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Factor Differentials in contraceptive use and demographic profile among females who had their first coital activity at most 16 years versus those at 16+ years old in a developing nation

Paul A. Bourne*
Socio-Medical Research Institute (Formerly Dep. of Community Health and Psychiatry), Faculty of Medical Sciences, The University of the West Indies, Jamaica
Corresponding Author: Dr. Paul A. Bourne, Chief-Executive Officer, Socio-Medical Research Institute, Kingston, Jamaica. Email: [email protected]; [email protected]; [email protected], Tel: (876) 457-6990.
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Abstract

Background: Previous studies have examined age at first sexual intercourse and factors which determine contraceptive use, but none have explored factors which determined method of contraception use between females whose first coital activity began at 16+ years and those who started < 16 years old.

Aims/objectives: This research aims to bridge the gap in the literature by elucidating information on the differentials in factors of contraceptive use between females whose first coital activity was < 16 years and 16+ years old as well as sociodemographic and reproductive health characteristics of these respondents.

Methods and materials: This descriptive cross-sectional study used a secondary dataset from a national probability sample survey. The current study extracted only females aged 15-49 years from 2002 Reproductive Health Survey to carry out this research. The study population was 7,168 women of the reproductive ages, with a response rate of 77.6%. Of those who responded, 32.5% had first coitus before 16 years old compared with 67.5% who began at 16+ years. Stepwise logistic regression analyses were used to fit the one outcome measure (contraceptive use) by different socio-demographic as well as reproductive health variables. Odds ratios were determined by logistic regression analyses. A p value < 0.05 (two-tailed) was used to establish statistical significance.

Results: More females whose first coitus was < 16 were currently in a sexual union (83%) compared with 79% of those who began at 16+ years old. Factor differentials on contraceptive use emerged between 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.

Conclusion: The current results are far reaching and can be used to guide new public health intervention programmes.

Keywords

Age at first coital activity, females aged 15-49 years, contraceptive use, adolescents, inconsistent condom use, sexual union, sexual assault

