ADOLESCENT SEXUAL BEHAVIOUR IN NAVRONGO: DOES FAMILY COUNT? A Research Report submitted to the faculty of Health sciences, University of the Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Medic ine in the branch of Population Based Field Epidemiology. Kanyiva Muindi Johannesburg, 2006. Student number: 0516329A ii Declaration I Kanyiva Muindi declare that this research report is my own work. It is being submitted for the degree of MSc Med in the field of Population Based Field Epidemiology in the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at this or any other university. Signature??????????????????????????. Full Name: Kanyiva Muindi Student number 0516329A 09th day of November, 2006. iii To my mother Koki Muindi For her love. iv Abstract In the face of diminishing traditional controls on adolescent sexual behaviour, parents are becoming the focal point of guidance on sexual issues. The main objective of the study is to establish if residing with one?s parents has any effect on one?s sexual behaviour among adolescents in the Kassena-Nankana District of Northern Ghana. A sample of 7056 adolescents aged between 10 and 24 years were interviewed between April and October 2003 while the 2004 household socio-economic data was used to generate a household wealth index. Females are less likely to have had sex (AOR 0.75; CI: 0.63; 0.88) and also less likely to initiate sex before age 16 (AOR 0.30; CI: 0.21; 0.43) compared to males. Living with one?s father only is associated with a 36% decrease in the likelihood of having had sex among males (AOR 0.64; CI: 0.42; 0.96) compared to living with both parents. Females living with neither parent were 76% more likely to have had sex than those living with both parents (AOR 1.76; CI: 1.21; 2.55). Discussion of sexual matters with parents increased the likelihood of initiating sex. Family structure is an important predictor of sexual behaviour among adolescents and therefore should be considered when designing and implementing interventions. Longitudinal and qualitative studies are recommended v Acknowledgements First I would like to thank God for making everything possible and for always being my strength. Secondly, I am deeply indebted to the INDEPTH Network and other donors for the sponsorship to pursue the MSc degree program. My gratitude goes to my supervisors Dr Cornelius Debpuur of the Navrongo Health Research Centre and Dr Khin San Tint of the School of Public Health, University of the Witwatersrand for their guidance in the development of the research protocol and the research report. My gratitude goes to the Director of the Navrongo Health Research Centre Dr Abraham Hodgson for allowing me to use their data for this report. I also thank all staff at the Centre for their support during my field attachment, especially Martin Adjuik for his guidance during the data analysis. My thanks go to the teaching and the administrative staff at the School of Public Health at the University of the Witwatersrand for their guidance during my studies and for ensuring that everything went on as scheduled. I am also indebted to the Director of the African Population and Health Research Center (APHRC) Nairobi; Dr Alex Ezeh for giving me the time off for my studies and for continually believing in me. Last but not the least; I thank all my family and friends for their constant prayers towards my success and for encouraging me. May God bless you all. vi Table of contents Declaration.....................................................................................................................ii Abstract ......................................................................................................................... iv Acknowledgements ........................................................................................................ v List of figures..........................................................................................................viii List of tables............................................................................................................viii Definition of Terms.................................................................................................viii Acronyms ................................................................................................................... x CHAPTER 1 ..................................................................................................................1 1.0. Introduction...........................................................................................................1 1.1. Rationale .............................................................................................................6 1.2. Aims and Objectives ...........................................................................................8 1.3. Background to the Kassena-Nankana District ....................................................8 CHAPTER 2 ................................................................................................................11 2.0. Methodology .........................................................................................................11 2.1. Study Design .....................................................................................................11 2.1.1. About the ASRH Project................................................................................11 2.1.2. Household Socio-economic data....................................................................12 2.1.3. Description of Variables ................................................................................13 2.1.3.1. Outcome Variables...............................................................................................13 2.1.3.2. Explanatory Variables..........................................................................................14 2.1.4. Data Management ..........................................................................................15 2.1.5. Data Analysis .................................................................................................17 2.1.6. Ethical Considerations ...................................................................................18 vii 2.1.7. Limitations .....................................................................................................18 CHAPTER 3 ................................................................................................................20 3.0. Results ...................................................................................................................20 3.1. Descriptive Results ...........................................................................................20 3.1.1. Adolescents? Background characteristics ...............................................................20 3.1.2. Sexual Behaviour ....................................................................................................21 3.2. Multivariate Results ..........................................................................................25 3.2.1. Co-residence with parents and adolescents? sexual behaviour ...............................25 3.2.2. Factors influencing sexual behaviour among adolescents ......................................26 CHAPTER 4 ................................................................................................................33 4.0. Discussion.............................................................................................................33 CHAPTER 5 ................................................................................................................37 5.0. Conclusion and Recommendations. ......................................................................37 5.1. Conclusion ........................................................................................................37 5.2. Recommendations .............................................................................................37 References ....................................................................................................................40 Appendices...................................................................................................................46 viii List of figures Figure 3.1: Proportion of respondents by sexual status at time of interview Figure 3.2: Proportion of respondents initiating sex before or after the age of 18 years List of tables Table 3.1: Distribution of respondents by background characteristics Table 3.2: Chi square tests for association between the outcomes and sex of respondent. Table 3.3: Summary of the logistic regression results for the outcome variables. Table 3.4a & b: Adjusted Odds Ratios from logistic regression models fitted by sex of respondent Definition of Terms Adolescent In this study an adolescent is any person aged between 10 and 24 years. This definition has been adopted from that used in the primary survey. Co-residence Living with biological parents in the same household. Early initiation of This has been defined as the initiation of sex before the age of sex 16 years, which is the legal age of sexual consent in Ghana. Family For the purposes of this study, family has been defined as biological parents. ix Household A social unit usually defined in the Demographic Surveillance System (DSS) as people who share a common cooking and eating arrangement and recognize a certain individual as the head. Sexual behaviour It has been defined as having had sexual intercourse and also includes other factors/activities such as sexual activity, condom use, and early initiation of sex. Sexual initiation This has been defined as having the first sexual encounter Sexual intercourse This has been defined as penile-vaginal intercourse. x Acronyms AIDS Acquired Immuno-deficiency Syndrome AOR Adjusted odds ratio DHS Demographic and Health Survey DSS Demographic Surveillance System HIV Human Immunodeficiency Virus ICPD International Conference on Population and Development INDEPTH International Network for Demographic Evaluation of Populations and Their Health STIs Sexually Transmitted Infections UNAIDS Joint United Nations Program on HIV/AIDS 1 CHAPTER 1 1.0. Introduction Adolescence is a time of change in an individual?s life. It is a time when most young people experiment with a variety of activities, including but not limited to sexual activity. It is also a time when they are most prone to coercion and influence from their peers, leading to the adoption of risky behaviours. At this formative stage, parental guidance becomes a crucial part of an adolescent?s life, since it is a time when they are making certain choices and decisions; which will ultimately shape their future. In many of the traditional African societies, guidance to adolescents was provided by elders from the community or by relatives; especially the grandmothers of initiates during the initiation period. This placed the control of sexual behaviour in the hands of the community (1, 2). With westernisation and modernisation and especially with the introduction of formal education, which may involve long periods when adolescents are away from home, the decision and control over sexual behaviour has become an individual affair. This is because parents are no longer able to monitor their children who spend most of their time in school as has been noted elsewhere (3). Most of the traditional and religious controls that were previously in place to protect adolescents from engaging in early sexual activity have broken down, been replaced with secular institutions or are viewed as outdated and ineffective. Studies show that adolescent sexual activity is increasingly being tolerated even in communities where traditionally, such activities were not accepted (1, 4, 5). 2 There is growing interest in the study of adolescent sexual and reproductive health in sub-Saharan Africa. This can be attributed to the consequences of adolescent sexual activity such as unwanted pregnancy, unsafe abortion and STIs including HIV/AIDS. Few studies have been carried out in several African countries to investigate parent- child interactions and communication on sexual and reproductive health issues. There have been consistent results showing that sexual and reproductive health issues that are a concern for the adolescent are rarely discussed within the family setting citing taboos that discourage discussing sexual issues with children. Other studies show that parents are ignorant of reproductive health issues thus acting as barriers to discussions with their children (6, 7). In sub-Saharan Africa, both premarital and marital adolescent sexual activity has been shown to be high with associated adverse social and health outcomes (4, 8). Sexual activity levels among adolescents aged 15 to 19 years have been estimated at 29% compared to 24% in Latin America & the Caribbean (9). Adolescent pregnancy and school discontinuation for