Furthermore, no statistical association existed between ‘were youforced to have sexual intercourse?’ based on the gender of the participants – males, 9.3% andfemales, 10.1% (χ2 = 0.190, P = 0.669). In addition, significantly more people with STI wereforced to have sexual relations (15.5%) compared to those who were not forced (7.0%) – χ2 =12.894, P < 0.0001. Table 14.4 examines particular demographic characteristics of the participants basedon gender. The results of the multivariate logistic regression model, shown in Table 14.5, weresignificant [Model χ2 = 32.526, P = 0.027]. Table 14.5 indicates that 20.3% of the variancesaccounted for by the independent variables used in the regression analyses: age of first sexualdebut, age at last birthday, having had STI, sex with commercial worker, union status, andprotecting self from the possibility of contracting the HIV virus. The model had statisticallysignificant predictive power (Model χ2 = 32.526, P = 0.027; Hosmer and Lemeshow goodness offit (χ2 = 3.202, P = 0.921), and correctly classified 82.5% of the sample (Table 14.5). 360
  • No statistical relationship existed between ‘would you be willing to do a HIV test in thefuture?’ and whether the individual was forced to have sexual intercourse – χ2 = 0.444, P =0.801: yes to be willing, 9.3%; no to be willing, 11.0%; and don’t know, 9.4%.Discussion Sexual relation is mainly the medium through which most people contract HIV/AIDS [17].This study provides invaluable insights into those who have done a HIV test and their sexualbehaviour and attitude towards future HIV testing. From the findings, clearly, people are linkinga low risk of contracting the HIV virus with having one sexual partner. Based on the perceptionof respondents in this sample, they are omitting the close association between inconsistentcondom usage, not knowing the HIV status of current and past partners, and having unprotectedsexual intercourse in a heterosexual way with high risk of contracting the HIV virus. Other issues which emerged from the current work are (1) the low probability of thosewho have had sex with commercial sex workers willingness to consider doing a HIV test in thefuture, (2) the inverse association between having had a STI and the likeliness of wanting to do aHIV test in the future, and (3) negative association between age of respondents and wanting todo a HIV test in the future. Within the context that 16.3% of the sample; having had STIs, 58%indicated a low risk of contracting the HIV virus, 6.2% having had sexual relations with acommercial sex worker, 50.3% consistently using a condom, and 60% not wanting to know theirHIV status, and notion that HIV/AIDS being a homosexual disease [7], there is a need to executeimmediate public health interventions to address these findings. More programs promoting safe sexual practices are definitely needed because between 10% and 15 % of the participants did not use a condom during sexual intercourse with their current,next recent and next most recent partner(s). What is worse is that; 3-5% of the participants stated 361
  • that their partner objected to them using a condom. Moreover, 32% of the participants do notwear a condom with their current partner compared to the 11% who do not wear a condom withtheir next recent partner. Not wearing a condom increases the risk of contracting and spreadingHIV [17]. Some 16.3% of the participants have STIs. Despite these risks, only 49.1% of theparticipants gave several reasons (participant or spouse having multiple partners, condom failure,negligence, blood transfusion, not wearing a condom) for a moderate to good chance ofcontracting HIV. More than one- half of the participants gave no reasons for a good to moderatechance of contracting HIV. It is not surprising then, that 59.7% of the participants did not want toknow their HIV status, which creates a problem in the reduction of HIV infection since morethan 10% reported that they did not use a condom and 36.1% reported that their current partnerhas other partners. Another explanation which accounts for high risk of contracting STIs andHIV/AIDS, despite the current respondents’ perception of their seemingly low risk, is women’sacquiescence to the vetoing power of men in reproductive health decisions. A research conductedby WHO showed that some women opined that reproductive health decisions are made by theirpartner because “he looks after me” [18], suggesting a rationale for inconsistent condom use. A related problem is sexual intercourse through coercion. Significantly more mencompared to women declared that they had coerced someone to have sex. Similarly, a greaterproportion of women (35.9%) stated that physical force was used in coerced sexual intercoursecompared to men (6.7%). Participants who experienced coerced sexual relations are less likely touse a condom because of the powerful influence of the situational context in which they findthemselves. This possibility increases the risk of these participants contracting HIV. The datasupports this assumption because a significant majority of the participants who were forced tohave sex had STIs compared to those who were not forced. Within the context that “HIV is more 362
  • easily passed from infected males to females than in the reverse and it is predicted thatproportionately more cases will occur in females than in males in Jamaica in the future” [19],and females being coerced to have sexual intercourse. If this abusive practice is occurringwithout the use of condoms, it will be accounting for greater risk of HIV infection in the future. An important issue which must be addressed in public health intervention is financialinadequacies of females which account for them relishing their reproductive health choices, oftencarte blanche to males. Jamaica is a middle-income developing country with the prevalence ofpoverty rate being 9.9% in 2007 (urban poverty rate, 6.2%; semi-urban poverty rate, 4.0%; ruralpoverty rate, 15.3%; prevalence of poverty among males, 7.2%; prevalence of poverty amongfemales, 8.0%) [20]. Economic deprivation of females more than males can also be explained bythe unemployment rates, and earnings. The unemployment rate for females was almost 2.3 timesmore than that of males (6.2) [21], indicating that if this economic inequity continues, femaleswill relinquish their reproductive health choices to males as they are providing the economiclivelihood. In 2004, the Economic and Social Survey of Jamaica [21], publication showed thaton an average the earnings of males (mean wage = $2.4 million) was 2 times more than that offemales ($ 1.7 million); and that 76 per cent of senior positions were held by males although 54per cent of executive and managerial positions were held by females [21]. Poverty andunemployment, therefore, are explanations of why people become engaged in risky activities aswell as take short-term health risks; in order to earning a living as they seek a change for thebetter. It is this belief in socio-economic development that spurs women to relinquish theirreproductive health choices to men as they perceive men, as having the economic resources tomake an improvement in their current status, even if it is temporary. 363
  • WHO stated that, on a yearly basis, there are approximately 340 million new cases ofSTIs and 5 million new cases of HIV infection [22]. Clearly, inconsistent condom usage canaccount for an increase in STI/HIV, indicating that the attitude of non-HIV testers in this sampleis reinforcing the pending public health problems that need to be addressed with some degree ofurgency. A study by Henry-Lee found that reasons given by Jamaican women for inconsistentcontraceptive use or even discontinuation were (1) cost of contraception, and (2) long waitingqueues at clinics (3) [23]. She contended that scheduling of appointments could reduce the longwaiting time at the clinics [23]. While Henry-Lee is correct about using appointments to reducewaiting at clinics, but the vetoing supremacy of males in the reproductive health decisions offemales could account for their non-return to the clinics. Due to the economic disparity, poverty,low education, low income, and inconsistent condom usage, many people do not want to knowtheir HIV status yet they believe that they are at a low risk of contracting the virus. Furthermore,significantly more females than males who have never had a HIV test indicated that they are notat risk of contracting the HIV virus, yet statistically more males than females consistently use acondom. Clearly, there is a denial among Jamaicans of their probability of contracting the HIVvirus as people still perceive that the virus is a homosexual disease. A study by Dunkle et al. [24]showed that more people that have had heterosexual intercourse had contracted the HIV virus inZambia and Rwanda [24] than those who are engaged homosexual relationships. Dunkle et al.’swork [24] provide some understanding of the rationale behind Jamaicans reluctance to have aHIV test done even though they may be in heterosexual relations, as the predominant culturalbelief is that it is a homosexual disease. One researcher noted that “Among Jamaican males,there is a substantial peer group pressure to engage in sex in order to avert the stigma of 364
  • homosexuality, and sexual initiation may occur as early as the age of 8 years” [25] indicating thedominance of the culture in causing or reverting to particular and even potentially deleteriousactions. The irony here is that Caribbean men are socialized to be promiscuous and indulge inpremarital sexual relations [25-28], which is evident in the male-to-female HIV prevalence ratio(1.3:1) [29-32], but if they are infected with HIV as a direct consequence of their sexualbehaviour, they will be scoffed at for having being homosexual. The public health dilemma of HIV infection is that we have been estimating a probabilityof prevalence among Jamaicans [29-31]. The Jamaican Ministry of Health estimated that 65% ofthose persons who are infected with HIV are unaware of their status, and this reiterates therationale for public health intervention programmes. Due to the sobering reality that people donot want to know their HIV status owing to the stigmatization associated with the virus.Currently the nation is not seeing the economic impact of HIV/AIDS, which may justify whynon-HIV testers were not researched on their sexual behaviour and attitude towards HIV testing.Research findings are in on non-HIV testers, and these should be integrated with public healthintervention so as to effectively address some of the present challenges of non-HIV testing in theJamaica and in the wider developing nations. World Bank revealed that over 95% of persons living with HIV/AIDS were in low andmiddle income countries [32]. Of this figure over 20 million of these persons have died fromAIDS in 2002. This HIV/AIDS epidemic has reduced life expectancy by more than ten years inmany countries [32]. Gebre postulated that the Caribbean countries have the highest incidencerates of HIV/AIDS in the Americas and the second highest prevalence rates in the world amongadults aged 15 – 44 years [33]. Statistics have showed that between 270,000 to 780,000 adultsare living with HIV in the region, which is about 2.3%. Almost 9453 cases of AIDS were 365
  • reported in Jamaica and of this amount 1100 of these cases were identified in 2004. This is anestimated 1.6% of the adult population that has been infected with HIV [33]. According toWHO, 60% of global mortality is caused by chronic illness [34], suggesting that HIV/AIDS willsubstantially influence the economic and social development of developing countries in thefuture and that we can no longer allow risky health practices to continue unabated. In 2006, the reasons persons have given for non-HIV testing were (1) they do not want tohear their status (11%), (2) 1.3% perceived seronegative status, (3) 1.0% stated that they werenot sexually active and (4) had no partner, 0.7% said that they were not interested in doing anHIV test [35]. Based on the findings of the current study the prevalence of Jamaicans notwanting to know their HIV status has increased exponentially, which speaks to the rise ofinconsistent condom usage, increase in STIs, increase in premarital sexual relations andpromiscuity. Those are the rationales which should vehemently dictate the urgency of HIV/AIDSregistry in seeking to thoroughly understand this threat and how to effectively tailor interventionthat the spread of STIs and HIV/AIDS can be reduced.Conclusion The time has come for the government to require HIV and AIDS to be reportable byname, and a national HIV/AIDS registry be kept in order to monitor the epidemic in Jamaica.While the researchers recognize the stigmatization surrounding the disease, the issue of privacy,discrimination, and understand that this may result in the continuation of the low willingness ofpeople to become tested for HIV; the findings are far reaching and cannot be allowed to continueinto the indefinite future. 366
  • DisclosuresThe authors report no conflict of interest with this work.DisclaimerThe researchers would like to note that while this study used secondary data from the JamaicanMinistry of Health (MoHJ), none of the errors in this paper should be ascribed to the MoHJ, butto the researchers.AcknowledgementThe authors would like to extend their appreciation to the Jamaican Ministry of Health thatcommissioned the data collection, Hope Enterprise Limited that collected the data and the SirAuthor Lewis Institute which made it available to us for use. 367
  • References1. Hageman KM, Dube HMB, Mugurunqi O, Gavin LE, Hader SL, St. Louis ME. Beyondmonogamy: Opportunities to further reduce risks for HIV infection among married women withonly one lifetime partner. AIDS and Behavior 2010; 14:113-124.2. Siddiqi OK, Atadzhanov M, Birbeck GL, Koralnik IJ. The spectrum of neurological disorders in Zambian tertiary care hospital. J of the Neurological Sci 2010; 290:1-5.3. Hendriksen ES, Hlubinka D, Chariyalert S, et al. Keep talking about it: HIV/AIDS-relatedcommunication and prior HIV testing in Tanzania, Zimbabwe, South Africa, and Thailand.AIDS and Behavior 2009; 13: 1213-1221.4. Thanh DC, Hien NT, Tuan NA. Thang BD, Long NT, Fylkesnes K. HIV risk behaviors andDeterminants among people living with HIV/AIDS in Vietnam. AIDS and Behavior 2009;13:1151-1159.5. Le Franc E, Wyatt GE, Chambers C, Eldemire D. Working women’s sexual risk taking in Jamaica. Social Science & Medicine 1996; 42:1411-1417.6. Andrinopoulos KM. Examining HIV/AIDS within the context of incarceration in Jamaica. Dissertation Abstracts International: Section B: The Sciences and Engineering 2008; 69:2260.7. White RC, Carr R. Homosexuality and HIV/AIDS stigma in Jamaica. Culture, Health & Sexuality 2005; 79: 347-359.8. Norman LR, Carr R, Uche C. The role of sympathy on avoidance intention toward persons living with HIV/AIDS in Jamaica. AIDS Care 2006; 18: 1032-1039.9. Norman L, Carr R, Jimenez J. Sexual stigma and sympathy: Attitudes toward persons living with HIV in Jamaica. Culture, Health & Sexuality 2006; 8:423-433.10. Hutchinson MK, Jemmott LS, Wood EB, et al. Culture specific factors contributing to HIVrisk among Jamaican adolescents. JANAC: J of the Association of Nurses in AIDS Care 2007;18:35-4711. Norman L, Figueroa JP, Wedderburn M, Byfield L, Bourne D, Gebre Y. Trends in HIV riskperception, condom use and sexual history among Jamaican youth, 1996-2004. Int J ofAdolescent Medicine and Health 2007; 19: 199-207.12. Green M, Hoffman IF, Brathwaite A, et al. Improving sexually transmitted diseasemanagement in the private sector: The Jamaica experience. AIDS 1998; 12: S67-S72.13. Douglas DL. Perspectives on HIV/AIDS in the Caribbean. In: Morgan O (ed). Health issues in the Caribbean. Kingston: Ian Randle; 2005:pp. xv-xxi.14. Barnett T, Whiteside A. AIDS in the twenty-first century: Disease and globalization.London: Palgrave MacMillan; 2002: p.11.15. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. Jamaica health and lifestylesurvey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies,Mona; 2008.16. Hope Enterprise Limited. HIV/AIDS Knowledge, Attitudes and Behaviour Survey, 2008.Kingston: Jamaica, Ministry of Health, National HIV/STI Programme; 2008.17. Steiner MJ, Cates W. Are condoms the answer to rising rates of non-HIV sexually transmitted infections? Yes. BMJ 2008;336:184.18. World Health Organization (WHO). Reproductive health research at WHO: a new beginning. Biennial Report 1998-1999. Geneva: WHO;2000: p.31. 368