Introduction

For decades, the developing countries like the developed nations have been experiencing lowered age at first coital activity, which commences during the adolescence years. Young people (ie. adolescents) continue to be engaged in sexual activities outside of marriage and even the statutes. The continuity of early sexual debut means that there are some health and social matters that will face the society because of early sexual relationships. It is well documented that early sexual initiation is associated with increased HIV, human papillomavirus (HPV), cervical cancers, teenage pregnancy, unwanted pregnancies, abortion (safe and unsafe), and lowered levels of education and financial opportunities [1-6]. While the developing nations have been plagued by the HIV/AIDS epidemic and lowered age at sexual debut, the developed world is more so experiencing lowered age at first sexual debut than the prevalence and incidence of HIV/AIDS epidemic faced by the developing societies. A previous study established that the lowering of the age of first coital activity has been so for the past 3 decades in developed nations, and particularly in New Zealand [7]. Furthermore, Dickson et al.’s work [7]; using a longitudinal study of a cohort born in Dunedin in 1972-3, found that there were young people who were engaged in sexual activities before 13 years old. This concurs with a five community ethnographic study carried out by Chevannes in the Caribbean [8], which found that sex among adolescents’ starts as early as 14 years. The aforementioned early sexual debut in the Caribbean and New Zealand is also obtained in the United States [9], and a group of researchers found that almost 12 out of every 25 individuals aged 15-19 years in the United States reported having had sexual intercourse at least once [10].
In United States, the median age at first sexual debut was 17 years, which is higher than that in Jamaica (15.0 years) [11, 12]. Like United States, New Zealand and Jamaica, some African nations (such as Uganda, Kenya, Ghana, Tanzania, Zambia and Zimbabwe) had a median age which is statistical the same, suggesting that premarital sexual behaviour is similar in many developing and particular developed societies. A previous study conducted by Wilks et al [13], using a national probability same survey of 2,848 Jamaicans aged 15-74 years, found that 22 out of every 25 people aged 15-24 years have had sexual intercourse - 21 out of every 25 males aged 15-24 years and 19 out of every 25 females of the same age [13]. The sexual expression and practices of young Jamaicans (aged 15-24 years) is embedded in the fact that 11 out of every 25 have sex at least once per week - 11 out of every 25 males and 10 out of every 25 females [13]. Statistics also showed that 2.6% of Jamaicans aged 15-24 years had a STI in the last 12 months compared with 2.4% of Jamaicans aged 15-74 years old. Comparatively between the United States and Jamaica, less Americans aged 14-22 years were sexually active compared to Jamaicans aged 15-24 years [9, 13]. However, there were similarities between Jamaica and the United States as the age at sexual debut for males and females was relatively close [9, 13], suggesting congruency in sexual expressions.
Using dataset for the 2002 Reproductive Health Survey in Jamaica [12], the mean age at first coitus was 14.7 years (SD = 3.1, median age at first intercourse = 15.0, range = 13 – 16 years) [14], and the median age of first coitus among females aged 16-49 years was 16.0 years in 2001, this fell from 17.3 years in 1997 [12]. The rationales for using < 16 years and 16+ are (1) the age of individual sexual consent is 16 years, and (2) the median age of first coitus among females aged 15-49 years was 16 years.
In spite of public health campaigns to address (1) the lowering of age of sexual intercourse, (2) HIV/AIDS among the population, particularly among adolescents and young adults, (3) sexual promiscuity, (4) inconsistent condom usage, (5) unwanted pregnancies and (6) better sexual practices in the world, particularly in Jamaica, the society has seen the continuous erosion of values because the aforementioned matters continue unabated and there seems to be no end in sight. Many developed nations such as New Zealand and the United States is experiencing the early age of sexual debut epidemic like Jamaica. Apart of the justification of this public health challenge is that lifestyle practices, cultural values and expectation as well as orientations which are changing in the 21st century.
Although females in world have been living longer than males (life expectancy or healthy life expectancy), which is the case in Jamaica, statistics revealed that the incidence of STIs among female for 2007/2008 in Jamaica were greater for them than their male counterparts [13]. This is within context of increased public health education campaigns on sexual responsibility and the rise of HIV/AIDS in the nation. Embedded in the incidence of STIs are the cultural values, lifestyle, norms, beliefs and sexual practices of females, which will not easily change because external agents such as health educators and professionals say that they are to do this.
The literature on age at first sexual intercourse is extensive but recent and factors that determine contraceptive use of female [2-7, 15, 16], but no research existed that examined differentials in factors of contraceptive use between females whose first coital activity was < 16 years and 16+ years old. Bourne et al. [16] eight factors were statistical associated with contraceptive use among females aged 15-49 years. The factors were age (OR = 0.95, 95%CI = 0.98 – 0.99); social class (upper class, OR = 0.83, 95%CI = 0.73 – 0.95); area of residence (rural, OR = 1.16, 95%CI = 1.02 – 1.32); currently pregnant (OR = 0.01, 95%CI = 0.00 – 0.02); had sex in last 30 days (OR = 2.29, 95%CI = 1.95 – 2.70); number of sexual partners (OR = 1.85, 95%CI = 1.57 – 2.17); age began using method of contraception (OR = 0.99, 95%CI = 0.98 – 1.00), and crowding (OR = 1.4, 95%CI = 1.21 – 1.60). If research provides an understanding of issues in our physical and social milieu, then, a study on the aforementioned is critical and timely as it would provide insights into their behaviour, thereby allowing health practitioners and educator to better understand how to address the increasing HIV/AIDS virus and other public health problems such as unwanted pregnancies and unsafe abortions. With previous studies having demonstrated that early sexual activities are associated with increased HIV/AIDS infections, cervical cancers and other health problems [1-6, 15], understanding early sexual activity (before the statutory age 16 years in Jamaica) and post the statutory age will provide invaluable insights into practices and measure that can be formulated to address the lifestyle of these individuals.
This current study, recognizing limitations of previous research on the aforementioned issue within the context of the increased HIV/AIDS virus, unwanted pregnancy, abortions and high fertility [17-19] coupled with the continuous lowering of age of sexual debut over the decades, can add value to public health by studying factor differentials in contraceptive use between females whose first coital activity was < 16 years and those 16+ years old as well as their demographic profile. Such a research is timely and will guide policy formulation and intervention programmes. The rationales for the study are primarily based on (1) females vulnerability in contracting HIV/AIDS and other STI, (2) females being less economic independent than their male counterparts, (3) the vetoing power of males over females’ reproductive health choices in developing nations, (4) income inequalities between the genders, and (5) the issue of survivability. This research aims to elucidate information on the differentials in factors of contraceptive use between females whose first coital activity was < 16 years and 16+ years old and to provide a socio-demographic and reproductive health profile of these individuals.