girls, unsafe abortion, poor health outcomes for infants born to young mothers, high maternal morbidity and mortality, HIV/AIDS and other sexually transmitted infections (STIs) have been documented as some of the consequences of sexual activity among adolescents (4, 10). The United Nations (UN) estimates that most of the HIV/AIDS infections occur in people below the age of 25. (11). Adolescent sexual behaviour in the developed countries, especially in the United States of America has been studied extensively and the protective and risk factors for the adoption of risky sexual behaviour identified. Parental presence in the home has been 3 identified as crucial in supporting healthy adolescent development. Because parents are a constant presence in adolescents? life, they can exercise some degree of authority over their children?s behaviour. Other protective factors identified include strong parent- child communication and high parental expectations of their children (12, 13, 14, 15, 16). A study carried out in the informal settlements of Nairobi, Kenya shows that fathers have a positive influence on the reproductive health outcomes of their adolescent children, especia lly their daughters. This was attributed to the strict rules fathers have regarding relationships of their daughters with the opposite sex. It was also thought that since one of the outcomes investigated was reported unwanted pregnancy, daughters who fell pregnant were likely to be chased out of their parental house and forced to live with their mothers or other relatives therefore increasing the numbers reporting sexual activity and pregnancy among those living without the father. In the same study, mothers? presence alone is negatively associated with adolescents? reproductive health outcomes (17). Other studies including a study conducted in Ghana do not find parental presence in the home a significant factor in adolescent sexual behaviour (10, 18). Most of these studies have however revealed a high incidence of pregnancy, multiple sexual partners, unsafe abortions and STIs including HIV/AIDS as well as low levels of contraceptive usage among adolescents (11, 18). Theoretical frameworks exist that have informed many studies on family process variables and their role in the development of adolescent behaviour. The social learning theory recognises family process variables as influential in learning and subsequent performance of behaviour (19, 20). Adolescent sexual behaviour will thus be influenced 4 by what they see through the process of modelling and their interaction with the environment in which they live as well as by existing norms and attitudes towards sex and contraception. Parent s? behaviour and attitude especially maternal attitudes have been identified as important process variables in the sexual socialization of adolescents. The study cited above (20) reveals that parental monitoring or supervision of adolescents? social activities and general and sexual communication are other variables associated with less risky sexual behaviour or delayed sexual initiation. In the developing countries adolescents are estimated to make up more than half of the total population (11). In most of these countries policies on adolescent reproductive health do not exist, and where they exist, they have not been translated into action. This situation has persisted even after several governments endorsed the Program of Action (POA) at the International Conference on Population and Development (ICPD) in Cairo in 1994. This program aimed at promoting the rights of adolescents to reproductive health education and care and the reduction of adolescent pregnancies. This lack of policies has left adolescents without access to reliable sexual and reproductive health information and services, leading to poor reproductive health outcomes among adolescents. According to the National Population Council of Ghana, youth aged between 15 and 24 years make up 30% of Ghana?s total population (7, 21). The government of Ghana, in recognition of the need for action, endorsed the ICPD-POA of 1994. It also endorsed the Platform for Action (PA) in the Fourth Women's Conference in Beijing in 1995. In addition it has developed its own youth policy as well as the Adolescent Reproductive Health Policy (21, 22). However there are still some gaps in the implementation of 5 these policies, leaving adolescent reproductive issues inadequately addressed (22). Challenges to these policies exist; for instance the 1998 Ghana Demographic and Health Survey (GDHS) shows that the median age at marriage among Ghanaian females was 19.8 years while among males it was 24.8 years (23). This has been attributed to the traditional practise of early marriage among girls, which was done even before the age of 15, immediately after girls underwent the puberty rites (24). This practice of early marriage for girls does not seem to have changed considerably. For instance, among women aged 20-49 years, the median age has risen slightly from 19.1 to 19.6 as reported in the 2003 GDHS. In addition, many African communities held and some still hold ambivalent views regarding adolescent sexual activity. Girls on the one hand were expected to remain virgins and maintain the family honour, while on the other hand it was acceptable for boys to have multiple sexual partners; which was taken as a sign of their manhood (23). Among the Kassena and Nankana people of northern Ghana however, girls were only expected to remain virgins until they underwent the initiation rites soon after which most were given in marriage. The practice of early marriage and societal attitudes towards adolescent sexual activity increase the vulnerability of this group to adverse reproductive health outcomes including HIV/AIDS. Estimates for Ghana indicate that in females, most HIV infections occur when they are below 20 years while males are infected in their early 20s (21). With the changes that have been experienced in most parts of Africa especially with regard to the family, adolescents now have to grow up within families that lack the 6 extended network which ensured they were well guided on sexual matters. With the weakening of the extended family and the traditional fibre that ensured adolescents received relevant guidance on sexual matters, attention is now turning to parents. The question that is being asked is what is the role of parents in the sexual behavior of their adolescent children? Are today?s parents taking on the role of guiding their adolescent children and is this being seen in the sexual and reproductive lives of adolescents? This study attempts to find answers to these and other relevant questions. 