  • 19. 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. 62-71.20. Planning Institute of Jamaica (PIOJ), Statistical Institute of Jamaica (STATIN). Jamaica Survey of Living Conditions, 2007. Kingston: PIOJ, STATIN; 2008.21. Planning Institute of Jamaica (PIOJ). Economic and social survey, 1990-2007. Kingston: PIOJ; 1991-2008.22. World Health Organization. Sexual and reproductive health – laying the foundation for a more just world through research and action: Biennial report 2004-2005. Geneva: WHO; 2006.23. Henry-Lee A. Women’s reasons for discontinuing contraceptive use within 12 months: Jamaica. Reproductive Health Matters 2001;9:213-220.24. Dunkle K, Stephenson R, Karita E, et al. New heterosexually transmitted HIV infections in married or cohabiting couples in Urban Zambia and Rwanda: An analysis of survey and clinical data. The Lancet 2008;371:2183-91.25. Drayton VLC. Contraceptive use among Jamaican teenage mothers. Pan Am J Public Health 2002;11:150-157.26. Jagdeo T. The dynamics of adolescents fertility in the Caribbean. St. John’s, Antigua: Caribbean Family Planning Affiliation; 1992.27. Chevannes B. Sexual behavior of Jamaicans: a literature review. Soc Econ Stud. 1993;42:1- 45.28. 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; 2001.29. Pan American Health Organization (PAHO). Health in the Americas 2007, volume II – countries. Washington D.C: PAHO;2007.30. Jamaica, Ministry of Health (MoH). The Jamaica road map to scaling up universal access to HIV prevention, care, and treatment support services. Kingston: MoH;2006.31. Jamaica, Ministry of Health (MoH). Annual report, 1997-2008. Kingston: MoH;1998-2009.32. World Bank. Public health at a glance: HIV/AIDS update. [cited 2010 April 17, fromhttp://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/33. Gebre Y. National HIV/STD prevention and control facts and figures, Jamaica. AIDS Report, 2004. Kingston, Jamaica: epidemiology Unit, Ministry of Health; 200534. World Health Organization. Preventing Chronic Diseases a vital investment. Geneva: WHO;2005.35. Norman LR. HIV testing practices in Jamaica. HIV Medicine. 2006; 7:231-242. 369
  • Table 14.1. Sociodemographic characteristics of sample, n= 1192Characteristic n (%)Gender Male 648 (54.4) Female 544 (45.6)Education Primary or below 40 (3.4) Secondary 1056 (88.6) Tertiary 96 (8.1)Employment status Employed: Full time 373 (31.3) Part time 138 (11.6) Unemployed 335 (28.1) Student 346 (29.0)Union status Married/common-law 299 (25.1) Visiting 398 (33.4) Single 494 (41.5)Ever had sexual relations Vaginal 964 (80.9) Anal 0 (0.0) Both 7 (0.6) No 221 (18.5)Condom usage on first sexual relations (with current partner) Yes 636 (53.4) No 295 (24.7) Non-response 261 (21.9)Condom usage on first sexual relation (next recent partner) Yes 337 (28.3) No 115 (9.6) Non-response 740 (62.1)Sexual relations with a commercial partner (ever had) No 946 (79.4) Yes 63 (5.3)Length of time living in community median (range) 7.5 years (0, 40)Age mean (SD) 27.1 years (11.5 years)Age of first sexual relations mean (SD) 15.2 years (3.2 years) 370
  • Table 14.2. Reason for not using a condom by current, next recent and next most recent partner PartnerCharacteristic Current partner Next recent Next most recent n = 743 n = 1055 n = 1125 % % %None available 11.6 16.1 20.9Partner objected 4.7 2.9 4.5Don’t like them 10.7 14.6 10.4Used other contraceptives 4.7 2.9 4.5Don’t need to 3.6 2.2 1.5Didn’t think of it 10.9 22.6 23.9Know partner well 46.1 29.2 29.9Other 0.9 2.2 1.5Medical problems 0.4 - -Husband/trust partner 2.0 0.7 3.0Allergic reaction 0.2 1.5 -No special reason 1.1 0.7 -Currently pregnant 2.0 1.5 -Burst 0.9 2.9 - 371
  • Table 14.3. Condom usage (ever) and precautions taken to avoid pregnancy by current, nextrecent and next most recent partner PartnerCharacteristic Current partner Next recent Next most recent n (%) n (%) n (%)Ever used a condom Yes 336 (69.9) 93 (58.9) 52 (65.0) No 145 (30.1) 65 (41.1) 28 (35.0)Precautions taken to avoid pregnancyCondom 467 (68.0) 284 (89.0) 183 (91.0)Pill 115 (16.7) 19 (6.0) 10 (5.0)IUD 4 (0.6) - -Injection 25 (3.6) 1 (0.3) 1 (0.5)Withdrawal 47 (6.8) 14 (4.4) 7 (3.5)Self or partner sterile 25 (3.6) - -Nothing 2 (0.3) 1 (0.3) -Other 2 (0.3) - - 372
  • Table 14.4. Some demographic characteristic by gender of participants GenderCharacteristic Male Female n (%) n (%)Had STI1 No 460 (80.1) 377 (88.5) Yes 114 (19.9) 4 (11.5)Actively practicing religion2 No 362 (56.2) 169 (31.2) Yes 282 (43.8) 373 (68.8)Ever had sexual relations3 Yes - Vaginal 563 (8.9) 401 (73.7) - Anal - - Both 4 (0.6) 3 (0.6) No 81 (12.5) 140 (25.7)Sexual relations with commercial sex worker4 No 508 (89.1) 438 (99.8) Yes 62 (10.9) 1 (0.2)Frequency of condom usage in last 12 months – currently5 Every time 213 (38.7) 100 (26.5) Most times 91 (16.5) 63 (16.7) Occasionally 101 (18.4) 72 (19.0) Never 145 (26.4) 143 (37.8)Chance of catching HIV6 None 334 (54.8) 306 (61.3) Little 187 (30.7) 148 (29.7) Moderate 43 (7.0) 27 (5.4) Good 46 (7.5) 18 (3.6)Willing to do HIV test in the future7 No 113 (17.6) 101 (18.7) Yes 508 (79.3) 412 (76.4) Don’t know 20 (3.1) 26 (4.8)Condom usage Current partner8 No 153 (27.7) 142 (37.5) Yes 399 (72.3) 237 (62.5) Most recent partner9 No 75 (22.7) 40 (33.1) Yes 256 (77.3) 81 (66.9) Next most recent partner10 No 41 (18.4) 14 (35.0) Yes 182 (81.6) 26 (65.0)1 χ2 = 12.521, P < 0.0001 4χ2 = 48.045, P < 0.0001 7χ2 = 2.676, P = 0.2622 χ2 = 74.571, P < 0.0001 5χ2 = 19.554, P < 0.0001 8χ2 = 9.868, P = 0.0023 χ2 = 34.305, P < 0.0001 6χ2 = 10.669, P = 0.014 9χ2 = 5.052, P = 0.02810 χ2 = 5.661, P = 0.033 373
  • Table 14.5. Logistic regression analyses: Variables of willing to do HIV test in the future, n = 950 Characteristic Wald Odds β coefficient statistic ratio CI (95%) Age of first sexual debut 0.06 3.03 1.06* 0.99 -1.14 Age at last birthday -0.03 4.26 0.97** 0.95 – 1.00 Had STI -0.50 3.52 0.61** 0.36 - 1.02 Actively practicing religion -0.26 1.42 0.77 0.50 - 1.18 Condom usage - always -0.17 0.38 0.84 0.48 - 1.46 Condom usage - moderate 0.11 0.12 1.12 0.60 - 2.10 Never used (reference group) 1.00 Male -0.19 0.66 0.83 0.52 - 1.31 Sexual relations with commercial worker -0.61 2.73 0.54* 0.26 - 1.12 Married 0.29 0.98 1.34 0.75 - 2.37 Visiting 0.45 2.71 1.56* 0.92 - 2.66 Single (reference group) 1.00 Vaginal sexual relations -0.38 0.11 0.69 0.08 - 6.26 No sexual relation 1.00 Tertiary -0.35 0.20 0.70 0.15 - 3.31 Secondary -1.04 2.53 0.35 0.10 - 1.27 Primary or below (reference group) 1.00 Full time employed 0.19 0.56 1.21 0.74 - 1.99 Part time employed 0.20 0.34 1.22 0.63 - 2.34 Student -0.12 0.12 0.89 0.46 - 1.73 Unemployed (reference group) 1.00 Protect sex from contracting HIV 0.48 2.83 1.61* 0.93 - 2.80 Confidentiality in test result 0.22 0.77 1.25 0.76 - 2.04 No chance of contracting HIV 0.18 0.63 1.20 0.77 - 1.87Model chi-square (19) = 32.526, P = 0.027-2 Log likelihood = 659.17Nagelkerke r-squared = 0.203Hosmer and Lemeshow test chi-square (8) = 3.202, P = 0.921Overall correct classification = 82.5%Correct classification of cases willing to do HIV test in future = 99.7%Correct classification of cases not willing to do HIV test in future = 18.8%*P < 0.1, **P < 0.05, ***P < 0.001 374
  • Chapter 15 Knowledge, attitude and practices of adults of the reproductive years on reproductive health matters, with emphasis on HIV infected people in a Caribbean society Paul A. Bourne, Neva South-Bourne, Cynthia G. FrancisIntroduction Human immunodeficiency virus (HIV) is the second leading cause of death in the world[1-3], the first in the Caribbean (among 15-49 year olds) [4] and the second in Jamaica [5]. Therisk of contracting HIV is considered higher in low-income countries, and lowers inindustrialized countries. Factors that contribute to such discrepancies in sexual and reproductiverisk all over the world are “weak and uneven distribution of health services, the concentration ofpoverty among certain population groups and geographic areas, gender inequalities and harmfulsocial practices” [1]. This paper focuses on adults in the reproductive ages of 15-49 years. This representsalmost 3 billion people in the world, and almost half of all new HIV infections [6]. In Jamaica,youth represents 20% of the population of 2.6 million. The public health dilemma of HIV amongyouths has led to commitments made by various nations (189 states) of the world at the UnitedNations General Assembly Special Session (UNGASS) on HIV and AIDS in New York in 2001.Such commitment was made via the signing of a Declaration of Commitment whichencapsulates promises to acknowledge the role and contributions of young people in addressingall aspects of HIV and AIDS, recognizing the full involvement and participation of the youth, indesigning, planning, implementing and evaluating programmes relating to responses to the 375
  • epidemic; reducing the prevalence of HIV among youths within the range of 15-24 years of ageby 25% by 2010, ensuring that 90% of youths have access to information and services that wouldreduce their vulnerability to HIV infection, ensuring access to information through primary andsecondary school curricula on matters of safe and secure environment, strengthening sexual andreproductive health programmes, and so on [6]. Under the CARICOM-PANCAP, the strategic objectives for national HIV responses are“to prevent the sexual transmission of HIV, to decrease the vulnerability to sexual transmissionof HIV; to establish comprehensive, gender-sensitive, and targeted prevention programmes forchildren (9-14 years old) and the youth (15-24 years old), to achieve universal access to targetedprevention interventions among the most at-risk populations (such as MSM, SW, drug users,prisoners, and migrant populations), to provide services for the prevention of mother-to-childtransmission of HIV to all pregnant women and their families; to strengthen prevention effortsamong PLHIV as part of comprehensive care; and to reduce vulnerability to HIV through earlyidentification and treatment of other sexually transmitted infections (STIs)” [7]. The achievementof these objectives can also be hindered by policies (for example, legislation against men havingsex with men (MSM), the capacity to address legal constraints that hinder access to services, thelack of integration of HIV policies and programmes into national development plans and [7]programmes, the lack of political support and incongruities between policies and legislations. Within the context of the high HIV incidence and prevalence rates among people indeveloping nations, and in particular the Caribbean, and more so among young people, theattitude toward consistent condom usage is problematic and needs to be examined in developingcountries. Hence, we wanted to elucidate information as to whether there are differences in theknowledge, attitude and practices of adults in their reproductive years regarding their 376
  • reproductive health issues, compared with those who have HIV in a Caribbean society, as well asto model factors which account for their willingness to do an HIV test in the future. No studyemerged in the Caribbean that has comprehensively examined adults in their reproductive ages(15-49 years) on their sexual and reproductive health attitudes, knowledge and practices, andcompares the result with those who are HIV-infected youth, as well as factors which explainpeople’s willingness to do an HIV test in the future. The present study examines core issues ofsexual and reproductive health among youths, particularly with respect to those who are HIV-infected in Jamaica in order to provide a comprehensive understanding of people’s perceptions,which will be used to fashion public health intervention programmes.MethodsSampleThe study population comprised people aged 15-49 years who resided in Jamaica at the time ofthe survey in 2004 (May-August). The population data for this research were collected by HopeEnterprises Limited8 on behalf of the Jamaican Ministry of Health. A multi-staged samplingdesign was used to collect the data. Each of the 14 parishes in Jamaica was stratified intoconstituencies, with each constituency stratified into three areas – rural areas, parish capitals(urban areas) and main towns (semi-urban areas). The areas which comprised a constituencywere then stratified into primary sampling units (PSUs) or enumeration districts (EDs). A random sample of each PSU was then selected, based on probability proportional tosize (PPS). Seventy-two EDs were selected for the study – 23 EDs in urban areas, 25EDs insemi-urban areas, and 24 EDs in rural areas. Twenty-five households were systematically chosenfrom each ED, and cluster sampling was carried out, where all the people living in the householdof the designated areas were interviewed for the survey.Data sources 377
  • A questionnaire was used to collect the data from respondents. It was a 154-item instrument. Thequestions were demographic characteristics, sexual history (including number and type ofpartners, and having sexual relations with commercial sex workers), condom usage, STIs andhealth issues, knowledge of HIV/AIDS (including “Have you ever had an HIV test?”, “Did yougo back for the results yourself or were you contacted by a health worker?, and “Would you bewilling to do an HIV test [in the future]?”). The interviewers were trained for a 5-day period, ofwhich 2 days were devoted to field practices [8]. Interviewers were assigned to a team composedof two females, two males and a supervisor. Oral consent was sought and given before the actualinterview would commence. Interviewees were informed of confidentiality and their right to stopthe interview at any time, if they should so desire. No names, addresses or other personalinformation were collected from respondents in order to ensure anonymity and confidentiality.The instrument used in the survey utilized indicator measures and definitions consistent withUNAIDS and the USAID Priority Prevention Indicator [8].Statistical analysesData were entered, stored and retrieved using SPSS for Windows, Version 16.0 SPSS Inc;Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographiccharacteristics of the sample. Statistical analyses used were an independent sample t-test,ANOVA, and Pearson’s Product Moment correlation. Multivariate logistic regressions werefitted using one outcome measure: self-reported, confirmed positive HIV test results. Weanalyzed correlation matrices to examine multicollinearity. Where collinearity existed (r > 0.7),variables were entered independently into the model to determine those that should be retainedduring the final model construction [9]. A p-value < 0.05 (two-tailed) was used to establishstatistical significance. 378
  • Analytic ModelFor this study, the analytic model used is one that can accommodate multiple independentvariables on a single binary dependent variable (positive HIV test result, which was confirmedby an agent of the state). Using logistic regression, this paper tested variables identified in theliterature as being associated with having a positive HIV test result (Equation [1]):HIVti = f(Ai, Xi, EDi, Ei, MSi, Ci, SIi, Ni, ASi, Li, CUi, Ki, Fi, Pi, Ti,STIi, Ri, Qi)…………Eqn [1] where HIVti denotes currently having a positive HIV test result for individual i, Ai is ageof individual i, EDi represents educational level of individual i, Ui, means employment status ofindividual i, SSi is social class of individual i, ARi indicates area of residence of individual i, Pidenotes currently having sexual relations with a commercial sex worker for individual i, MSi ismarital status of individual i, Ci means length of time dwelling in community for individual i,SLi is age of first sexual intercourse of individual i, Si represents type of sexual practice ofindividual i, Ni is number of sexual partners of individual i, Ri denotes actively practicingreligion of individual i, Ki is having had an STI of individual i, Wi represents crowding inhousehold of individual i, Qi denotes frequency of condom usage of the individual i, and theparameter εi is the model’s error term. Using logistic regression to test the hypothesis (Equation [1]), we now know that maritalstatus, employment status, age of respondents, and other variables are associated with those whoare currently HIV positive individuals, and can write equation [2]. HIVti = f(Ai, MSi, Ui, Pi, εi) Eqn [2]MeasurementCrowding is the total number of persons who dwell in a room (excluding kitchen, bathroom andverandah). 379