Methods

Sample (participants) and procedures

A descriptive cross-sectional study was carried out by the National Family Planning Board (Reproductive Health Survey or RHS). There are two sets of inclusion criteria, which are females and ages. The eligibility criterion for age was 15 to 49 years at last birthday. In 2002, RHS collected data on Jamaican men ages 15-24 years as well as women 15-49 years old. The current study extracted only females aged 15-49 years from 2002 Reproductive Health Survey (RHS) dataset to carry out this research. The female sample for the 2002 RHS was 7,168 women of the reproductive ages, with a response rate of 77.6%. Of those who responded (n=5, 565), 32.5% had first coitus before 16 years old compared with 67.5% who began at 16+ years old. Thus, the entire female sample for the 2002 RHS that responded to the survey was used for this study.
Stratified random sampling was used to design the sampling frame from which the sample was drawn. Using the 2001 Census sector (or sampling frame), a three-stage sampling design was used. Stage 1 was the use of a selection frame of 659 enumeration areas (or enumeration districts, EDs). This was calculated based on probability proportion to size. Jamaica is classified into four health regions, which constitute particular parishes (there are 14 parishes). Region 1 is composed of Kingston, St. Andrew, St. Thomas and St. Catherine; Region 2 comprises Portland, St. Mary and St. Ann; Region 3 is made up of Trelawny, St. James, Hanover and Westmoreland, with Region 4 being St. Elizabeth, Manchester and Clarendon. The 2001 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 each PSU constituted an ED, which in turn was comprised of 80 households. The previous sampling frame was in need of updating, and so this was performed between January and May 2002. The previous sampling frame was in need of updating, and so this was carried out between January 2002 and May 2002. The new sampling frame formed the basis upon which the sampling size was computed for the interviewers to use. Again, the sample was selected based on probability proportion to size of the four regions, and interviewers were given particular ED(s) which they exhausted in a clockwise manner.
Stage 3 was the final selection of one eligible female from each sampled household and this was done by the interviewer on visiting the household [12].
The Statistical Institute of Jamaica (STATIN) provided the interviewers and supervisors, who were trained by McFarlane Consultancy, to carry out the survey. The instrument administered was a 35-page questionnaire. The data collection began on Saturday, October 26, 2002 and was completed on May 9, 2003. Prior to the date of the final data collection, pre-testing of the instrument was conducted between March 16 and 20, 2002. Modifications were made to the pre-tested instrument (questionnaire), after which the final exercise was carried out. Validity and reliability of the data were conducted by many statisticians, statistical agency, and university scholars before the data was used as the data are for national policy planning [12]. After which it was released to the University of the West Indies, Mona, Data Bank for use by scholars. The data was weighted in order to represent the population of female aged 15 to 49 years in the nation [12].