1.1. Rationale In most African societies, sex and reproductive health issues still remain sensitive subjects for discussion between adolescents and their families. There appears to be indecision about who is responsible for instructing adolescents on sexual issues. Educational institutions on the one hand appear unwilling to offer family life education, while on the other hand parents have continued to look to these institutions as the place where adolescents can receive guidance on reproductive health and sexual issues (2, 10). In addition, parents and policy makers feel that providing information on reproductive health to adolescents will encourage them to become sexually active. (25) Adolescents thus tend to turn to unreliable sources of information such as the media, their peers and siblings; who are most likely not well informed having received little or no guidance of their own. The family can therefore play a very important role in the provision of education on sexual and reproductive health and therefore bridge the gap that exists in the guidance of adolescent children and help reduce the incidence of adverse reproductive health and social outcomes. 7 In Ghana, as in many other sub-Saharan African countries, there is growing concern that previously observed low HIV/AIDS prevalence rates especially in the rural areas are currently on the increase. Data from UNAIDS indicates for instance that the HIV/AIDS prevalence rate for Navrongo increased from 2.36% in 2001 to 5.07% in 2002 (26). Therefore if Africa is to achieve one of the millennium development goals, namely to reverse the infection trends observed for HIV/AIDS and in addition avert an eminent social crisis of increasing adolescent childbearing and unsafe abortions and their attendant socio-economic problems, the reproductive and sexual health needs of adolescents need to be matters of priority for parents as well as policy makers. Few studies on the role of the family in adolescent sexual behaviour have been carried out in Africa. Most of these studies have been based largely on samples drawn from institutions such as schools/colleges; however these samples are not representative of the general adolescent population. Majority of these studies have investigated knowledge, attitude and practice concerning sexual issues among adolescents with only a few investigating the risk and protective factors of adolescent sexual behaviour. This study seeks to find out the role of the family in the sexual behaviour of adolescents in a non- institutional sample in Northern Ghana. It is hoped that the study will provide information that is useful in reproductive health programs/interventions targeting adolescents and in addition enrich the existing literature. Hypothesis: In this study, we hypothesize that the presence of biological parents in the home is protective against the initiation of sexual activity among adolescents. We do not 8 consider the presence of figures of authority such as grandmothers or other relatives who might be influential in the sexual lives of adolescents. 1.2. Aims and Objectives The aim of this study is to establish the association between parental presence in the home and adolescent sexual behaviour. The specific objectives of the study are: 1) To assess the sexual behaviour of adolescents and its variation by gender. 2) To determine if there are differences in the sexual behaviour of unmarried adolescents living with one parent, both parents and those living without any parent. 3) To determine the factors that influence sexual behaviour among adolescents. 1.3. Background to the Kassena-Nankana District The Kassena-Nankana District is on Ghana?s northern border with Burkina Faso. The area is dry with low rainfall experienced from June to October. Subsistence agriculture, mainly food crop farming and livestock rearing is dominant and the district has been classified as one of the poorest in the nation. Most of the district is rural with majority of the population living in areas that lack modern amenities such as electricity (27, 28). In the year 2002, the district had a population of 96,833 (29), with the Kassem and Nankam being the two predominant ethnic groups. The two groups, although having different languages have been identified as having similar cultural practices (30). 9 Families in the district live in residential units referred to as compounds whose head is often a male since the community is patrilineal. Within a compound are found mostly mud houses belonging to the head and his wife/wives as well as their sons and their families. A single compound can have more than 20 individuals (28, 30). This exposes adolescents to several relatives other than their biological parents, who may be involved in their upbringing. With regard to initiation into adulthood, traditionally, the Kassem and Nankam people did not consider female virginity until marriage a virtue. However, girls were expected to remain virgins until their initiation rites were performed. Immediately after the initiation, sexual unions were accepted especially if the two intended to marry. Most often however, girls were married off soon after initiation (30). Estimates of female genital cutting (FGC) in the district for the year 2000 indicate that about 83% of women aged 35 years and above and 8% of 15 to 19-year-old girls had undergone the rite. (31). Traditionally male circumcision was not practised as it was considered a taboo; however this is no longer the case due to changes in practices where more men are seeking circumcision while female circumcision has been on the decline due to government laws forbidding the practice (32). The district has one of the highest illiteracy levels in the nation with illiteracy levels among females aged 6 years and above reaching about 62% (33). Males achieve higher levels of education than females according to the 2003 Ghana DHS. A higher proportion of females in the Upper East Region have no education (72.4%) compared to 48.9% of males (34). This low level of educational attainment among females could 10 have a bearing on the sexual behaviour of adolescents who may be forced into risky behaviours due to their limited economic choices. With regard to access to health care, the district has several primary health care clinics and community based health workers that serve the community. Decisions to access modern health services especially for women are however made by the male head of the compound, who, often has to first seek the services of a soothsayer to interpret illness or obtain assent from the spirits (28). These issues highlighted above and the fact that reproductive health services to the youth have not been improved to fit in with the ICPD and Beijing resolutions may inhibit utilization of services by adolescents. Therefore given the prevailing poverty, poor educational attainment, the male- dominated social structure and the prevailing reproductive health service delivery system that has not factored in adolescents as possible clients, it is evident that adolescents in this community face challenges that may lead to poor reproductive health outcomes. 