  • Contraceptive method is any device or approach that is used to prevent pregnancy. Thesemethods include tubal ligation, vasectomy, implant (Norplant), injection, emergencycontraceptive protection, pill, condom, foaming tablets, creams, jellies, diaphragm, abstinence,withdrawal, the rhythm method, calendar or Billings.Non-steady sexual partner denotes sexual relations that are casual, with someone with whom theindividual is not having a common law sexual union, a visiting relationship or to whom theindividual is not legally married.Education is taken from the question, ‘How many years did you attend school?’ This is coded asjunior high or below (0 – 9 years), secondary (10-12 years) and tertiary (13+ years).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.New HIV infection was measured using “Did you go back for the results yourself or were youcontacted by a health worker?” If the individual indicated that he/she was contacted by a healthworker, this was used to indicate a positive HIV result.Old HIV infected people were measured using self-reported information on the “Do you knowthe result of the test [HIV]”, and whether this was positive or negative (1= know positive status,0 = otherwise).Knowledge in this study was measured using the following issues: Have you heard of HIV?,Have you heard of a disease called AIDS?, Do you think that a healthy looking person can beinfected with HIV, the virus that causes AIDS?Attitude for this research was measured using the following issues: If a member of your familybecame sick with HIV, the virus that causes AIDS, would you be willing to care for him or her in 380
  • your household?, Have you ever had an HIV test?, Would you be willing to do an HIV test [inthe future]?Practice was evaluated from the following questions: Have you ever had sexual intercourse? By‘sexual intercourse’ I mean vaginal sex (penis in vagina) or anal sex (penis in bottom). At whatage did you first have sex?, With how many persons have you had sex during the last 3 months?,Frequency of condom usage with recent, next recent or next most recent partners (in the last 12months), what did you do to avoid getting pregnant?, ‘the last time you had sex, did you or thispartner do anything to delay or avoid getting pregnant?, and ‘have you ever had sex withsomeone whom you paid for sex, that is, a commercial partner?’ResultsTable 15.1 presents the sociodemographic characteristics of the sample. The sample consisted of1,800 respondents (of which males accounted for 48.8%). No significant statistical association existed between the gender of a respondent andhis/her positive HIV test result (χ2 = 0.900, P = 0.343). There was a statistical differencebetween the mean age at first sexual relations for males (14.1 years (SD = 3.2 years) and offemales (16.7 years (SD = 2.7)) – t-test = 16.416, P < 0.0001. The mean age of females in thesample was 28.7 years (SD = 11.3 years) compared to that for males (27.8 years, SD = 10.9years) – t-test = 1.656, P = 0.098. The mean age of first sexual relations for the sample was 15.4 years (SD = 3.2 years), anda significant statistical difference was found for the mean age of first sexual intercourse amongthe union statuses (F-statistic = 31.96, P < 0.0001): The mean age of first sexual relations formarried people was 16.2 years (SD = 3.1 years); partner who stays overnight (15.2 years(SD=3.0 years)), sees partner occasionally (14.2 years (SD = 3.0 years)), and single (15.6 years 381
  • (SD = 3.3 years)). Furthermore, the mean age of first sexual relations was greater for those whoare actively practicing religion (15.9 years (SD = 3.4 years)) compared to those who are notactively practicing religion (14.8 years (SD = 2.9 years)) – t-test = -6.768, P < 0.0001. Likewise,there was a significant statistical difference for the mean age of first sexual relations andtypology of sexual acts performed – F-statistic = 4.273, P = 0.005. The mean age at first sexualrelations for those who have had anal sex was 14.0 years (SD = 0.0) compared to those whopractice vaginal sex (15.4 years, SD = 3.2) or those who did both (vaginal and anal sex), 12.9years, SD = 4.17 years. A statistical correlation existed between the age at first sexual relations and number ofsexual partners in the last 12 months (r = - 0.246, P < 0.0001). When the sample was asked “Do you think this partner [current] has other partner(s)?”35% indicated yes; “Do you sometimes feel embarrassed to buy a condom?” only 12% remarkedyes, and “To what extent do you usually have a condom on you?” every time, 20.4%; mosttimes, 14.2%; sometimes, 13.2%; rarely, 13.6% and never, 38.7%. When asked “Can you alwaysfind your favourite brand [condom] when you need one in a hurry?” 89.7% said yes. “If thatbrand [condom] is not available would you take another brand or you would rather do without?,only 1.6% indicated that they would rather go without using a condom, and 22.5% stated thattheir partner would be upset if he/she found that they had a condom ready available. The sociodemographic characteristics of those with positive HIV test results wereexamined in Table 15.1. Almost 6% of those with HIV had sexual relations with a commercialsex worker. Of those who have had sexual relations with a sex worker, 75% indicated that theyhad used a condom. Approximately 16% of those with HIV had contracted an STI infection inthe past, all of them knew that they had the HIV virus, and 61% were actively practicing religion. 382
  • Twenty-nine percent of the HIV-infected individuals had given birth in the last 2 years or were atleast 6 months pregnant. Twenty-seven percent of the sample indicated that they always used acondom; most times, 13.4%; occasionally, 25.4%; and never, 34.3%, with their most recentpartner. When respondents were asked why they did not used a condom on the last sexualrelations, most of them indicated that they knew the person well (44.7%), 2.6% said they bothhad HIV, 2.6% indicated that a condom was not available, 5.3% mentioned that the other partnerobjected to its usage, 7.9% mentioned that they used other contraceptive methods, 5.3% said thatthey did not need to, 7.9% said no special reason and 13.2% indicated that they had not thoughtof it. Table 15.2 presents information on knowledge of the sample and those who are infectedwith HIV. Among those who are infected with the HIV virus, almost 73% indicated that they hadat most a slight chance of contracting the virus compared to 86.6% of the sample. Only 8.1% ofthe infected respondents stated that there was a good probability of their contracting the viruscompared to 6.1% of the sample. Seventy-eight percent of the sample indicated a willingness to do a HIV test, and whenasked “What is your reason for not being willing to do the test?” the majority did not want toknow their status, 59.9%; no need to know (because not sexually active), 15.3%, and 9.9%mentioned that they know that they do not have the virus. Figure 15.1 shows that more people who are HIV positive indicated that they had neverused a condom with their recent partner as well as the next most recent partner. Table 15.3 shows the variables which explain those who are willing to do an HIV test inthe future. Using logistic regression analyses, four variables emerged as statistically significant 383
  • factors of Jamaicans’ willingness to do an HIV test in the future. The model had statisticallysignificant predictive power (model χ2 = 31.86, p = 0.032; Hosmer and Lemeshow goodness offit χ2 = 5.17, P = 0.74), and correctly classified 87.0% of the sample.Discussion Approximately 33.2 million people in the world are living with HIV or AIDS, of which30.8 million are adults and 15.5 million are women, while 2.0 million are children [10]. In theCaribbean, HIV prevalence represents 1% in 2007, with 15,000-17,000 newly infected cases andapproximately 11,000 deaths, with a higher infection rate among men than women (ratio = 2:1)[7]. However, young women are more likely to become infected with the virus because the tissuelining of the genital tract is not fully developed; hence their thinner mucus membranes are lessprotective than older women [11]. In other words, the transmission of HIV from male to femaleis two to ten times more likely than female to male [12]. As a result, the people of Thailand andUganda, for example, blame women for the transmission of the virus; while in East Africa, theword STI is referred to as a disease of women [11]. In the case of Jamaica, approximately 1.3% of the adult population is infected, with two-thirds not knowing their status [8]. Of the number of infected adults, 4,447 [13] (out of the27,000 infected cases) started antiretroviral treatment – thus representing 69% coverage of theestimated 7,000 persons who require antiretroviral therapy [13]. This also includes 400antiretroviral-treated children out of those who are infected [13]. This is tantamount to bringingJamaica closer to providing universal coverage with respect to HIV treatment [14]. 384
  • Adolescent females (age 10-19) have a two and a half times higher risk of HIV infectionthan boys of the same age group. This is owing to social factors such as young girls havingsexual intercourse with older men [15]. In terms of sexual orientation, the HIV/AIDS endemic has plagued humanity for morethan 20 years; and infection rates continue to grow. Persistent behavioural, social and culturalfactors continue to fuel the HIV epidemic [16]; coupled with the fear that friendship with an HIVpositive person would cause self-stigmatization [17]. Owing to the stigma and discrimination,people living with HIV (PLHIV) tend not to disclose their HIV status, hence the potential spreadof the infection [7]. Other factors include fear of rejection, side effects of HIV drugs, uncertainlife span, disclosure of transmission and the impact of loss [18]. The authors also noted thatwithout support it becomes extremely difficult for adolescents and youth, the most vulnerablegroup (15-24 year olds), to adhere to treatment. Research has shown that more than 25% individuals are not cognizant of the status oftheir sexual partner and that 40% do not use condoms [7]. With regard to Jamaica, approximatelyeight out of every hundred persons (7.9% of the population) engages in risky sexual activity [8].Research has shown significant relationships between age, relationship status and condom use[8]. In addition, condom usage was not prevalent among main partners, especially wheremultiple partnerships existed (75.1% males aged 25-49; 70.1% females aged 15-24), thusresulting in approximately 25-30% of individuals who expose themselves as well as theirpartners to HIV and other STIs [8]. STI case rates (per 100,000 persons) reported a steady increase over the period 2006(637.77 ), 2007 (787.17 ) and 2008 (850.43) for infections such as Pelvic Inflammatory Disease,Herpes, Chancroid, Bacterial Vaginosis, Trichomoniasis, Candidiasis, Opthalmia Neonatorum 385
  • and Congenital Syphilis [13]. Where cost of and access to condoms poses a challenge, youthsbecome more vulnerable to HIV. This results in 90% of girls (10-15 year olds) refraining fromusing male condoms, while both cost and concerns regarding the female condom become abarrier [19]. In some instances, access to contraceptives (especially male condoms) is morefavourable to males than females, as the latter encounter barriers such as being shunned orchastised [20]. In terms of sexual orientation and status, approximately 10% of HIV cases in theCaribbean represent men having sex with men (MSM); while commercial sex workers (CSW)vary from 9% to 31% [7,21]. While there are persons who are ignorant of their HIV statusbecause of non-testing [22, 23], there still remain those who lack knowledge about HIV. Theliterature pointed out that where there is a lack of knowledge, combined with early sexualactivity, these factors put youths at risk of not only unintended pregnancy, but STIs and HIV [5].This resulted in 86% of 1,000 participants who were surveyed not considering themselvespersonally responsible for being pregnant and/or contracting STIs and HIV [5]. Despitewidespread information on HIV, the global community still lags behind in prevention efforts. Forinstance, in 24 Sub-Saharan countries approximately two-thirds of young women lack adequateknowledge of HIV transmission [6]; also fewer than one in five people at risk for infectionglobally have access to basic prevention services [6]. Sexual relation is mainly the mediumthrough which most people contract HIV/AIDS [24], indicating that the lack of knowledge (orlow) is affecting the risky sexual behaviour. It is imperative to note that a lack of knowledge regarding HIV is fuelled in part bypoverty, which makes it difficult for persons to learn about HIV or to purchase condoms orantiretroviral drugs [25]. However, the adoption of voluntary counselling and testing (VCT) is 386
  • seen as a way to remedy a lack of knowledge regarding the infection and thus facilitates saferbehaviour [26]. Nonetheless, although there has been evidence of success regarding VCT, theissue of confidentiality is often expressed. Adults and young people, who refrain from VCT,claim that they fear being identified at a testing site, with the possibility of having a health careprovider who knows them and may share their information with someone else [26]. It is alsorecognized that many young people, especially adolescents, do not have independent access toHIV prevention services, despite the fact that the age of sexual debut is earlier than the age oflegal majority [27]. Another way of curtailing the spread of HIV among adolescents and reducing newinfection was the recommendation for routine, opt-out HIV screening without separate writtenconsent or prevention counselling for persons within the age range of 13 to 65 years [28].Jamaica’s prevention and service strategies for young females (15-24 years of age) encompassescomponents such as legislation, policy, programmes, service availability, participation and rights[19]. The social reality is that the age at first sexual intercourse of Jamaicans was 15.4 years and15.6 years for those with HIV, which indicates that intervention measures must be instituted withurgency to address this public health concern. Among the realities that emerged from this study is the inconsistency with whichJamaicans used a condom, and this was also the case with HIV patients. A study by Wilks et al[22] found that 24.4% of Jamaicans (ages 15-74 years) had more than one partner, 48.4% hadsex once per week, while those with secondary education were more likely to have more partnerscompared to those with at most primary level education, while those with tertiary education werethe least likely to have multiple partners. 387