Measures

Age at first sexual debut (or initiation or intercourse) was measured based on a respondent’s answer to the question “At what age did you have your first intercourse? Crowding is the total number of persons in a dwelling (excluding kitchen, bathroom and verandah). Age is the number of years a person is alive up to his/her last birthday (in years). Contraceptive method comes from the question “Are you and your partner currently using a method of contraception? …”, and if the answer is yes “Which method of contraception do you use?” Age at which began using contraception was taken from “How old were you when you first used contraception? Area of residence is measured from “In which area do you reside?” The options were rural, semi-urban and urban (1 = rural, 0 = otherwise; 1 = semi-urban, 0 = otherwise, and urban is the reference group). Currently having sex is measured from “Have you had sexual intercourse in the last 30 days?” (1=yes, 0 = otherwise). Education is measured from the question “How many years did you attend school?” Marital status is measured from the following question “Are you legally married now?”, “Are you living with a common-law partner now? (that is, are you living as man and wife now with a partner to whom you are not legally married?)”, “Do you have a visiting partner, that is, a more or less steady partner with whom you have sexual relations?”, and “Are you currently single?” Age at menarche is measured from “How old were you when your first period started (first started menstruation)?” Gynaecological examination is taken from “Have you ever had a gynaecological examination?” (1 = yes, 0 = no). Pregnancy was assessed by “Are you pregnant now?” (1=yes, 0 = otherwise or no). Religiosity was evaluated from the question “With what frequency do you attend religious services?” The options range from at least once per week to only on special occasions (such as weddings, funerals, christenings et cetera) (1=frequent attendance from response of at least once per week, 0 = otherwise). Subjective social class is measured from “In which class do you belong?” The options are lower, middle or upper social hierarchy (1 = middle class, 0 = otherwise; 1 = upper class, 0 = otherwise; reference group is lower class). Forced to have sexual relations was assessed from the question “Were you forced to have sex at your first intercourse?” and the options were yes, no, don’t know and refused to answer (1= yes, 0 = otherwise). Age at first sexual debut, age at menarche, age at first contraceptive use, and years of schooling were used as continuous variables. Early sexual debut is having sexual intercourse before the statutory legal age to do so (in Jamaica, this is 16 years old).

Statistical analyses

Data were entered, stored and retrieved using SPSS for Window, Version 16.0 SPSS Inc; Chicago, IL, USA). Descriptive statistics were performed on particular sociodemographic characteristics of the sample (frequency, mean, standard deviation (SD), and range). All metric variables were tested for normality (age at first sexual debut, crowding, age, and years of schooling). Where skewness was found to be less than 0.5, the variable was used in its current form and a value more than 0.5 was normalized by natural log. Independent sample t-test was used to examine differences in age at sexual debut between those who frequently attend churches and those who infrequently visit churches and F-statistic was employed for age of sexual debut and subjective social class (Table 4). Chi-square analyses were used to examine two nonmetric variables (Table 4). Pearson Product Moment correlation was used to evaluate statistical association 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 (contraceptive use) by different sociodemographic as well as reproductive health variables. Thus, only explanatory variables (i.e. statistically significant variables) are shown in Table 5. Where collinearity existed (r > 0.7), variables were entered independently into the model to determine those that should be retained during the final model construction [19]. To derive accurate tests of statistical significance, we used SUDDAN statistical software (Research Triangle Institute, Research Triangle Park, NC), and this adjusted for the survey’s complex sampling design. A p-value < 0.05 (two-tailed) was used to establish statistical significance.

Results

Demographic characteristic of sample

Table 1 presents information on the demographic characteristic of the studied population by age at first coital activity (< 16 years or 16+ years old). Of the studied respondents, 7.3% had their first sexual intercourse at most 13 years old, 16.7% at most 14 years old, 32.5% at most 15 years old, 51.4% by at most 16 years, 92.6% by at most 20 years old and 99% by at most 26 years old. Twenty one percentages of the respondents had no sexual partner, 75.6% had one sexual partner compared with 3.4% who had 2+ sexual partners.
Table 2 highlights particular reproductive health characteristic of studied population by age at first coital activity (< 16 years or 16+ years old).
Table 3 displays information on methods of contraception Method of contraception and when began using by age at first coital activity (i.e. < 16 or 16+ years old).
Table 4 forwards information on particular demographic variables by subjective social class 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 the past 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).
A significant statistical difference was found among the subjective social classes and age at first sexual intercourse (F = 187.4, P<0.0001). Females in the lower socioeconomic stratum began having sex at 16.0 years (SD = 2.3) compared with 16.5 years (SD = 2.4) for those in the middle 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 of sexual partners (F = 2.23, P = 0.107).
On average, crowding was 1.9 persons (SD = 0.30) among females who were in the lower socioeconomic stratum compared with 1.8 persons (SD = 0.43) for those in the middle stratum and 1.3 persons for those in the wealthy socioeconomic stratum – Fstatistic = 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 5 shows explanatory factors which account for contraceptive use among females in Jamaica aged 15-49 years based on age at first sexual activity that the individual is classified in (i.e. < 16 or 16+ years old).