11 CHAPTER 2 2.0. Methodology 2.1. Study Design The study involves secondary analysis of data collected by the Navrongo Health Research Centre. The two data sets used in this study come from the 2003 cross- sectional adolescent health survey which was conducted as part of the adolescent sexual and reproductive health (ASRH) project; and the 2004 household socio-economic data collected as part of the Demographic Surveillance System (DSS). 2.1.1. About the ASRH Project The adolescent sexual and reproductive health project is an on-going study being conducted in the Kassena-Nankana District of northern Ghana. It aims at providing adolescents in the district with essential skills that will ensure they enjoy healthy sexual and reproductive lives; through several intervention programs both for the in and out of school adolescents. As part of the initial activities, a cross-section of the adolescents who live in the five zones of the district was interviewed. Information was collected in 2003 from April to November using structured questionnaires (see appendix A1). Interviewers were well trained for the survey, and the languages used during the interviews were Kassem and Nankam which are the widely spoken dialects in the district. During the data collection phase, field supervisors were charged with ensuring data quality by conduc ting spot-checks and re- interviews to 12 check how well the interviewers were handling the questionnaire. Completed questionnaires were edited to ensure they were complete and consistent before being passed on to the data entry team, which captured the data using software that had in- built consistency checks. The adolescent survey targeted individuals aged between 10 and 24 years. Sampling for the primary study was done from the large population that is currently under surveillance in the on-going DSS. Compounds were randomly selected from the DSS and in each compound; eligible adolescents were identified and interviewed. Overall, a total of 7,056 adolescents (3,612 males and 3,444 females) were interviewed. The questionnaires used in the survey were adapted from the Demographic and Health Survey (DHS) with modifications to suit the community and to collect extra information not usually collected in the DHS. The questionnaires were different for females and males; however the content for most of the issues covered was the same. The questionnaires had sections covering diverse issues including background information, sexual activity and pregnancy, contraceptive usage, STI/HIV/AIDS knowledge and attitudes, sexuality and gender norms, health seeking behaviour, exposure to the media and community concerns. 2.1.2. Household Socio-economic data Since the adolescent survey did not collect data on the economic status of households, this information was obtained from the DSS data. The DSS is a longitudinal study that involves visiting each compound within the district once every four months (previously 13 this was done once every three months) to collect information on demographic events such as births, migration and deaths. Also collected are indicators of the economic status of each household. This is done using the INDEPTH Network?s socio-economic status tool that has been developed for use by various DSS sites. It involves the collection of information on the possession of certain household goods and assets such as cattle, land, motor vehicles, radios and the availability of amenities like piped water, electricity, etc. This information was then used to generate an index of household socio- economic status. In this study, household information collected in 2004 was used to generate the socio- economic status indicators. This was more preferred to the information collected before 2004 because previous years? information was collected at the compound level which would have made it difficult to define the household economic status, which was of interest in this study. Also the 2004 information was collected shortly after the adolescent survey and it was considered to be more representative of the economic status prevailing during the time the survey was conducted. 2.1.3. Description of Variables 2.1.3.1. Outcome Variables The primary outcome variable being measured was sexual initiation among adolescents which was measured using the report of ever having had sex. Other outcome variables that were considered were; early sexual initiation (which was defined as initiation of sex before the age of 16 years), condom use at last sexual encounter and sexual activity reported in the three month period preceding the survey. 14 2.1.3.2. Explanatory Variables The primary explanatory variable being considered was the co-residence of adolescents with their biological parent(s), a factor that has been shown to be influential in the sexual and reproductive health of adolescents. There were four types of co-residence; those who live with both of their parents, those living with the father only, those living with the mother only and those living with neither parent. In addition, the question addressing whether adolescents ever discussed sexual and reproductive health matters with their parents was used as an indirect measure of adolescent-parent communication on sexual and reproductive health. Age and sex as well as education status and religion of the adolescents were used to investigate any differentials in sexual behaviour that may exist, since studies show that sexual behaviour varies with age, sex and educational status (1, 4). Age was of particular importance in determining the proportions of adolescents who initiate sex at an early age. The economic status of the family was of interest since other studies have shown an association between adolescent sexual behaviour and household economic status (10, 11). This was measured using a wealth index computed from data on the possession of certain household assets as an indicator of a household?s economic status because direct information on income and consumption is lacking. These possessions included among other things motor vehicle(s), television, radio, electricity and tap water in residence and number of cattle owned. 