  • It is also evident that parental consent is deemed to be the greatest legal barrier tominors/adolescents being able to access HIV testing on their own. In cases where parentalconsent is not required under state law or policy, an increased number of minors visit test sitesand receive antibody tests. The literature recommended therefore that the desire of minors toreceive HIV testing without parental consent should be treated as a right of the said minors [29].Conclusion In summary, HIV is not a homosexual virus but a heterosexual phenomenon. While moreJamaicans between the ages of 15-49 years who were diagnosed with HIV were in visitingrelationships, marginally less of them were married or in common-law unions.References 1. Population Action International. A Measure of Survival. Calculating Women’s Sexual and Reproductive Risk. Washington DC: Population Action International; 2007 2. World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009. 3. Rawlins J, Crawford T. Women’s Health in the English-Speaking Caribbean: The Case of Trinidad and Tobago. Journal of Social and Economic Studies; 2006; 55:1-31. 4. Camera B, Lee R, Gatwood J, et al. The Caribbean HIV/AIDS epidemic epidemiological status: Success stories—a summary. CAREC Surveillance Report (CSR), 2003; 23:1–16. 5. Thomas T. Youth Reproductive and Sexual Health in Jamaica. Washington DC., Advocates for Youth;2006 6. Audelo S Revisiting the United Nations General Assembly Special Session on HIV and AIDS. Washington D.C.: Advocates for Youth; 2006. 7. CARICOM-PANCAP. Caribbean Regional Strategic Framework on HIV and AIDS 2008-2012. Pan Caribbean Partnership Against HIV/AIDS: Scaling up the Caribbean’s Response. CARICOM-PANCAP; 2008. 8. Hope Enterprise Limited. HIV/AIDS Knowledge, Attitudes and Behaviour Survey, 2008. Kingston: Jamaica, Ministry of Health, National HIV/STI Programme; 2008. 9. Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton & Lange Publisher; 1996. 10. UNAIDS/WHO. Worldwide HIV and AIDS Statistics. UNAIDS/WHO; 2007. 11. Stine GJ. AIDS update 2005. San Francisco: Benjamin/Cummings Publishers; 2005. 12. World Health Organization. Women’s Health. In: Stine GJ. AIDS update 2005. San Francisco: Benjamin/Cummings Publishers; 2005. 13. National HIV/STI Programme. Annual Report 2008. Ministry of Health, National HIV/STI Programme; 2008. 388
  • 14. UNICEF (n.d.). Children and HIV/AIDS. Accessed at http://www.unicef.org/jamaica/hiv_aids.html on April 16, 2010.15. Jamaica, Ministry of Health. Facts and Figures. HIV/AIDS Epidemic Update 2004. Kingston, Jamaica, Ministry of Health, National HIV/STD Prevention and Control Programme; 2004.16. Jamaica, Ministry of Health. Jamaica’s HIV/AIDS Response 2006-2007. `Ministry of Health, National HIV/STI Control Programme; 2007.17. Phillips D. Youth HIV/AIDS in the Caribbean: Teenage Sexuality in Montserrat. Journal of Social and Economic Studies; 2006; 55:2006:32-54.18. Henry-Reid L, Weiner L, Garcia A. Caring for Youth with HIV. Quarterly Journal on HIV Prevention, Treatment and Politics; 2009.19. International Planned Parenthood Federation (IPPF). The role of religious and conservative groups in the United States. IPPF’s Opposition Manual 2006.20. Crawford TV, McGrowder DA, Crawford A. Access to Contraception by Minors in Jamaica: A Public Health Concern. North AmJ. Med Sci. 2009; 1:247-255.21. Duncan J, Gebre Y, Grant Y, et al. HIV prevalence and related behaviors among sex workers in Jamaica. Sexually Trans Dis 2010;22. Wilks R, Younger N, Tulloch-Reid M, et al. Jamaica health and lifestyle survey 2007-8. Kingston: Tropical Medicine Research Institute, University of the West Indies, Mona; 2008.23. Nnedu ON, McCorvey S, Campbell-Forrester S, et al. Factors influencing condom use among sexually transmitted infection clinic patients in Montego Bay, Jamaica. The Open Reproductive Science J 2008;1:45-5024. Steiner MJ, Cates W. Are condoms the answer to rising rates of non-HIV sexually transmitted infections? Yes. BMJ 2008; 336:184.25. Population Action International. Fact Sheet. How Reproductive Health Services and Supplies are Key to HIV/AIDS Prevention. Washington DC: Population Action International; 2004.26. McCauley AP. Equitable Access to HIV Counselling and Testing for Youth in Developing Countries: A Review of Current Practice. Washington DC: Population Council Inc; 2004.27. World Health Organization. Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities. Geneva: World Health Organization; 2007.28. Hahn EK. Incorporating the CDC Recommendations for Adolescent HIV Screening into Practice. Journal of Nurse Practitioners 2009; 5:265-273.29. Meehan TM, Klein WC. The Impact of Parental Consent on the HIV Testing of Minors. Am J public Health 1997;87:1338-1341 389
  • Table 15.1. Sociodemographic characteristics of sample and HIV infected peopleCharacteristic Sample HIV infected people n (%) n (%)Sex Male 878 (48.8) 31 (41.9) Female 920 (51.2) 43 (58.1)Education Primary or below 51 (2.8) 3 (4.0) Secondary 1546 (85.9) 57 (70.3) Tertiary 203 (11.3) 19 (25.7)Employment status Employed: Full time 626 (34.8) 31 (41.9) Part time 201 (11.1) 5 (6.8) Unemployed 563 (31.3) 26 (35.1) Student 410 (22.8) 12 (16.2)Union status Married/common-law 561 (31.2) 25 (33.8) Visiting 619 (34.4) 26 (35.1) Single 619 (34.4) 23 (31.1)Ever had sexual relations Vaginal 1543 (85.7) 69(93.2) Anal 1 (0.1) 1 (1.1) Both 14 (0.8) 1 (1.4) No 242 (13.5) 3 (4.0)Number of sexual partners in Last 4 weeks median (range) 1 (0,17) 1 (0,4) Last 3 months median (range) 1 (0,30) 1 (0,13) Last 12 months median (range) 1 (0,100) 1 (0,30) More than 12 months median (range) 1 (0,24) 1 (0,3)Condom usage on first sexual relations (with currentpartner) Yes 1042 (57.9) 52 (70.3) No 454 (25.2) 13 (17.5) Non-response 304 (16.9) 9 (12.2)Condom usage (last time had sexual relations) Yes 718 (39.9) 29 (39.2) No 792 (44.0) 40 (54.0) Non-response 290 (16.1) 5 (6.8)Sexual relations with a commercial partner (ever had) Yes 89 (5.6) 66 (5.7) No 1498 (94.4) 4 (94.3)Length of time living in community median (range) 7.5 years (0, 40) 5.0 years (0, 30)Age mean (SD) 28.3 years (11.1 years) 32.3 years (10.4 years)Age of first sexual relations mean (SD) 15.4 years (3.2 years) 15.6 years (3.5 years) 390
  • Table 15.2. Knowledge, attitude and practices of sample and of HIV infected sampleCharacteristic Sample HIV infectedHeard about HIV Yes 1798 (99.9) 74 (100.0) No 1 (0.1) 0 (0.0)Heard about AIDS Yes 1796 (99.8) 74 (100.0) No 3 (0.2) 0 (0.0)Methods of protection from HIV or AIDS Have one sexual partner 574 (32.0) 16 (21.9) Use a condom 756 (42.3) 42 (57.5) Use a condom sometimes 7 (0.4) - Use a condom at all times 339 (18.9) 8 (11.0) Abstain 95 (5.3) 6 (8.2) No sex with strangers 4 (0.2) - No blood transfusion 0 (0.0) - Avoid homo/bisexuals 0 (0.0) - Other 3 (0.2) 1 (1.4) Nothing 13 (0.7)Protective measure from contracting HIV/AIDS Yes 1516 (84.5) 62 (83.8) No 279 (15.5) 12 (16.2)Have you spoken about safe sex with current partner Yes 995 (58.6) 57 (79.2) No 702 (41.4) 15 (20.8)Can healthy people contract HIV/AIDS virus? Yes 1732 (96.9) 71 (95.9) No 41 (2.3) 2 (2.7) Don’t know 15 (0.8) 1 (1.4)Knowledge of someone with HIV or who died from AIDS Yes, close relative or friend 284 (15.8) 13 (17.6) Yes, not a close friend or relative 437 (24.3) 20 (27.0) At a workshop 8 (0.5) 1 (1.3) No 979 (54.4) 40 (54.1) Not sure 90 (5.0) -Would you care for a family member with AIDS? Yes 1404 (78.2) 58 (78.4) No 117 (6.5) 6 (8.1) Don’t know 275 (15.3) 10 (13.5)Chance of contracting HIV None 887 (52.8) 30 (40.6) Little 569 (33.9) 24 (32.4) Moderate 116 (6.9) 8 (10.8) Good 108 (6.4) 6 (8.1) Don’t know - 6 (8.1) 391
  • Figure 15.1: Frequency of condom usage with recent, next recent and next most recent partnerfor Sample and HIV infected sample 392
  • Table 15.3. Logistic regression analyses: Variables of willing to do HIV test in the future Wald CI (95%) Variable β Coefficient statistic Odds ratio Married -0.83 3.96 0.44* 0.19 - 0.99 Visiting unions -0.69 2.70 0.50 0.22 - 1.14 Single (reference group) 1.00 Practice vaginal sexual acts 0.06 -0.51 0.18 0.60 6.12 Practice anal sexual acts 22.22 0.00 4476198076.84 0.00 - No sexual relations (reference group) 1.00 Full time employed -0.15 0.17 0.86 0.42 - 1.76 Part time employed -0.61 0.83 0.54 0.15 - 2.02 Student 1.16 4.46 3.20* 1.09 - 9.42 Unemployed (reference group) 1.00 Tertiary -0.79 0.66 0.45 0.07 - 3.05 Secondary -1.32 1.97 0.27 0.04 - 1.69 Primary or below (reference group) 1.00 Age 0.04 4.15 1.04* 1.00 - 1.08 Sexual relations with commercial worker 0.27 0.13 1.30 0.31 - 5.55 No. of sexual partner in last 12 months 0.01 0.03 1.01 0.93 - 1.09 Used condom on first sexual relation (with current 1.06 6.48 2.90** 1.28 - 6.58 partner) Only one time had sexual relations with person -0.27 0.15 0.76 0.19 - 3.04 Had STI -0.58 1.60 0.56 0.23 - 1.37 Actively practicing religion -0.36 1.27 0.70 0.38 - 1.30 Age at first sexual relations -0.05 1.13 0.95 0.86 - 1.05 At least most time used a condom -0.67 2.49 0.51 0.22 - 1.18 -0.04 0.01 0.96 0.42 - 2.19 Moderate condom usage Never used condom 1.00 Male 0.37 1.00 1.44 0.70 – 2.96 Constant -0.30 0.03 0.74Model χ2 (19) = 31.86, P = 0.032-2 Log likelihood = 316.37Nagelkerke r-squared = 0.127Hosmer and Lemeshow (df = 8) = 5.17, P = 0.74Overall correct classification = 87.0%*P < 0.05, **P < 0.01, ***P < 0.001 393
  • Chapter 16 Females of the reproductive ages who have never used a condom with a non-steady sexual partner Paul A. BourneIntroduction According to Edwards, “Unmarried American women who had first intercourse whenthey were younger than 17 and those who were born in the western United States are more likelythan other women to have recently had more than one sexual partners, ...”[1]. While Edwards’research provides pertinent information on the statistical association between age at first sexualintercourse and multiple sexual partners, the exclusion of married and widowed females from thesample may create a perspective that they are not involved in extra-marital relationships orpolygamy. Another reality of multiple sexual relationship is the high risk of contracting sexuallytransmitted infections (STIs), particularly HIV/AIDS and human papillomavirus [2-4],suggesting that the exclusion of any cohort will be detriment to public health policy interventionoutreach. The recognition that risky sexual behaviour is opened to humans, and so the exclusionof heterosexual [3] is similar to that of married females as sexual intercourse is a practices of alland not a specified human population. If public health practitioners need to institute programmesthat will effectively address and change behaviour, understanding why people with multiplesexual partners do not use a condom with non-steady sexual partners cannot be left unresearched. Previous studies have demonstrated that those with multiple sexual partners are morelikely to be unmarried, younger (in adolescence years), and have a greater risk of contracting asexually transmitted infection [1-4] than those with single sexual partners. One group ofresearchers found that only a small percentage of female undergraduate students, in China, with 394
  • multiple sex partners were having unprotected sexual relations [5]. Such a reality is a publichealth concern within the general context of the association between unprotected sexualintercourse and the risk of contracting a STI. Furthermore, according to Yan et al. [5], 5.31% offemale undergraduate students in China had multiple sexual partners, and although thepercentage who have a high risk of contracting a STI was low, the reality is STIs, in particularHIV/AIDS, have been increasing in the young aged cohort in the developing world, and this ismoreso among young women [6-9]. HIV is the 2nd leading cause of death in the World [8] andthe 1st in the Caribbean (among 15-49 year olds) [8] and the 2nd in Jamaica [9], indicating thatinconsistent condom usage and promiscuity are account for the HIV statistics in the developingnations. Using stratified probability sample of 2,848 Jamaicans aged 15-74 years, Wilks et al. [10]found that 24.4% indicated having at least 2 sexual partners (females, 8.4%; males, 41.0%).Furthermore, 11% of female population reported having had a STI (3.4% in the last 12 months)compared to 18.2% of males (1.3% in the last 12 months). While, Wilks et al. [10] did not statethe prevalence of STIs among those with multiple sexual partners compared to those with asingle sexual partner, it can be extrapolated from their study that inconsistent condom usage,premarital sex and multiple sexual relations are a reality among Jamaicans. With the positiveassociation between multiple sexual partners and STI as well as inconsistent condom usage andSTIs [11], earlier sexual relations and risk factor of contracting STIs, despite those realities, noempirical studies exist that examined females in the reproductive ages who never use a condomwith a non-steady sexual partner in Jamaica and their reproductive health matters. There is high importance in wanting to understand females in the reproductive ages whonever use a condom with a non-steady partner, factors which account for their method 395
  • contraception, and factors that explain age at first sexual intercourse of this cohort. The aims ofthe current study is to elucidate (1) the sociodemographic characteristics of females who neverused a condom with a non-steady partner, (2) factors which account for their methodcontraception, and (3) factors that explain age at first sexual intercourse of this cohort.Methods and materialSample Data for this analysis is taken from the 2002 Reproductive Health Survey (RHS) [12].The RHS is an annual household interview survey of the civilian, noninstitutionalized populationaged 15-44years for females and 15-24 years for males. Since 1997, the National FamilyPlanning Board (NFPB) has been collecting information on women (ages 15-49 years) inJamaica regarding contraception usage and/or reproductive health. Stratified random samplingwas used to design the sampling frame from which the sample was drawn. Using the 2001Census sector (or sampling frame), a three-stage sampling design was used. Stage 1 was the useof a selection frame of 659 enumeration areas (or enumeration districts, EDs). This wascalculated based on probability proportion to size. Jamaica is classified into four health regions.Region 1 consists of Kingston, St. Andrew, St. Thomas and St. Catherine; Region 2 comprisesPortland, St. Mary and St. Ann; Region 3 is made up of Trelawny, St. James, Hanover andWestmoreland, with Region 4 being St. Elizabeth, Manchester and Clarendon. The 2001 Censusshowed that region 1 comprised 46.5% of Jamaica, compared to Region 2, 14.1%; Region 3,17.6% and Region 4, 21.8%. [12]. Stage 2 saw the clustering of households into primary sampling units (PSUs), with eachPSU constituting an ED, which in turn consisted of 80 households. The previous sampling framewas in need of updating, and so this was carried out between January 2002 and May 2002. The 396
  • new sampling frame formed the basis upon which the sampling size was computed for theinterviewers to use. Stage 3 was the final selection of one eligible female this was done by theinterviewer 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 interviewersadministered a 35-page questionnaire. The data collection began on Saturday, October 26, 2002and was completed on May 9, 2003. The data was weighted in order to represent the populationof women ages 15 to 49 years in the nation [12]. The current study extracted a sample of 109 female respondents aged 15-44 years whoindicated having never used a condom with their non-steady sexual partners from a sample of7,168 individuals (1.5%). A questionnaire was used to collect the data from respondents. It was a154-item instrument. The questions were demographic characteristics, sexual history (includingnumber and type of partners, having sexual relations with commercial sex workers), and condomusage. The interviewers were trained for a 5-day period, of which 2 days were devoted to fieldpractices. Interviewers were assigned to a team of which there were two females, two males anda supervisor. Oral consent was sought and given before the actual interview would commence.Interviewees were informed of confidentiality and their right to stop the interview at any timethey so desire. No names, addresses or other personal information was collect from respondentsin order to ensure anonymity and confidentiality.Statistical analysesData were entered, stored and retrieved using SPSS for Window, Version 16.0 SPSS Inc;Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographiccharacteristics of the sample. Multivariate logistic regressions were fitted using one outcome 397