Discussion

A previous study had that “Experiences at sexual debut may be linked to reproductive health later in life” [21, p. 1] and that the age of first sexual debut is associated with future reproductive health outcomes [1-6]. The current works concurs with the literature, and provide detailed information on the differences on demographic profile and factor differentials in contraceptive use 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 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 of contraception, but they were more likely to be in the lower socioeconomic stratum, live in rural areas, have a lower educational level, first sexual intercourse was forced, use injection as a method of contraception, shared sanitary convenience, currently in a sexual relationship, sexual partnerships in last 3 months and unemployed. Factor differentials on contraceptive use emerged between 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 is the fact that females who are in the upper socioeconomic stratum that commenced sexual intercourse 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 with males [22, 23]. This reality means that there is high economic dependence of females on males for financial survivability, making young females within the lower socioeconomic stratum having different reproductive health outcome than those in the wealthy socioeconomic strata because of their socio-economic marginalized situation. Many of these females commenced sex at an early age because of economic vulnerability, and so they are likely to be engaged high-risk behaviours [21].
On the other hand, in order to provide for themselves many females who are within the lower socioeconomic stratum become involved with older men who expose them to the same risk of pregnancy, STIs, and HPV. With females in the lower socioeconomic stratum having more people in a dwelling area compared with those in the other socioeconomic strata, they will turn outside the household for financial assistance and oftentimes this is provided in visiting sexual unions in which the males are older. In such unions, because females are in a socioeconomic vulnerable position and by extension poorer and marginalized, males are able to dictate many things including reproductive health choices. Females, therefore, in those income class will bear children as an economic flows and/or some will have unsafe abortions, but those in the upper class are able to carry out safe abortions compared with those in the lower class because of access to financial resources, and where they consider their lives. Thus, the aforementioned arguments justify female who began sexual intercourse at most 15 years who are more likely to be in the lower class, dwell in rural areas, unemployed, have multiple sexual partners and less educated were more likely to be engaged in sexual relationships, and forced into sexual activities. Their economic vulnerabilities account for the rationale of using fewer condoms as a method of contraception because this is vetoed by the male.
Money is important to women, but the risky sexual behaviour of upper class females whose first sexual activity begins before 16 years old is not for the money as those in the lower socioeconomic strata. The high risk sexual behaviour among upper class females whose first sexual intercourse was before 16 years, suggests that many of them would have abortions, STIs and even HPV because of their lifestyle practices. The work also showed a negative correlation between number of sexual partners and age at first coitus, indicating that younger females are more promiscuous and that this changes with age at they move into stable sexual unions. Simply put the adolescence years are about fun, frolic, sexual freedom, sexual expression, inconsistent condom usage and sexual carelessness, which seems to continue even in the adult years among wealthy females.
Even though money is important to particular reproductive health outcomes (such as safe abortions), early sexual intercourse comes with less likeliness of a method of contraception, which is because of ignorance. It was revealed from the findings that those females who commenced sexual intercourse at older ages were more likely to use a particular method of contraception (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 this finding is the influence of knowledge of contraceptive with age, and not money. While money is associated with employment and other socioeconomic benefits, it is not responsible for lower method of contraception among Jamaicans females.
Rural poverty in Jamaica is about twice urban poverty, with more people residing in rural areas and a sex ratio that is greater for females than males [22, 26], if money matters, then rural females who begins having sexual intercourse at 16+ years would not be 1.3 times more likely to use a method of contraception compared with those in urban areas. Or, those in those whose families are in the wealthy strata would be more likely to use a method of contraception compared 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 as well as the age of the initiating partner that account for lower contraceptive use based on age at first sexual coital activity than money. According to Gomez et al. [21], “Sixty-five percent of women reported sexual initiation with a partner younger or less than 5 years older, 28% with a partner 5 to 10 years older, and 7% with a partner 10 or more years older”, and in Jamaica a study revealed that many young women began their sexually initiation with men at least 5 years older than them [12]. Embodied here is an understanding of the lifestyle of adolescents in regarding to sex, and how older men can expose them to sexually transmitted infections. The media continues to glamorize sex and sexuality, which are capturing the attention and practices of young people. The young females are culturized in sex, and this they see to explore as they become cognizant of sex during the adolescent years when there is growth and development of the body.