15 2.1.4. Data Management Data cleaning was done to resolve any inconsistencies; nine respondents were excluded from the analysis for the primary outcome ever had sex, since they had conflicting information regarding their sexual initiation status. Also excluded from the analysis for the primary outcome were 581 individuals (468 females and 113 males) who reported being in a marital union (either married or in a cohabiting relationship) at the time of the survey. Fifty three individuals stated they did not know the age at first sex or were aged five or less at first sex, hence were excluded from some of the analyses. Four females were excluded from all analyses because they did not know their age at the time of the survey. Some variables were recoded into categories which would make analysis and the interpretation of the results easy. Four categories of education levels were created namely, no education, primary, junior secondary school (JSS) and higher which included the senior secondary and higher levels. Tertiary education levels were combined with senior secondary school due to the small numbers in each of these levels. Religion was categorised into four groups with all Christian denominations coming under one category, ?Christian?; Muslim; traditional religion and other religions were grouped into one category, ?traditional/other?; and no religion. Age was used as a continuous variable for some of the outcomes because of few numbers of individuals in the younger (below 13 years) and older respondents (20 years 16 and above), which would have resulted in improper estimates of the association between age and the outcomes. All four outcomes were dichotomised to enable the use of logistic regression models in the multivariate analysis. For the outcome ?ever had sex? the entire sample of unmarried adolescents was considered while for the other three outcomes; early initiation of sex, condom usage and sexual activity in the three months before the survey, a sub-sample comprising those who reported to have ever had sex was used. For early initiation of sex two categories were created; those who initiated sex before age 16 years and those who initiated sex at age 16 years and above. This age was chosen because it is the age of sexual consent in Ghana. A sub-sample of the respondents reporting they ever had sex was taken. This sub-sample included respondents who were aged 16 years or above during the time of the survey and those who were aged below 16 years and had reported to have ever had sex. This is because the interest was in those who had already initiated sex. Condom usage was considered at last sexual encounter since the survey did not collect information on the consistency of condom use among adolescents. This was considered as an important outcome since condoms play a dual protective role against STIs including HIV/AIDS and unplanned pregnancies. Due to the lack of information on income and consumption which are a direct measure of economic status of the households, a wealth index was computed using the principal component analysis (PCA) method. This is a statistical technique in which, ?the 17 variation in a set of data is described in terms of a set of uncorrelated linear combination of the original variables? (35). The method seeks to explain the largest variation in the original data and assigns weights to each asset included in the calculation of the wealth index. The technique has however been criticized as lacking a theoretical base to guide in the choice of variables and weights to be used in the index calculation. A score of the variables included in the generation of the wealth index was obtained in STATA software. These variables included possession of household goods such as television, refrigerator, radio; type of floor and roofing material, source of drinking water and ownership of cattle. This score is a sum of all variables weighted by the vectors associated with each component generated. After the score was calculated, quintiles were generated to represent levels of wealth. The choice of five levels of wealth was justified by the fact that the study area is classified as one of the poorest in the country with approximately nine out of ten people living below the poverty line (33). Therefore, five levels would better represent any economic differences that may exist within the communities. 2.1.5. Data Analysis Data were already in STATA format and analysis was done using STATA software release 8.1 (STATA corp., Texas). Three levels of analysis were adopted; the first level was simple tabulation of demographic and socio-economic characteristics to get a profile of the respondents. The second level involved bivariate analysis which was carried out to establish the relationship between the outcome variable s and the explanatory variables. Chi square tests were done to establish if there were significant 18 associations between the outcomes and the explanatory variables. The tests also indicated if there were significant differences in the proportions. The third level was the univariate and multivariate logistic regressions, which were done to find out which variables were associated with the outcomes. Logistic regression models were used because the outcome variables are dichotomous. All variables were included in the models except for some outcomes where some categories were having missing values. 2.1.6. Ethical Considerations Studies on sexual behaviour are sensitive due to the intimate information respondents are required to provide. Therefore the primary data was collected only from respondents who gave their written consent if they were 16 years or older while for individuals younger than 16, parental consent and individual assent were obtained. Ethical clearance for the primary study was obtained from the review committee of the Ghana Ministry of Health and the institutional review board of the Navrongo Health Research Center. This study received ethical clearance from both the institutional review board of the Navrongo Health Research Centre and the ethics committee at the University of the Witwatersrand (see appendix A2). 