  • measure: self-reported confirmed positive HIV test results. We examine correlation matrices toexamine multicollinearity. Where collinearity existed (r > 0.7), variables were enteredindependently into the model to determine those that should be retained during the final modelconstruction [13]. To derive accurate tests of statistical significance, we used SUDDANstatistical software (Research Triangle Institute, Research Triangle Park, NC), and this adjustedfor the survey’s complex sampling design. A p-value < 0.05 (two-tailed) was used to establishstatistical significance.MeasurementCrowding is the total number of persons in a dwelling (excluding kitchen, bathroom andverandah). 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 amethod of contraception? …”, and if the answer is yes “Which method of contraception do youuse?” Age at which began using contraception was taken from “How old were you when youfirst used contraception? Area of residence is measured from “In which area do you reside?” Theoptions were rural, semi-urban and urban. Currently having sex is measured from “Have you hadsexual intercourse in the last 30 days?” Education is measured from the question “How manyyears did you attend school?” Marital status is measured from the following question “Are youlegally married now?”, “Are you living with a common-law partner now? (that is, are you livingas man and wife now with a partner to whom you are not legally married?)”, “Do you have avisiting partner, that is, a more or less steady partner with whom you have sexual relations?”, and“Are you currently single?” Age at first sexual intercourse is measured from “At what age didyou have your first intercourse?” Gynaecological examination is taken from “Have you ever hada gynaecological examination?” Pregnancy was assessed by “Are you pregnant now?” 398
  • Religiosity was evaluated from the question “With what frequency do you attend religiousservices?” The options range from at least once per week to only on special occasions (such asweddings, funerals, christenings et cetera). Subjective social class is measured from “In whichclass do you belong?” The options are lower, middle or upper social hierarchy.ResultsTable 1 presents information on the sociodemographic characteristic of the study population.Almost 81% of the sample had have sex in the last 30 days, and the mean age was 30.4 years(SD = 8.1 years). Further examination of the age composition of the population revealed that8.3% was 15-19 years; 19.3% was 20-24 years; 17.4% was 25-29 years; 20.2% was 30-34 years;19.3% was 35-39 years; 10.1% was 40-44 years, and the remaining was 45-49 years. All therespondents indicated that they have had sexual relations in the past. One and one halfpercentage of females aged 15-49 years (based on the sample size for 2002 Reproductive HealthSurvey) indicating having never used a condom with a non-steady sexual partner. Table 2 shows information on fertility and other reproductive characteristics of the studypopulation. Six percentage of the respondents indicated that they have had at least 2 sexualpartners in the last 3 months. Of those who were sexually assaulted over their lifecourse (22%),41.7% indicated that they occurred once; 37.5% mentioned 2-5 times; 4.2% stated 6-10 timesand 12.5% reported at least 11 times. When they were asked ‘By whom?’ most of them statedby their boyfriends (45.5%) followed by close friends (22.7%), husbands or common-lawpartners (13.6%), visiting partner (9.1%) and lastly by casual acquaintances (4.5%) and otherindividuals (4.5%). Forty-nine percentage of the respondents stated that they began using a method ofcontraception before their first child; 43.1% indicated after the first child; 4.6% reported after the 399
  • second child, 1.8% started after the third child and 0.9% after the fourth child. Although thestudy did not used a condom with their non-steady sexual partner during sexual intercourse,51.4% stated that they always use one with their stead partner; 38.5% mentioned most times and10.1% revealed seldom. Forty-three percentage of the respondents indicated that they want tohave more children in the future and 9% stated that they were uncertain about this. When they were which method of contraception they were on, most were on the pill(56.8%) followed by injection (32.4%), tubal ligation (8.1%) and IUD/coil (2.7%). Only 2% ofthe sample was commercial sex workers. Fifty percentages of the respondents have had agynaecological examination in the last 12 months, and 27% have done a Pap smear in the sameperiod.Multivariate analyses Table 3 examines those variables which explain (or not) age at first sexual encounter ofstudy population. Two variables emerged as statistically significant factors of age at first sexualintercourse of the sample (F-statistic = 4.324, P < 0.0001), and they explain 38.8% of thevariance (R-squared) in the dependent variable (age at first sexual intercourse). Table 4 presents information on variable which explain (or not) age began using methodof contraception for the study population. Three variables emerged as statistically significantfactors explaining age at which females (15-49 years), who never used a condom using their non-steady sexual partner, began using a method of contraception (F-statistic = 4.564, P < 0.0001),and these explain 40.1% of the variability in age at which females began using contraceptivemethod.Discussion 400
  • This study found that although the sample never used a condom with a non-steady partner, theyused one with their steady partner (always, 51.4%; most times, 38.5%; seldom, 10.1%); 2% ofthe sample was commercial sex workers; 43% wanted more children; 47% of sample was in themiddle class; 47% of sample was in the rural area; 49% was in visiting unions; 13.8% hadurinary tract infection; 22% was forced into sexual encounter; 17.6% was forced into sexualintercourse for their sexual debut; and the mean age at first sexual intercourse of the sample was16.5 years while the mean age of the person that the sample had the sexual debut with was 29.7years. The factors of age at first sexual intercourse were area of residence and age began usingmethod of contraception; and the variables which account for age began using method ofcontraception were marital status, age of respondents and age at first sexual intercourse. Like was the case of the undergraduate students in China [5], only a small percentage offemale Jamaicans aged 15-49 years indicated having never worn a condom with a non-steadysexual partner. The current work provides a thorough examination of the reproductive healthpractices of those individuals unlike the study in China [5]. Females with multiple sexualpartners, who do not wear a condom with non-steady partners, 1 in every 2 of them consistently,used a condom with their steady partners. It can be extrapolated from the current work that (1)these female do not see their current partners as a possible parent of their future child/ren, (2)sexual promiscuity is such that the rush of the encounter over-rides the logistics of high risk ofsexually transmitted infections, and the (3) desire to have child/ren is a rationale which isexplaining this activity. Clearly multiple sexual partnerships and polygamy among female istheir desire to become parents, which is so dominant their sexual urge overshadows the high riskof sexually transmitted infections as well as the cultural role of polygamy, while them aretrapped within economic and material deprivation. It can be deduced from the work that 401
  • childbearing is used by females are economic leverage over males, and that some children wouldbe illegitimate for the females’ steady partners. Another issue which is embedded in this study is females sexual dissatisfaction with theirsteady partner and otherwise, which is supported by literature [14]. When the respondents wereasked who was responsible for the sexual assault, 46 out of every 100 indicated a boyfriend; 23of every 100 by a close friend; 14 out of every 100 by a husband or common-law partner 9 out ofevery 100 by a visiting partner. Females’ sexual dissatisfaction, therefore, is embodied in theirreduced sexual autonomy with their steady sexual partner, and that their choice of having sexualrelations with a non-steady partner is a choice, and that this could also be autonomous andfinancial. Clearly, sex is important to humans, but the role of economic is critical [14] and hasoverridden the risk of pregnancy. Sexual promiscuity appears to be more economic on the part ofthe females as most of them are using a second method of contraception to prevent pregnancy,that the non-usage of a condom could be a part of the economic plan that will be used to exhortmoney from the non-steady sexual partner. This study revealed that as female become older, she is more likely to wear a method ofcontraception as well as married, in common-law unions and age at first sexual debut. The factthat as females become older, they are more likely to use a method of contraception that supportsthe literature which demonstrates that young people are less likely to use a method ofcontraception. The present work highlights that females begin having sexual relations with malesat least 13 years their senior, suggesting the importance of economic in sexual relationships. Itshould be understand that this transactional sex is not seen as commercial as only 2% of therespondents indicated being commercial sex workers. According to Shelton [14], “Rather than aspecific fee-for-service, transactional sex describes a social norm of expectation of gifts and 402
  • economic support from men as part of a sexual relationship, in part expressing value,commitment, love, and respect.” Thus, multiple sexual relationships and the non-usage of acondom by some of females is a transactional encounter that is used by women to assistthemselves economically from their financial and material deprivation; and this is the rationalefor the choice of older men. Older men in these types of sexual relationships provide luxurygoods, gifts and money to younger females that they are sexually engaged with, and the youngerfemales offer sexual favours [15, 16]. Polygamy, within the context of transactional sexual relationship, clearly is a low riskactivity for many females as only 14 out of every 100 of them indicated having urinary tractinfection. Although this research did not have information on the prevalence of STI among thestudy population, using Wilks et al.’s study [10] which demonstrates that 11 out of every 100females aged 15-74 years had STIs even though 8.4% had multiple sexual relationships.Furthermore, they found that 4.2% of females aged 15-24 years had STIs, 5.5% of those aged 25-34 years, 3.9% of females aged 35-44 years and 1.1% of females aged 45-54 years and 0% ofthose 55-74 years, suggesting that the younger females, in particular adolescents may be morevulnerable to STIs more than older females which is demonstrated by the literature [11, 17]. Theresults revealed that 41 in every 100 females in the study sample was employed, which indicatesa high dependency on a partner, family or relative for survivability. While there are cleareconomic benefits of females being involved with older men, the opportunity cost of sexuallyengaged with them is STIs, particularly HIV/AIDS and human papilomavirus [6, 17]. Inconsistent condom usage, promiscuity and multiple sexual relationships are accountingfor the high HIV infection in South Africa [6], and women in rural South Africa on averagebegin having sexual relations at 18.5 years. While the prevalence of HIV in South Africa is 403
  • greater than that in Jamaica, inconsistent condom use among females with non-steady partners inJamaica is exposing many of them to the virus, and means that public health must immediatelyaddress this reality. A study by Nnedu et al. [18] which demonstrated that 1.5% of aged 15-49years had HIV/AIDS is not any solace for the reproductive health matters of females aged 15-49years who were having risk sexual relations with their non-steady partners. Empirical, it isestablished that HIV is greater among heterosexuals [19] and young risk taking individuals [20],which means that the practice of females who do not use a condom with their older non-steadysexual partners could be at high risk of contacting any STIs in the future. This is evidence thatenvelopes in this work that futuristic challenges of public health can rest without using a multi-level approach to alleviate and change, the sexual behaviour of these females. Human behaviour is a complex phenomenon and so is human behaviour change. Peoplewill not just change a particular behaviour because outsiders indicate that this is best to do so.Thus people’s participation in healthy behaviour and changing risky behaviour is embedded inrisk perception. People was to live, and the desire is such that the culture, economic deprivationmay not be enough for them to practice behaviour modification despite the threat tosurvivability. Risk perception is different between age and gender, which can account formotivation (or lack of) in lifestyle changes [21]. Using results from Wilks et al. [10], the risk offemales contracting a STI in Jamaica is low and the findings from the current work equallydemonstrate this fact as only 14 out of every 100 females who do not use a condom with a non-steady partner indicated that they had urinary tract infection or 1 in every 100 had pelvicinflamatory disease. According to Gibbison [22], the cumulative AIDS prevalence in Jamaicawas 100 per 100,000 in rural areas to about 1000 per 100000 in urban zones, which validates the 404
  • self-reported statistics. Clearly the results from these findings and that of the literature supportwhy people would have a low risk perception to change their risky behavioural practices. It is not for lack of knowledge why females in this study do want use a condom with anon-steady partner as they are cognizant of the risk factors such as HIV/AIDS, humanpapillamavirus among other STIs. According to Goldberg et al. knowledge of condom is high inLatin America and the Caribbean [23], demonstrating the role of the risk perception in thebehavioural choices of women in the study. The reality is the probability of sexually violenceamong females is greater than the risk of contracting a STI, particularly HIV, AIDs or a pelvicinflamatory disease. The aforementioned findings can be supported by a study conducted on sexworker in Jamaica. The study found that 9% had HIV, 90% having easy access to a condom,30% used a condom with a non-paying partner [24]. Outside of the previous mentioned rationale for the behaviour of study population,another issue which must be examined is sexual unions. According to Ebanks “First, womenbelieve that children in themselves add more stability to a union, than is achieved by the merelycompanionate relationship; and second, women want these additional children because the menwant them and if they (the women) do not comply, the men will go elsewhere” [25]. Here is apotent explanation for the risky behaviour exhibited by the study population as 49 out of every100 are in a visiting union and although the average number of children that they have is 2, thepremarital sexual relationship can be a sexual union transition seeking mechanism for thesewomen. It is for this reason that makes a plausible case of why many of the females in the studystill desire to have another child, the current instability of unions. With visiting unions being theshortest in duration in Jamaica [26], historically, fertility has been a part of the approach used tochange sexual unions and this clearly has some merit in contemporary Jamaica. Drayton [27] 405
  • provides an apt explain for the need to have children in Caribbean societies, when he opined that“In the Caribbean, however, many pregnancies may be unplanned, but few babies are unwanted”because the babies are the opportunity of stable unions, financial assistance and a leverage overthe male. Hence, the need to have a multifaceted approach to public health intervention strategieswhich are geared toward countering the issues raised here.ConclusionMultiple sexual relationship, polygamy and inconsistent condom usage are practiced by femaleswho had non-steady partners in Jamaica. These individuals include married, rural, employed,wealthy, educated, religious, sexually assaulted females, and some whom are currently pregnant.Therefore delaying public health intervention for this cohort will only add to the number ofindividuals who will comprise future HIV/AIDS cases. Thus, these results provide pertinentinformation upon which public health and policy specialists can use to remedy some of the issueswere raised herein. In Jamaica, transactional sex is not construed by females the same way ascommercial sex and so, the practices that emerged in this study highlight how this should beaddressed in order to reduce STI infections and risky sexual behaviours. Adolescents and adults learn and fashion an elaborate set of norms, practices and ideasabout their culture including sexuality and their sexual roles well in advance of their engagementin sexual relationships. Although people are somewhat knowledgeable about risky sexualbehaviours, particular the link between STIs and infertility, ectopic pregnancy, preterm birth,foetal abnormality, HIV/AIDS, and premature mortality, there is a degree understanding inignorance about the probability of contracting a STI, particularly HIV/AIDS, from riskperception which they would have also learnt. Even thought this is not scientific, with regard totheir risk perception, this guides their sexual involvements. The challenge of public health, 406