Even with age, knowledge, exposure and high accessibility to method of contraception and low cost of contraceptives, inconsistent condom use and condom use is low among Jamaican women aged 15-49 years. The current work revealed that 42.5% of those who began having sex before 16 years old currently use a condom consistently with their steady partner and the figure was 2.5% more among those who started at 16+ years old. This finding provides evidence of the difficulty to change lifestyle practices as although the majority of people in Jamaica have been exposed to public health education and intervention programmes [12], this has not significantly change their sexual behaviour as the age of sexual initiation continues to fall as well as an increase prevalence of HIV/AIDS among the populace. Abel-Smith is correct, therefore, when he claimed that people are prisoners of their lifestyle [27], suggesting that values, customs, norms and early socialization are difficulty to change, but that it is still possible over time. Apart of the Caribbean 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 use and risky sexual practices.
School is an agent of socialization, in which people are provided the tools of socioeconomic survivability, has become a place of indirectly promoting sex through sexual education and peers of different socioeconomic situations and background. The current findings revealed that 43% those whose first sexual activity started before 16 years old began using a method of contraception during school compared with 7% who started at 16+ years. With there being an inverse association between age and contraceptive use [4-7, 10, 16], it can be deduced that high contraceptive use is associated with sexual activities. Like Gomez [21], this study recognizing the importance of age and gender-based power differentials between the sexes regarding sex note that delaying sexual debut must understand those differences as well as the educational system.
Dickson [7] opined that adolescent sexual behaviour is influenced by social factors. It can be deduced from Dickson’s work that educational system is able to change sexual practices and particular reproductive health outcome. From the current research, the educational system has modified 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 and orientations. With the glamorization of sex in the media, on cable television, many children are exposed to a diet of sex, and some will seek to practice this while attending school. This is reinforcing sex, sexuality and orientation of sex that is even covertly reinforced with reproductive health education in schools.
Based on Bourne et al.’s work [29] that “Health education and health promotion are driven based on understanding lifestyle practices of a population” [29], the current findings provide some critical information that can be used for a new thrust into public health intervention programmes in the future that can be used to modify current practices. As formal educational is not able to change the sexual practices and/or reproductive health behaviour of females because more than 55% of the sample have tertiary level education (or have attained this level) compared to 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 not modifying the lifestyle practices that public health specialists and behaviouralists would want to change.
Clearly, a public health problem that emerged from the current paper is that 1.5 times more females who had sex before 16 years were sexually assaulted compared to those who began at 16 years and older. Outside of the obvious that many early sexual encounters among females at most 16 years is as a result of rape, the perpetrators are normally friends, family members and/or acquaintances who carry out these acts against the physical vulnerable adolescents and children [30, 31]. Such abase leave an indelible psychological scar for the adolescent and Lowe et al. [32] posited that this leaves immense psychological trauma which are sometimes are suicidal. Another psychological matter which is a consequence of sexual assault of is aggression on the path of the victim [33], suggesting that the sexual appetite of Jamaican males is exposing female adolescent and children to future psychological traumas as well as reproductive health problems.
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 positive statistical correlations between poverty and not seeking medical care (R = 0.576), and poverty and unemployment (R = 0.48) [34], indicating that economic vulnerable adolescents and their families are likely to see the young female doing unsafe abortion, carrying the pregnancy to term and going into depression and/or other psychological traumas because of socioeconomic deprivation. No or little access to money means less choices including abortion for females who become pregnant as a result of rape and the economic power of the perpetrator is also able to change the outcome of criminal conviction. Thus public health practitioners need to recognize money and power as influencing reproductive health, and how these may retard self autonomy of the females, particularly those young females who are from low socioeconomic background. The socio-economic consequences of poverty, low educational attainment, self-esteem and social isolation can, therefore, influence public health intervention programmes [36], making it difficult for public health practitioners to be effective in meeting their objectives without addressing those inadequacies and the social structure in the society.
Religiosity is associated with better sexual practice as it increased the age of first sexual intercourse, which concurs with the literature [20, 37, 38]. The church which is a part of the social structure is delaying sexual intercourse among Jamaican females aged 15-49 years by one year, which speaks to the embedded sex culture and the difficulty in changing this practice without structural and cultural changes, over time. Again this reinforces the fact that delaying early sexual behaviour is also a future good as people will continue bad practices if they start early in life. Research evidence demonstrates that the religiosity network in which the adolescent involved as well as the friends’ religious positively lowers age at first coital activity [39]. With the number of churches in Jamaica, particularly in the lower socioeconomic areas, it is paradoxical that age at first sexual intercourse continues to fall. Some of those issues can be explained by the economic deprivation in inner-city communities and the culture values, beliefs and customs within the society as well as the sub-cultures and countercultures on sex and sexuality.