2.1.7. Limitations The primary outcome variable is measured by self-reported behaviour, a fact that can lead to inaccurate estimates of the age at which adolescents initiate sexual activity as well as the level of sexual activity and condom use in the different gender groups. 19 The wide age range used in this study presents some challenges in that most of the older adolescents may be already married, given the practice of early marriage especially among girls. This would increase the proportion of adolescents who ever had sex; consequently their exclusion from the analysis of sexual behaviour and co-residence with parents on the basis of their marital status would reduce the analytical sample size for the secondary outcomes that are dependent on a sample of those who ever had sex. Also the older adolescents are more likely to have initiated sex at the time of the survey and therefore this may lead to an overestimate of the effect of age on the outcomes. Lack of qualitative data on the parent-child interactions especially with regards to sexual and reproductive health issues is a major limitation. There is therefore no opportunity to explore why the different family structures have different effects on the sexual behaviour of adolescents. Being a cross-sectional study, there is no way of establishing if sexual initiation and adoption of other sexual behaviours preceded discussion of sexual issues with parents or vice versa. One therefore cannot state conclusively if the observed relationships between the explanatory variables and the outcomes are causal. 20 CHAPTER 3 3.0. Results 3.1. Descriptive Results 3.1.1. Adolescents? Background characteristics Table 3.1 summarizes the background characteristics of the overall sample of both married and unmarried adolescents. Majority of the respondents in both sexes were aged between 13 and 19 years with a higher proportion of males (60.6%) compared to 58.7% of females being found in this age range. Most of the respondents had attained primary school education and were in school at the time of the survey. A larger proportion of females (15.0%) than males (11.5%) had no education while females also formed the larger proportion of adolescents who were in a marital union at the time of the survey (13.6% compared to 3.1% of males). An investigation of adolescents who were married (results not shown) shows that majority of the females either had no education (39.7%) or had a primary level education (35.3%). Among the males, majority of the married had a primary level education (43.4%). When the co-residence status was considered, more males than females were found in each category except the category in which the adolescent lives with neither parent. Christianity appeared to be the dominant religion while the two major ethnic groups in the district, the Kassem and Nankam dominated the sample. 21 Table 3.1 Distribution of Unmarried Respondents by Background Characteristics Female = 2975 (45.9%) Male = 3499 (54.1%) Characteristic Frequency Percentage Frequency Percentage Age (years) Pre-teen(10-12) 826 27.8 787 22.5 Teen (13-19) 1886 63.4 2189 62.2 Post-teen (20-24) 263 8.8 635 15.3 Total 2975 100.0 3499 100.0 Education No education 331 11.1 378 10.8 Primary level 1881 63.2 2250 64.3 JSS level 553 18.6 632 18.1 SSS & higher 210 7.1 239 6.8 Total 2975 100.0 3499 100.0 Ethnicity Kassem 1405 47.2 1732 49.5 Nankam 1396 46.9 1591 45.5 Other 174 5.9 176 5.0 Total 2975 100.0 3499 100.0 Religion Christian 2466 82.9 2215 63.3 Muslim 163 5.5 237 6.8 Traditional/other 263 8.8 707 20.2 No religion 89 2.8 340 9.7 Total 2975 100.0 3499 100.0 Co-residence Living with father 213 7.2 295 8.4 Living with mother 688 23.1 885 25.3 Living with both 1575 52.9 1881 53.8 Living with neither 499 16.8 438 12.5 Total 2975 100.0 3499 100.0 Wealth index Poorest 553 18.8 683 19.7 Poorer 579 19.7 786 22.6 Poor 774 26.4 929 26.7 Less poor 499 17.0 571 16.4 Least poor 531 18.1 505 14.5 Total 2936 100.0 3474 100.0 Place of residence Rural 2662 89.5 3232 92.4 Urban 313 10.5 267 7.6 Total 2975 100.0 3499 100.0 3.1.2. Sexual Behaviour The first objective of the study sought to assess the sexual behaviour of adolescents and its variation by sex. Of the 7056 respondents interviewed, 468 females and 113 males 22 were in a marital union (those who were married or in a cohabiting relationship) at the time of the interview, so they were excluded from the analysis. Of the remaining 6474 unmarried adolescents, 361 females (12.1%) reported ever having had sex compared to 589 males (16.8%). The distribution of the respondents by the ir sexual status (ever had sex) is shown in Figure 3.1. 0 10 20 30 40 50 60 70 80 90 100 Never had sex Ever had sex Sexual Status Pe rc an ta ge Females Males Both Figure 3.1 Proportions of respondents by sexual status at time of interview Figure 3.2 shows the distribution of the respondents depending on whether they initiated sex before the age of 12 years, between 13 and 15 years of age, between 16 and 19 years and at the age of 20 and above. Males had the highest proportion who had initiated sex at or before the age of 12 years (26.3% compared to 5.6% among the females). On the other hand females had the highest proportion (49.1%) who reported initiating sex between ages 16 and 19; compared to 31.7% for males (see appendix A3- i 23 for the data table). The median age at first sex for females was 17 years while among males it was 16 years. 0.0 10.0 20.0 30.0 40.0 50.0 60.0 females males Sex Pe rc en ta ge had sex<=12 had sex between 13-15 had sex between16-19 had sex at 20+ Figure 3.2 Proportion of respondents initiating sex at different ages. To obtain aggregate proportions for each sex depending on whether they initiated sex before or after the age of 16 years, those who reported to have ever had sex were categorised into two broad categories: those initiating sex before and those initiating sex after the age of 16 years. It was found that 25% of the female respondents had sex before they were aged 16 years while 49.5% of the males had sex before the same age. Apart from the outcomes ever having had sex and early sexual initiation, the study also examined other indicators of sexual behaviour such as sexual activity in the three months before the survey and condom usage during the first and last sexual encounters. 