  • therefore, is not to increase access to contraceptive method and to provide more knowledgeabout the risk factors, but it is make the linkage between personal risk, further economic andsocial deprivations that are likely to result with contracting a STI that is life treating, causeinfertility and remove the vetoing power of sexuality from the male partner. In summary, evidence exists which showed that socioeconomic deprivation is accountingfor aspects of the transactional sexual relationship between females and males in Jamaica.Clearly, addressing polygamy, inconsistent condom use and risk perception among females whohave non-steady partners in Jamaica must use a multi-level approach to intervention; otherwisethe risky behaviour that emerged in this study will not be modified.Conflict of interestThe authors have no conflict of interest to report.DisclaimerThe researchers would like to note that while this study used secondary data from theReproductive Health Survey, none of the errors in this paper should be ascribed to the NationalFamily Planning Board, but to the researchers.AcknowledgementThe 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, and the NationalFamily Planning Board for commissioning the survey. 407
  • References 1. Edwards S. Having multiple sexual partners is linked to age at first sex and birthday. Family Planning Perspectives 1994; 2. Eversley RB. AIDS risk among women with multiple sexual partners: HIV risk screening data from a family planning population. Int Conf AIDS 1989; 5:750. 3. Van Doormum GJ, Prins M, Juffermans LH, et al. Regional distribution and incidence of human papillomavirus infections among heterosexual men and women with multiple sexual partners: a prospective study. Genitourin Med 1994; 70:240-246. 4. Santelli JS, Brener ND, Lowry R, et al. Multiple sexual partners among U.S. adolescents and young adults. Family Planning Perspectives1998; 30:271-275. 5. Yan H, Chen W, Wu H, et al. Multiple sex partner behaviour in female undergraduate students in China: A multi-campus survey. BMC Public Health 2009; 9:305. 6. McGrath N, Nyirenda M, Hosegood V, et al. Age at first sex in rural South Africa. Sex Transm Infect 2009; 85:i49-i55. 7. World Health Organization (WHO). World health statistics, 2009. Geneva: WHO; 2009. 8. Rawlins J, Crawford T. Women’s Health in the English-Speaking Caribbean: The Case of Trinidad and Tobago. Journal of Social and Economic Studies 2006; 55:1-31. 9. Thomas T. Youth Reproductive and Sexual Health in Jamaica. Washington DC. Advocates for Youth; 2006. 10. 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. 11. George C, Alary M, Otis J. Correlates of sexual activity and inconsistent condom use among high-school girls in Dominica. West Indian Med J 2007; 56:433-438. 12. Jamaica, National Family Planning Board (NFPB). Reproductive Health Survey 2002. Kingston: NFPB; 2005. 13. Polit DF. Data analysis and statistics for nursing research. Stamford: Appleton & Lange Publisher, 1996. 14. Shelton JD. Why multiple sexual partners. Lancet 2009; 374:367-369. 15. Leclerc-Madlala S. Transactional sex and the pursuit of modernity. Soc Dynam 2004; 29:1-21. 16. Moore AM, Biddlecom AE, Zulu EM. Prevalence and meanings of exchange of money or gifts for sex in unmarried adolescent sexual relationships in sub-Saharan Africa. Afr J Reprod Health 2007; 11:44-61. 17. Caribbean Task Force on HIV/AIDS. The Caribbean Regional strategic plan of action for HIV/AIDS. Caribbean Task Force on HIV/AIDS; 2000. 18. Nnedu ON, McCorvey S, Campbell-Forrester S, et al. Factors influencing condom use among sexually transmitted infection clinic patients in Montego Bay, Jamaica. The Open Reproductive Sci J 2008; 1:45-50. 19. Vickers IE, Alveranga H, Smikle MF. Clinical and epidemiological characteristics of adult and adolescent patient newly diagnosed with the human immunodeficiency virus at 408
  • a Jamaican clinic for sexually transmitted infections. West Indian Med J 2005; 54:360- 363.20. Penfold SC, Van Teijlingen ER, Tucker JS. Factors associated with self-reported first sexual intercourse in Scottish adolescent. BMC Research Notes 2009; 2:42.21. Deeks A, Lombard C, Michelmore J, et al. The effects of gender and age on health behaviours. BMC Public Health 2009; 9:213.22. Gibbison GA. Attitude towards intimate partner violence against women and risky sexual choices of Jamaican males. West Indian Med J 2007; 56:66-71.23. Goldberg HI, Lee NC, Oberle MW, et al. Knowledge about condoms and their use in less developed countries during a period of rising AIDS prevalence. Bulletin of the World Health Organization 1989; 67:85-91.24. Duncan J, Gebre Y, Grant Y, et al. HIV prevalence and related behaviours among sex workers in Jamaica. Sexually Transm Dis 2010; 37:306-310.25. Ebanks GE. Fertility, union status, and partners. Int J of Sociology of the Family 1973; 3:48-60.26. Wright RE. The impact of fertility on sexual union transition in Jamaica: An event history analysis. J of Marriage and Family 1989; 51:353-361.27. Drayton VLC. Contraceptive use among Jamaican teenage mothers. Pan Am J Public Health 2002; 11:150-157. 409
  • Table 1: Sociodemographic characteristics of study population, n = 109Characteristic n PercentEmployment status Employed 45 41.3 Unemployed 7 6.5 Housewife 81 28.4 Student 8 7.3 At home, not keeping house 18 16.5Are of residence Urban 44 40.4 Semi-urban 14 12.8 Rural 51 46.8Socioeconomic class Lower 25 22.9 Middle 51 46.8 Upper 33 30.3Marital status Legally married 16 14.7 Common-law 36 33.0 Visiting 53 48.6 Divorced, separated, widowed 4 3.7Frequency of condom usage (with steady partner) Always 56 51.4 Most times 42 38.5 Sometimes 11 10.1 NeverNumber of sexual partners (in last 3 months) None 0 0.9 1 1 93.4 2+ 2+ 5.7Religiosity At least once a week 29 26.6 At least once a month 21 19.3 Less than once a month 13 11.9 Only on special occasions (weddings, funerals, christening) 34 31.2 Does not attend at all 11 10.1 No response 1 0.9Shared sanitary convenience No 86 80.4 Yes 21 19.6Age of respondents mean (SD) 30.4 years (8.1 years)Age of first sexual intercourse mean (SD) 16.5 years (2.3 yrs)Age of person had sexual debut with mean (SD) 29.7 years (23.5 yrs)Education (in years of school) mean (SD) 13.4 (2.9) 410
  • Table 2: Fertility and other reproductive health characteristic of study population, n = 109Characteristic n PercentCurrent had sexual relations (in last 30 days) Yes 88 80.7 No 21 19.3Current pregnant (at time of survey) Yes 2 1.8 No 107 98.2Ever been pregnant Yes 86 78.9 No 23 21.1Want to be pregnant Yes 0 0.0 No 0 0.0 Refused to answer 109 100.0Want more children Yes 45 42.8 No 51 48.6 Unsure 9 8.6Forced sexual relations on sexual debut Yes 19 17.6 No 89 82.4Forced sexual relations (over lifetime) Yes 24 22.0 No 85 78.0Tested for HIV/AIDS (when pregnant) Yes 38 44.7 No 30 35.3 Not sure 16 18.8 Refused to answer 1 1.2Pelvic inflamatory disease Yes 1 0.9 No 107 98.2 Don’t know 1 0.9 Refused to answer 0 0.0Urinary tract infection Yes 15 13.8 No 91 83.5 Don’t know 1 0.9 Refused to answer 2 1.8Number of pregnancy that resulted in Live births median (range) 2 (1 – 9) Still births median (range) 0 (0 – 0) Miscarriages median (range) 0 (0 – 4) Abortions median (range) 0 (0 – 0)Age at menarche mean (SD) 13.2 years (1.5 yrs) 411
  • Table 3: Multiple linear regression: Variables of age at first sexual intercourse Std. Dependent variable: Age at first sexual intercourse Coefficient error CI (95%) Constant 9.805 1.871 6.079 - 13.532 Shared sanitary convenience (1=yes) 0.465 0.565 -0.661 - 1.591 Married or in common-law union (1=yes) -0.204 0.444 -1.088 - 0.679 Employment status (1=employed) 0.513 0.458 -0.399 - 1.426 Lower class -1.283 0.666 -2.609 - 0.043 Middle class -0.627 0.581 -1.784 - 0.531 Upper class (reference group) Semi-urban -2.834 - - -1.438* 0.701 0.042 Rural 0.321 0.570 -0.815 - 1.456 Urban (reference group) Forced into having sex (1=yes, over lifetime) -0.496 0.478 -1.448 - 0.457 Age 0.014 0.029 -0.044 - 0.071 Education (in years of schooling) 0.092 0.078 -0.063 - 0.248 Age began using contraceptive method 0.289* 0.078 0.133 - 0.446*P < 0.05 412
  • Table 4: Multiple linear regression: Variables of age began using method of contraception Dependent: Age began using method of β Coefficient Std.contraception Error CI (95%) Constant 6.479 2.866 0.770 - 12.188 Shared sanitary convenience (1=yes) -0.831 0.763 -2.352 - 0.689 Married or in common-law union (1=yes) 1.283* 0.583 0.121 - 2.445 Employment status (1=employed) -0.106 0.626 -1.352 - 1.141 Lower class -0.270 0.923 -2.110 - 1.569 Middle class -0.101 0.793 -1.680 - 1.479 Upper class (reference group) Semi-urban 0.225 0.975 -1.717 - 2.168 Rural -1.170 0.762 -2.688 - 0.348 Urban (reference group) Forced into having sex (1=yes, over lifetime) 0.813 0.646 -0.473 - 2.099 Age 0.090* 0.038 0.015 - 0.165 Education (in years of schooling) 0.098 0.106 -0.113 - 0.309 Age at first intercourse 0.531* 0.144 0.245 -0.818 *P < 0.05 413
  • Chapter 17 Male Prostitution: An exploratory study on Initiation, Practice and Behaviour of young adults in a Kingston Metropolitan Region, Jamaica Paul A. BourneIntroduction Generally, Jamaicans are homophobic. Nevertheless, there are sub-cultures within thegeneral practices as the issue of homosexuality is a social reality. Homosexual practices may bewidespread in this society but this is not of which I speak, it is the male prostitution trade ofyoung adults (i.e. 16 to 25 years), the socio-demographic characteristics of this group along withtheir explanation for the justification of their current behaviour. In addition to what has beenpreviously stated, another issue is the dual life that some of these young adult men are engagedin. This study examines the male prostitution trade of young adults who practice their trade inthe Kingston Metropolitan Region. The researcher will use the survey approach, but it will bevoid of probability sampling technique as the sample could only be obtained using snowballing(i.e. non-probability sampling technique). Despite this seemingly limitation, the research givesan insight into the lifestyle of young adult males who practices the trade of prostitution inKingston and St. Andrew. In a qualitative research conducted by the National HIV/STI Control Programme of theMinistry of Health (Jamaica) concluded that an estimated 2,500 persons were engaged incommercial sex work. Of that number, 550 were male prostitutes who cater to the homosexual-male population of Jamaica. The data showed that large numbers of both male and femaleprostitutes were adolescents. This information caused public outrage when it was revealed that 414
  • 50 of the estimated 350 male prostitutes in the Kingston Metropolitan Area were under the age of15 years old (Gayle, H. 2002). The National HIV/STI and Control Programme of the Ministry of Health identifyCommercial Sex Workers (CSW) as a specific risk group. This group is commonly associatedwith high-risk sex practices, with multiple partners. The Commercial Sex Work in Jamaica isdynamic, complex and multi-dimensional. (Campbell, A.M. & Campbell, P. 2001). The malesex work phenomenon appears to be steadily increasing. There are different types of sex workersrepresenting all ages, backgrounds and locations to include street, bars, hotels, go-go clubs,cruise ship ports, beaches, escort services and massage parlors. Field- work further indicates thatsex work in Jamaica is starkly evident in both rural and urban settings, involving heterosexuals,homosexuals and bisexual relations. High levels of movement among sites and parishes occurwhile CSW travel between locations either in search of, or with clients (Campbell & Campbell,2001). There are certain kinds of characteristics that define a CSW; many commence sex workat quite an early age, usually as children or adolescents. This means that young men begin withlittle or no knowledge of issues of sex, sexuality and disease prevention. Some of these youngmen are kidnapped and forced to engage in sexual activity, with little or no tool to protectthemselves from HIV and other Sexually Transmitted Infections (Watson, P. 2003). Sex workers usually migrate from rural areas to urban settings to seek jobs or arerecruited by clubs, bars or brothel owners (Watson, 2003). They are generally unskilled and areusually unprepared for work in the sex work industry. Many are the sole income earners in theirfamily or are expected to contribute to family incomes. Studies have shown that sex work thrivesin situations where economic opportunities are scarce and where the socio-economic situation 415
  • make sex work affordable to clients and an opportunity to earn well needed cash by the sexworker. Sex work can be classified as formal, that is, it takes place in an establishment with amanager who acts as an intermediary between the worker and the client. The informalarrangement includes those who stand on the street and depend on their own ingenuity to attractclients. There are some boys who depend on clients to advertise for them. Outside of these twocategories, there are those who work seasonally to supplement incomes or to meet short-termeconomic needs, such as school fees (Watson, 2003). Dunn (2001) states that distorted value systems that place priority on material thingsrather than wholesome relationships are also seen as factors contributing to child prostitution.Western values promoted through travel, the print and electronic media, films and cabletelevision, have become the desired lifestyle of many Jamaicans including adolescents. Society’sdemands place a high value on material goods (designer clothing, expensive cars) and thelifestyle of the wealthy; have induced some children to engage in prostitution. Dunn furtherstates that economic poverty, poverty of values and poor parenting practices are among thebackground factors associated with children in prostitution.Conceptual Framework The objectives of this research are to determine the existence and extent of prostitutionamong males 16 – 25 years, investigate and determine the socio-economic profile of males 16 –25 years who are involved in prostitution, identify the factors that motivate them to becomeinvolved in this profession, the impact of prostitution on adolescents/youths and the nature of it,that is, male/male or male/female. This research will explore the factors influencing initiation, 416
  • practice and risk behaviours of adolescent/youth male prostitution in the Kingston MetropolitanArea. Additionally, the research will evaluate the strategies aimed at reducing adolescent/youthrisk behaviours. The review will focus on risk factors that adolescent/youth adopt; antisocialbehaviours; the socio-economic factors that contribute to male adolescent prostitution;psychological impact; factors influencing initiation and strategies for reaching young men.Commercial Sex WorkersThe concept of sex work emerged in the 1970’s through the prostitutes’ rights movement in theUSA and Western Europe and has been discussed in various publications (Kempadoo, 1999).Troung’s (1989) study of Prostitution and Tourism in the south East Asia produced one of thefirst extensive theoretical elaborations on the subject. Defining human activity or work as theway in which basic needs are met and human life produced and reproduced, she argued thatactivities involving purely sexual energy should also be considered vital to the fulfillment ofbasic human needs: both for procreation and bodily pleasure. Troung introduces the concept ofsexual labour to capture the notion of the utilization of sexual elements of the body as a way ofunderstanding a productive life force that is employed by men and women. She proposes thatsexual labour be considered similar to other forms of labour that mankind performs to sustainitself – such as mental and manual labour, all of which involves specific parts of the body andparticular types of energy and skills (Kempadoo, 1999). Sex work in Jamaica, as in most other societies, exists in some shape or form since thebeginning of time. Its appeal as an area for in – depth social scientific research is, however, morerecent. Henrigues (1963) explored its manifestation in Jamaica during slavery, post –emancipation and the early twentieth century. In all three periods he found that sex work offeredwomen an opportunity to improve their lot through sexual liaisons with white men or because of 417