Clearly, the culture in inner-city communities coupled with crowding are fostering early sexual intercourse because those in the lower socioeconomic stratum commenced sexual intercourse on average at 16 years compared with 16.5 years for those in the middle class and 17.8 years among those in the wealthy stratum. It can be deduced and extrapolated from those figures that men are using the economic vulnerability of young females against them, and this is resulting in those females becoming engaged in transactional sex. They are exchanging sex for good, commodities and other support things for sex from older men. Although the same is not the case for females in the wealthy socioeconomic stratum, those who starting having sex before 16 years old are currently engaged in risky sexual behaviour. This speaks to the early lifestyle practices, 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 to tackle, those who began having sexual intercourse at most 15 years old as they are high sex risk takers 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 mother had 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 are perpetrated by acquaintances. With the crowding being an issue in inner-city communities (or lower socioeconomic areas), a number of the sexual initiations occur as a result of this fact. The adolescents are sometimes gullibly encourages to become involvement in sexual activities with family members, household members and friends. With the crowding in inner-city communities means that many of the rapes are perpetrated by non-household members by acquaintances in the area. The next issue is the associations of the adolescents, and whether those networks are among religious members or non-religious individuals. Hardy and Raffaelli [38] provide an explanation for the previously mentioned situation. They opined that religiosity delay the transition of adolescents 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 level of control and will initiate sexual intercourse early. The peer group influences the reproductive health outcome of people, particularly children and/or adolescents as well as adults [41] and increases early sexual practices which in this case justify future sexual behaviour of adults. It is this explanation why public health practitioners need to address social institutions in thwarting a campaign that will foster better sexual practices of adults as early as childhood and during their adolescence years.
The traditional approach to health behaviour modification was to give people knowledge about a particular issue, practice or happenings within their sociophysical milieu and instruct them into a new path [42]. According to one group of researchers, in 2009, “Knowledge about the prevalence of sexual risk behaviour (SRB) in adolescence is needed to prevent unwanted health consequences” [43], and this justifies the continuation of poor sexual practices in the future. Such an argument implies that lifestyle behaviour is easily changeable, which is the fartherest from the reality. This is captured in the current work which showed that educational attainment is not associated with usage of contraceptives. On the contrary, those in the wealthy income stratum had the greatest prevalence of tertiary level education, yet those who started having 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 a particular issue. This is capture in the Wilks et al.’s work [13] which found that in 2002 78.3% of Jamaicans aged 15-74 years used a condom with their main partner and this fell to 43.1% in 2008 although 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 in visiting and/or single unions compared with married and common law, and the more people had 2+ 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 were more likely to use a method of contraception than those who started before 16 years, this suggests that risky sexual behaviour which commenced early in life is likely to continue into adulthood. Again, people are prisoners to their culture, social structure, values, beliefs, and socialization. Cohen, Scribner and Farley [44] developed a model for behaviour change using structural modeling which addresses physical structures, social structures, cultural and media messages. Like Cohen et al. [44], Bourne et al. opined that health promotion for Jamaicans must include social, economic, and lifestyle choices [29]. In the previous works, the authors recognizing the complexity of humans have coalesced a multidimensional apparatus to address behaviour change and not simply imparting knowledge or by formal education. Although a group of scholars found that the women’s level of education and that of her spouse and age determine contraceptive 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 the literature [16, 45], but the same cannot be said about education. Education is not changing sexual practice as it relates to contraceptive use among Jamaica females, despite its provision in imparting knowledge and behaviour medications. People are not barrels in which they are fed a diet of information from external sources such as health educators to want them to carry out a particular 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 social and other factors which are associated with contraceptive use, when they postulated that, “Social and environmental variables were found to affect contraceptive preparedness at 1st intercourse only, and not subsequent initiation of contraceptive practice” [47]. Outside of this clarification, it is evident that the culture, physical milieu, values, and beliefs impact on people behaviour and this include education, but that this is not the case among female Jamaicans aged 15-49 years old whether sexual initiation was < 16 years or 16+ years old. There is cultural conflict among female Jamaicans, the health care system and the health care educators because the symbols of the culture and ways of life are not supported by the health care educators, particularly related with sexual practices, sex and reproductive health matters. Embedded in the current findings is the value of the social environment in which these females live and grow, which fashion their cultural development, identification and belief system. Those are the reasons why “Morally unacceptable policies designed to pressure or compel people to limit their fertility have been shown to be unnecessary and thus have been abandoned, except in China” [48] as well as being ineffective in behaviour medication, and any such similar public health intervention programmes that used force, moral suasion or dictatorial stance.