  • the potential it provided during the post – emancipation period for women to earn an income indeclining socioeconomic conditions (Kempadoo, 1999).Socio-economic factors Various sector studies (Endoc 1994, Ross – Frankson 1987) together with newspaperarticles in 1998 have supported the view that sex work provides an alternative income indeclining socioeconomic conditions. These reports point to an idea largely unsupported by thefact that an increasing number of younger women and men are entering the trade as economichardships increase. Nevertheless, a fast growing tourist sector and further declining economicconditions have facilitated an increase in female and male prostitution (Kempadoo K, 1999).Since the early 1970’s, islands such as Barbados and Jamaica have become well knowndestinations for female tourists. (Karch & Dann, 1981) posits this as “Close encounters of thethird world” kind. Males, mostly young, cruise the beaches in search of unattached touristwomen. They are known as “beach boys”. They are usually identified by their tight muscle T-shirt and cropped pants. Pruitt and Lafont (1995) have provided a fairly detailed account of female tourist and“Rent – A – Dread” in Jamaica in an article entitled “For Love and Money: Romance tourism inJamaica”, Rent – A – Dread is the Jamaican equivalent of Barbadian Beach Boys. However theydiffer from the Barbadian beach boys in a number of ways. They are for the most partunemployed, have less formal education and are mostly migrants from rural areas living inshacks on “captured land” (squatters) around the tourist resorts towns as Ocho Rios, MontegoBay and Negril. Their long dread locks easily identify them. Rent – A – Dreads are familiarfixture along the beach strip. They do this an attempt to solicit tourist women. They are veryadept with the lyrics in attracting the women. 418
  • The various music festivals in Jamaica (Reggae Sunsplash, Sumfest, Eastfest, RebelSalute, Sting and Heineken Star- time) attract tourists from around the world, mainly from NorthAmerica, Europe and Japan. Female tourists who are traveling alone or with other femalefriends find it advantageous to connect with these Rent – A – Dreads not only to serve as a“culture broker” (Pruitt & Lafont, 1995) but also to negotiate taxis and tickets to the variousshows, ward off persistent vendors and assorted hustlers and generally to provide added security.In return for these services, the tourists provide food, drinks and tickets to the music festivals,movies, transportation, gifts and money. If they are looking for sex as well, there are greaterexpectations regarding gifts and money. Commercial sex work is not always a steady activity. Commercial sex workerssupplement their income by other paid activities such as informal commercial trading(higglering), vending, modelling and housekeeping among others. Sex work does not offer anylong-term guarantees. In Jamaica for example, it is still an illegal activity and the sex workersoperate very covertly. There is a high element of danger connected with the activity. That is,fight for turf or even the consumption of illegal drugs. Sex work is commonly just one of themultiple activities employed for generating income, and very few stay in prostitution for theirentire adulthood (Kempadoo, 1998). Street and working children are a particularly vulnerable group to prostitution. Thesechildren lack family and social support. (Dunn, 2001) posits that small boys between the ages of6 and 17 years were most exploited. They did not have the protection of adult family members orinstitutional environment for support and as such were exposed to extreme economic deprivationand abuse. Those involved in sexual activity were between 12 and 18 years. The majorities were 419
  • from very poor backgrounds and were out of school; although a few attended school regularlyDunn, (2001). Adult homosexual males were the main clients of adolescents. However, someadolescents had female prostitutes. Their inability to meet certain basic needs made these boysdesperate and severely reduced their ability to bargain with adult clients. Some become involvedin prostitution because of a perceived lack of financial opportunities. Adults who exploited theirneeds and dependency coerced some boys into sexual activities. Reports of boys engaging insexual intercourse in exchange for a basic meal of a patty and a box drink were not uncommon.Risks of physical violence from peers on the streets and others were also high because ofJamaica’s strong homophobic culture. Adolescent involvement in homosexual relations aresometimes very covertly done, thus making them invisible to other children involved inprostitution and were less accessible for rehabilitation and support (Dunn, 2001). The “toy boy” phenomenon is an emerging form of prostitution in Jamaica. Schoolboysare enticed by gifts and other monetary rewards from older women for sexual pleasures. Thesewomen sometimes pick up the boys at school on Friday afternoons and keep them for the entireweekend while engaging them in various types of sexual activities, then taking them back toschool on Monday mornings. The boys are showered with expensive gifts of jewellery, brandname sneakers and expensive clothes. They are sometimes taken to the North Coast forvacation. This practice occurs with boys who are less supervised at home or living on their ownwhile one or both parents have migrated. There are instances when this behaviour occurs inhomes where both parents are present. Some parents are aware of the alliances and are evenaccepting of it. Others are completely unaware of what is happening because of the ingeniousmethods that the boys employ to cover their tracks (Researcher’s observation). 420
  • Although often hidden and frequently denied by political and community leaders, mensell sex to other men in many countries. Young men and boys are more likely to be involved insex work than older males. Many different motives underlie men’s involvement in sex work.While money is usually the driving force, some young men, particularly in cultures where sexbetween men is strongly abhorred, sell sex because that is the only way they can find malepartners, or because they do not acknowledge to themselves their attraction to other men. Theyounger the male sex worker is, the less he is to be able to protect himself from HIV infectionbecause of his inability to negotiate condom use. The lure of payment, physical or emotionalforce from the client, or the craving for a drug which the money will buy, can force young mento agree to sex without a condom. Older more experienced sex workers are likely to have theconfidence and assertiveness to negotiate safer sex.FACTORS INFLUENCING INITIATION Robinson, Bain, and Thompson (2001) were concerned that a number of boys were beingsexually abused on Jamaican streets. Klao Bell, in an article entitled, “Street boys feel the bruntof sex crimes” discussed the plight of street boys. She cited a number of observed incidentswhere men pick up the boys in expensive automobiles. It is extremely disturbing that the Rapeand Juvenile unit of the Jamaica Constabulary Force has had no report of these incidents. It isobvious that occasional patrols are not enough to protect these adolescents/youth from sexualabuse (Gayle, 2002). Sahil (1998) in a research report on adolescent reproductive health states that the primeage for male prostitutes in Pakistan is 15-25 years. It is likely that less is known about theworking environment and specific problems because of the social taboo for boys admitting to sex 421
  • with male clients are even greater than for girls. Preliminary findings of Sahil’s research intomale child prostitution in northern Punjab show that children are usually runaways who arecoerced by local hotel owners in urban centres to exchange their bodies in return for board andlodging. This points to the reality that children and adolescents have limited skills to rely on tosupport themselves if they need to do so. Prostitution is often the most practical and lucrativemeans of achieving this. Children as young as eight years were found working as maleprostitutes. There are similarities here to what occurs in Jamaica, seen in Dunn’s research onchildren in prostitution. Another practice, common in the North West Frontier Province (NWFP) Pakistan but notyet the subject of much formal research, is Bachabazi, or older men keeping boys as their sexualpartners. A man who wishes such a partner will select a boy, usually fair of skin and in his earlyteens. He will slaughter a goat in front of the boy’s house to publicly demonstrate his choice.From that point on, the man will be responsible for the education, clothing and general care ofthe boy in return for sexual favours. Needless to say the boy himself lacks decision-makingpower in this institutionalized and socially accepted form of sexual abuse. The study concludedthat there was a high prevalence of male sexual abuse and commercial sexual exploitation ofchildren in NWFP and that the social norms such as bachabazi helped to perpetuate the widelytolerated practice of adults keeping young boys for sexual services. Stephen-Claude Hyatt (2001) believes that in Jamaica, the modern prostitute is no longeronly female, as there are a growing number of men and children who have either worked theirway in, or forced into the sex work industry. The reality in the Jamaican society is that childrenhave been encouraged or forced by their parents to sell their bodies for money and favours.Many Jamaican women, for years have been content with the understanding that their teenaged 422
  • daughters are sexually involved with mature men, old enough to be their fathers, in exchange fortaking care of the family. What is not known is that there are Jamaican women who will sendtheir daughters and sons out nightly to prostitute themselves and take home the money. Many ofthese children are not allowed back into the home unless a certain amount of money is madenightly (Hyatt, 2001). Quite a few of these children, some of whom are boys, have to sell their bodies to oldermen in order for the families to survive. The boys have to perform sexual acts with the men,some of whom take advantage of them without paying. The dilemma here is that some of thesechildren may be exposed to HIV and other sexually transmitted infections (STI). Many of themadmit they do not use a condom as some of the men do not want to use the condoms. Thispractice has caused severe emotional and psychological problems for the adolescents/youthbecause of careless parents and care givers who have become pimps instead of providers (Hyatt,2001). 423
  • Adolescent Risk Behaviour The planning institute of Jamaica reports that the incidence of HIV / AIDS and otherSTI’s is increasing among adolescents. The number of reported new HIV infections inadolescents had doubled each year since 1995. The knowledge, attitudes, behaviour and practice(KAPB) survey 2004 prepared for the Ministry of Health by Hope Enterprises showed someinteresting findings on adolescent risk behaviours. A sample of 1800 participants (878 men; 922women) was interviewed. For example, commercial sex work increased significantly amongmales over the period 2000 – 2004. Males 15-24 years from 2% in 2000 to 6% in 2004 andmales 25- 49 years from 1.2% in 2000 to 15% in 2004. The most worrying factor among males25-49 (given that the WHO definition of youth is 15-25 years) is the phenomenal growth inadvertised massage parlours in recent years (Hope Enterprises, 2004). Hope Enterprises further report that protective behaviours are not practiced by all menengaged in sex work. It was 82% of the younger cohort and 75% of the older who reportedconsistent condom use in transactional sex. In fact, among the older age cohort, 28% of those inmain partner relationships are not protecting themselves when engaging in transactional sex.One night stands (most recent partner) are high among adolescent males. Among those who hadsex just once; 35% of males in the 15 -24 years interviewed; only 74% used a condom. Of the17% of those interviewed in the 25 – 49 age groups, only 52% used a condom. Hope Enterprisesused the indicator; risky sex in the last year to ascertain the percentage of respondents who havehad unprotected sex with a non marital, non cohabiting partner in the last 12 months, of all therespondents reporting sexual activity in the last 12 months; the 15 – 24 years, (30.5%) & the 25 –49 years (26.6%). Based on the definition of a risky sexual encounter as one in which thepartners are not living together, just under a third of the sexually active, (15 – 49 years) are still 424
  • not protecting themselves in risky situations with no significant difference by age or genderHope Enterprise (2004). Research done on the activities of adolescents of urban St. Catherine conducted byHerbert Gayle et al (2004) found that openness and willingness to participate in taboo sexualpractices seems to increase with the length of time that one is doing sex work. Five informantsreported having in excess of 100 partners throughout their sexual history. Indeed, the highnumbers of sex partners are overwhelmingly related to prostitution. Male prostitutes typicallyservice more customers than their female counterparts. One informant, a 15 year gigolo statedthat he had had 300 partners since his first sexual encounter and over 180 sexual partners in atwelve month period. The high number of sexual partners did not prevent the majority of therespondents from maintaining stable committed relationships. Those without stable relationshipswere likely to have more business partners (Gayle, 2002). Many young persons whose avenues of opportunities are blocked by poverty and lack ofeducation turn to the sex industry. However, there are risks associated with the sex industryagainst which these participants are ill-prepared. While there is a relatively high awareness ofsexually transmitted diseases and measures to prevent their spread, the age of many proved to bean impediment to procuring condoms and other means of protection. One participant mentionedthat some health care providers refused to sell him condoms initially but now that his moustachewas growing, he could access the condoms. Pharmacies reluctant to condone early sexualactivity inadvertently exposed these young persons to a greater evil: HIV/AIDS (Gayle, 2002). Mature looking adolescents were more readily able to bypass this obstacle. Manyinstances were related of staff; including cashiers, elder staff members and secretariesdisregarded the need for confidentiality and an environment conducive to reproductive health 425