Conclusion

Early sexual initiation is influencing future health and reproductive health outcomes among Jamaican women aged 15-49 years old. Those outcomes include more coital activity, involvement in sexual unions, and less contraceptive use. Despite reproductive health education programmes in Jamaica, the culture is clearly retarding good reproductive health practices and sexual lifestyle. In Jamaica, although fertility is lower and educational advancement is greater in urban than in rural areas, rural females whose first coitus began at 16+ years were more likely to use a method contraception compared with their urban counterparts. Clearly, there is a lifestyle change occurring among females in rural areas which needs examination, and equally so is the risky sexual practices of affluent females who started having sex before 16 years old.
With the global economic downturn, sexual autonomy of female Jamaicans will be further reduced, particularly those in the lower socioeconomic stratum, unemployed, uneducated, and young because males will now have greater vetoing powers over sex, sexuality and reproductive health matters. Public health practitioners have not begun to address those realities in the communities and human rights of women will be thwarting because money is important in survivability. Sexual rights of women cannot be supported by merely ascribing it to them or 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 is power, and with the economic downturn in the Jamaican economy there will be greater promiscuity as women seek more assistance in sexual relationships, which is embedded in Wilks et al.’s work which showed an increase in visiting unions and number of sexual concurrent partners 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 avoid pregnancy, why do they not use a method of contraception?” [49] is to deny people of their social environment and the role of money in it. There will be in social justice in society that does not understand the factors which are associated with sexuality, rights and sexual justice; and the role of money in influencing health and reproductive health matters. It means that a part of the sexual 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 must begin to address the new reality as all the gains that have been accomplished in past decades will be erodes because of the increased economic vulnerability of peoples and economic marginalization of the poor, particularly among young, uneducated, and unemployed females.
In summary, delaying age at first sexual intercourse influences contraceptive use, by increase methods of contraception. It also fosters good sexual practices in the future. Clearly, the reproductive health problems in Jamaica are structurally driven which care embedded in the cultural values that make it difficult for public health practitioners to address without including those issues in health education, communication and intervention programmes. Because people are sexual being, sex will always be a part of their social existence and an issue that cannot be left unaddressed by public health policies makers within the current findings and the global economic downturn. There is a need for structural changes in developing as well as developed nations to address many reproductive health matters. The factors of method of contraception are not the same across the age cohort at which a female began having sexual intercourse, and they are also some different to those of women in the reproductive ages 15-49 years old. The findings which emerged from the current results are far reaching and can be used to guide new public health intervention programmes.

Disclosures

The authors report no conflict of interest with this work.

Disclaimer

The researchers would like to note that while this study used secondary data from the Reproductive Health Survey, none of the errors in this paper should be ascribed to the National Family Planning Board, but to the researchers.

Acknowledgement

The authors thank the Data Bank in Sir Arthur Lewis Institute of Social and Economic Studies, the University of the West Indies, Mona, Jamaica for making the dataset (2002 Reproductive Health Survey, RHS) available for use in this study, and the National Family Planning Board for commissioning the survey.
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