  • assistance. Though accessing contraceptives from shops were easier, confidentiality issuessurfaced Gayle (2002). Data in the study – “Adolescents of urban St. Catherine: CommercialSexual Activities as a Survival” strategy, showed evidence of the disparity between theawareness of STIs and prevention and actual implementation of this knowledge. Fourinformants admitted to contracting gonorrhea and one, oral herpes, at some point in their sexualhistory. This means that 50% of them have contracted an STI indicating that this group isroughly ten times more vulnerable than the respondents of comparable age from the main frameof the study. Of the 260 sexually active adolescents from the main frame of the study, only 13 or55% reported that they contracted an STI, including those who were raped. In spite of this detailmost of the respondents involved in commercial sexual activities felt that they were unlikely tocontract HIV (Gayle, 2002). There are dangers associated with the sex industry that are not related to STIs. Prostituteswho ply their trade on the streets are vulnerable to rape and robbery and many acquire a pimp toexercise selectivity in the hope of minimizing the chances of doing business with a psychopath.Though there is evidence in the data of the use of drugs, the majority of respondents’ drug habitis limited to ganja (cannabis) and alcohol. The use of hard drugs cannot be ignored.Adolescents involved in commercial activity are far more vulnerable to contracting STI as wellas using hard drugs when compared to adolescents of the urban poor. They also seem to useother drugs in greater proportions. Responses suggest that increased use of alcohol could be anattempt to cope with the demands of the occupation (Gayle, 2002).Antisocial BehavioursJuvenile Sex Offenders 426
  • There is some correlation between juvenile sex offenders (JSO) and prostitution becauseboth groups commence sexual activity in early adolescence. Juvenile sex offenders andadolescent male prostitutes have a tendency to recruit their younger peers. They have similarinterests in pornography, exhibitionism, fetishism and telephone sex. It is prudent to show thesesimilarities in explaining how JSOs were related to this study. Sexually abusive behaviour hastraditionally been viewed as perpetrated exclusively by adult men. More recent crime statisticsand research on sexual offenses have consistently shown that this is not the case and in the pastfifteen years, sexual abuse perpetrated by JSOs has received increased attention. Conservativeestimates indicate that between 15% and 20% of all sexual offences are committed by youthunder 18 years and as many as 50% of all molestations may be committed by youth younger than18 years (Davis & Leitenberg, 1987; Furby, Weinrott & Blackshaw 1989). Furthermore, many adult sex offenders began their offending as juveniles. (Abdel,Mittelman & Becken, 1985). The only fairly definitive conclusion that can be drawn to date isthat JSOs are a very heterogeneous group. Weinrott (1996) cites that there is great variation invictim characteristics, degree of force, chronicity, variety of sexual outlets (that is, otherparaphilias), arousal profiles and motivation and intent. The model age of offenders reported inthe studies tends to be 14 to 15 years, with a first offence most likely to occur at age 13 or 14years. However, there is some evidence indicating that about 25% of JSO samples had engagedin sexually abusive behaviours before 12 years (Metzner & Ryan, 1995; Ryan et al., 1996,Weinrott, 1996). In his review of the literature, Weinrott, (1996), concluded that it is rare forjuvenile child molesters to have both male and female victims. Victims are most likely to befemale acquaintances or siblings; rarely are they strangers. In general, the victims of JSOs are atleast acquainted with the perpetrator. Reports consistently indicate that more than 50% of 427
  • perpetrators know their victim and in cases of child molestation, 75% of victims were eitherrelated to or acquaintances of the perpetrator (Davis & Leitenberg, 1987). Ryan et al (1996)reported that almost 40% of the JSOs in their national sample were blood relatives of the victimsand that sexual victimization of strangers only accounted for 6% of the cases. Most offences committed by JSOs are verbally coercive rather than overtly aggressive orviolent (Ryan et al, 1996) and the intensity of the coercion may increase with the age of thevictim. Finkelhor, Dziuba &Leatherman (1994) found that only a small fraction of JSOs commitcrimes that result in physical injury and generally no more force is used than is necessary tocomplete the act. Although about one third of offenders blame the victim for their offence, mostoffenders report using some coercion, ranging from bribes and promise to some level of force togain compliance (Metzner & Ryan, 1995). Prevalence of conduct disorder is reportedly highamong juvenile child molesters. Whereas serious delinquency, substance abuse problems andinterpersonal aggression are relatively uncommon, some researchers have reported that generaldelinquent behaviour is often quite common pre- and post adjudication for sexual offence.Psychopaths Another Antisocial behaviour embraced by adolescents is that of Psychopaths. Apsychopath is a person with an antisocial personality disorder, manifested in aggressive,perverted, criminal or amoral behaviour without empathy or remorse (The American HeritageDictionary of the English Language). Antisocial Personality Disorder (APD) is a personalitydisorder, which is often characterized by antisocial and impulsive behaviour. APD is generallyconsidered to be the same as, or similar to, the disorder that was previously known aspsychopathic or sociopathic personality. Approximately 3% of men and 1% of women havesome form of APD (Source: DSM-1V). The reason for inclusion in this study is that both the 428
  • psychopath and the prostitute share certain similarities. Neither is committed to lastingrelationships and they both use some deception in these relationships. Robert Smith (1984)posits that philosophers have shown increasing interest in the psychopath as a paradigm case inexamining value theory, moral responsibility and even rationality. Haksar V. (1965) raises theissue of the extent to which we could expect the psychopath to be able to get rid of criminalvalues once acquired. The psychopath does not seem able to do this, and thereby illustratespsychological illness. Haksar (1965) believes that values are not relative, but objective; to bediscovered in concrete reality (nature). Still the person, including the psychopath, may recognizediscoverable objective truths in moral matters but choose not to adopt them. Haksar (1965)argues that there is a meaningful distinction relevant to psychopathy between moral insanity andmoral sickness. Even if one did subscribe to moral relativism, the morals recognized by a givengroup could also be recognized by the psychopath, but because of moral sickness, he could notfollow them. Moral sickness would involve not the inability to see moral facts, it is thisincapacity to choose that Haksar (1965) believes is sufficient to excuse psychopaths fromresponsibility. He believes that the psychopath is not insane but morally ill. The prototypical psychopath is also characterized by having a history of uncommittedsexual relationships. In the language of parental investment theory, psychopaths can bedescribed as short-term sexual strategists who minimize commitment in relationships andparental investment in any resulting offspring (Seto, M., Khattar, A., Lalumiere, L. and Quinsey,V. 1996). Seto et al (1996) have suggested that psychopathy may not be pathology, as it isusually understood; the characteristics associated with psychopathy, could have contributed toDarwinian fitness under a variety of conditions; one possibility is that psychopathiccharacteristics were maintained in the population by frequency – dependent selection. 429
  • Frequency – dependent selection describes a situation in which traits are advantageous whenindividual possessing them occur at a certain frequency in the population but aredisadvantageous when these individuals are more or less common. Although it is clear that psychopaths use deception in social exchanges (Hare, Forth &Hart 1989), the nature and extent of this deception has not been empirically established. Matingis one domain in which deception might be advantageous. There are similarities in mateselection criteria for males and females but because of differences in their reproductive lifehistories, males place more emphasis on cues of health, youthfulness, indicating fertility, whilefemales place more emphasis on cues of social status and resource acquisition, indicating abilityto invest potential offspring Buss (1994). Reflecting female – typical preferences, Tooke &Counrie (1991) found that male students presented themselves to potential female partners asmore resourceful, trustworthy and sincere than they actually were. At the same time becausefemales were the choosier sex, there is intense male – male competition for mates; males cantherefore be intrasexually deceptive by presenting themselves as more sexually promiscuous andpopular than they really are (Seto et al, 1996). Psychopaths are characterized by a history ofshort, unstable sexual relationships Ellis (1987), consistent with short-term sexual strategy (Buss& Schmitt, 1993).Psychological Impact While focusing on the psychological development of young prostitutes and thepsychological impact of being involved in the sex trade, Coleman (1989) found that disruption inthe psychosexual and psychological development of young males might contribute to theirparticipation in “destruction and non-ego enhancing prostitution activities.” 430
  • Some adolescent males are involved in situational prostitution while others make a livingfrom prostitution. The professional “call” and “kept” boys frequently work gay male urban areas;they are the most gay-identified, usually with a well-integrated sense of their sexual identity.These youths are often from a middle-class background and are sufficiently physically attractiveto support their prostitution business (Savin-Williams, R.C. 1994). There are others who areclassified in a lower status than those above. They are “street hustlers”, “bar boys” and “prisonpunks” who frequently come from lower socioeconomic backgrounds and are conflicted abouttheir sexual identification. Many of these adolescent prostitutes drop out of schools, use alcoholand run away from home or are thrown out by the family because of their sexual orientation.Many of the parents are heavy alcohol and drug users. Consistent with their family pattern, 20%to 40% of prostitutes also abuse drugs and alcohol. They run away from home to escape a familysituation that is frequently chaotic and where they feel misunderstood, unwanted and rejected.Those adolescent prostitutes who become street hustlers face a different life; they viewthemselves as “sluts” and “whores”, have low self-esteem and want to quit hustling but see noother option. Many male street hustlers are victims of rape and exploitation. They face thetrauma of male-male rape and the difficulties that gay male youths have in being taken seriouslyin reporting the crime and garnering support from authorities. They often have feelings of being“less of a man” and experience physical, emotional and psychological problems. There are other youths who become involved in prostitution to meet non-sexual needs,such as to be taken care of, to receive affection, and for others to help them cope with theirhomosexuality. Among their fellow prostitutes, they found camaraderie and kinship thatsubstituted for the neglect or rejection they received from their biological families and peer(Savin-Williams, R.C. 1994). 431
  • Ann Lucas (2004) recounts David Henry Sterry’s memoir, Chicken where the authorworked as a teenage prostitute (age 17yrs.) for one year in Southern California. Sterry refers tohis time in prostitution as “the life” (sterry pg. 125) indicating recognition of prostitution in thelimited status is no simple vocation, but rather has larger implications for its practitioners and abroader significance in society. Sterry’s book helps demonstrate why “the life” is often used as asynonym for prostitution: illegal and stigmatized, for most, prostitution is no mere way to paythe rent. Instead it may involve false names and cover stories; the threat or actuality of violence;uncertainly due to the risk of arrest, eviction, expulsion, deportation, emotional distance fromloved ones and inner turmoil. Whether a prostitute embraces or regrets his work, the fact ofstigma and criminality often lead prostitutes into “the life” of prostitution because of the thingsthey must do to conceal their activities from others and the opportunities they forego because ofthe risk of disclosure (Lucas, 2004).Erikson’s Developmental Cycle Several theorists including Erikson and Piaget in their findings on the social developmentof adolescents have forwarded a number of theories. For the purpose of this study, Erikson’stheory has been selected. Erikson (1950, 1968) was the pioneer who recognized identity crisis as the majorpersonality achievement in adolescence and as a critical step towards becoming a productive andhappy adult. The identity versus identity confusion, Erikson’s fifth of his eight developmentstages is experienced during the adolescence years. At this stage, the adolescent faces the task offinding out who he is, what are his values, what he is about and where he is going in life. 432
  • Adolescents are confronted with many roles and adult status related to vocational andromantic choices. This period according to Erikson, forms the framework for organizing andintegrating behaviours in diverse areas of life.Strategies for reaching Young Men One of the most persuasive arguments for targeting young boys and young men is the factthat they are receptive to influences while they are still in the process of developing theirattitudes and sexuality. Targeting them while they are still finding out about their bodies andresponsibilities to others makes more sense than trying to counter habitual attitudes and patternsof behaviour in older adults. In addition, many youths are still in school, where structures are inplace to deliver Health and Family Life Education (HFLE) (Scalway, T. 2001). Existing services for young men’s sexual health vary from country to country. The keyprinciple to all successful strategies is considering the needs of young men, from the point ofview of the young men themselves. This can vary from culture to culture, and within cultures.For example, the age and sex of educators and other health professionals needs to be considered.Most young men prefer to discuss aspects of sex with other men. Sometimes an age gap canrelieve their anxiety when the impression of authority or expertise is required during an intimatephysical examination. The UNFPA/WHO/UNICEF 1998 study group on adolescent health andthe 13th World AIDS Conference cites 7 principles for improving sexual and reproductive healthprogrammes for young men: 1. Young men’s needs differ according to age, sexual experience and other social characteristics. 2. Sexual health organizations need to assess what young people actually want and what they are already doing to obtain information and services. 433
  • 3. Instead of just providing information, service providers need to build life skills, such as assertiveness, confidence and a respect for the opposite sex. 4. More settings need to be used to provide sexual health and AIDS-related services. These services should include formal and informal and community-based settings 5. Build upon what exists by linking existing services in new ways so that they reach larger numbers of young people. 6. More opportunities need to be created for young men, both for income generation and for safe recreation. 7. Educational and recreational activities that promote dialogue and mutual respect between the sexes need to be encouraged.Having noted the principles stated above by the United Nations group, here are some strategiesthat have proven to be very effective in adolescent health care:Peer Education Peer education works on the principle that the best people to address young men are otheryoung men. Peer educators provide information in schools, bars, sports clubs, religious groupsand street gangs. This form of intervention is inexpensive and is often the only way to reach themost marginalized boys and young men – for example, sex workers, street kids and men whohave sex with men (Scalway, 2001). The Ministry of Health (MOH) and other NGOs haveinitiated training for peer counselors in the area sex and sexuality, promotion of abstinence,reproductive health, knowledge and skills related to HIV/AIDS and communication skills. Peereducators are trained to engage their peers in discussion related to