24 The results showed low proportions of both males and females who had sex in the three months preceding the survey. Only 15.2% of females and 17.2% of males reported to have been sexually active in the three months before the survey. The larger proportion in both sexes reported no sexual activity in the given time period. Condom usage among adolescents appeared to be especially low among females during the last sexual encounter, reflecting a substantial drop from the levels reported in the first sexual encounter; 29.4% of females and 40.6% among females and males respectively. During the last sexual encounter condom usage was 6.7% among females and 8.8% among males. Though this level is still higher than the national average reported from national surveys at 5.2% among married women aged 15-19 years and 7.7% among married women aged 20-24, it is still unsatisfactorily low considering the risks in unprotected sex. Other types of contraceptives used were investigated (See Appendix A3-iii). Chi square tests indicate that sex of respondent was significantly associated with two of the outcomes except reported sexual activity in the last three months and condom use. The tests also indicate that there were differences in the proportions in each of the two outcomes when disaggregated by sex of respondents. Table 3.2 gives a summary of the proportions of the different outcomes. 25 Table 3.2 Chi square tests for association between the outcomes and sex of respondent. Female Male Total Outcome Frequency Percentage Frequency Percentage Frequency Percentage Ever had sex 361 38.0 589 62.0 950 100.0 Never had sex 2614 47.3 2910 52.7 5524 100.0 Pearson chi2 (1)=28.3546 Pr = 0.000 Early initiation of sex 80 22.5 275 77.5 355 100.0 Late initiation of sex 240 46.2 280 53.8 520 100.0 Pearson chi2 (1)=50.7348 Pr = 0.000 Had sex past 3 months 55 35.3 101 64.7 156 100.0 Not sexually active 306 38.5 488 61.5 794 100.0 Pearson chi2(1) = 0.5963 Pr = 0.440 Used condom 24 31.6 52 68.4 76 100.0 Did not use 337 38.6 537 61.4 874 100.0 Pearson chi2(1) = 1.4456 Pr = 0.229 3.2. Multivariate Results 3.2.1. Co-residence with parents and adolescents? sexual behaviour The second objective was to determine if there were any differences in the sexual behaviour of unmarried adolescents depending on their co-residence with their biological parents. To achieve this objective, bivariate analysis and the chi square test were carried out as well as univariate logistic regression. These were done to determine if there was an association between sexual behaviour and co-residence status as well as establish if there were significant differences in the proportions. Logistic regression was used to estimate the magnitude and direction of the association between co-residence and sexual behaviour. From the chi square tests, only ever having had sex was significantly associated with co-residence with parents, while sexual activity, condom use and early initiation of sex were not. The proportions reporting they ever had sex were also significantly different for the different types of family structures (as indicated by the variable ?co-residence?). 26 When univariate logistic models were fitted for all the outcomes with co-residence as the explanatory variable (see appendix A3-ii), compared to those living with both parents, living with the mother only and living with neither parent were both associated with increased likelihood of having ever had sex. Living with the father only was associated with a reduced likelihood of initiating sex before the age of 16. Sexual activity in the three months before the survey; and condom use were not significantly associated with co-residence with parents. 3.2.2. Factors influencing sexual behaviour among adolescents The third objective was to determine the factors that influence sexual behaviour among adolescents in the district. From the logistic regression models (see Table 3.3), it was found that education level, ethnicity, co-residence with parents, age, sex, discussion of sexual matters with parents and religion were the factors associated with sexual behaviour among adolescents (both males and females combined). There was an observed increase in the likelihood of having had sex with an increase in respondent?s age. Compared to those aged 13 -19 years, the younger adolescents were less likely to have ever had sex while the older were more likely to have ever had sex and to have been sexually active in the three months preceding the survey. For the main explanatory variable; co-residence with one?s biological parents, all outcomes except ever having had sex, did not have a significant association with this variable. Among respondents who said they lived with the mother only, there was an 27 22% increase in the likelihood of reporting to ever have had sex compared to those living with both parents. One?s religion was significantly associa ted with having ever had sex; compared to Christians, those reporting to profess the Muslim faith were 62% more likely to report to have ever had sex while those who reported to have no religion were 62% less likely to report to have ever had sex. In addition to the co-residence with parents, whether adolescents ever discussed sex with their parents was investigated. Compared to those who reported no discussion of sexual matters with their mother, those who reported they ever discussed were more than twice as likely to report to ever have had sex. On the other hand, discussion of sexual issues with the father increased the likelihood of reporting to have had sex by 71%. Sex of the respondent was significant for the outcomes ever having had sex and early sexual initiation. Females were less likely to report these outcomes compared to males. When household wealth is considered, there was no significant relationship when the poorest households were compared with the least poor. This was observed for all the four outcomes. One?s ethnic group was associated with ever having had sex with the Nankam being 63% less likely to report this outcome compared to the Kassem. 28 Table 3.3 Summary of the logistic regression results for the outcome variables. Ever Had sex Early Sexual initiation Sex past 3 months Condom use Variable OR 95% CI OR 95% CI OR 95% CI OR 95% CI Age ^0.12* 0.02; 0.22 13-19 years 1.00 1.00 1.00 10-12 years 0.33* 0.24; 0.45 0.32 0.08; 1.40 20-24 years 7.17* 5.92; 8.69 0.18* 0.13; 0.26 1.77* 1.19; 2.62 Education No Education 1.00 1.00 1.00 1.00 Primary 0.66* 0.51; 0.86 1.28 0.75; 2.17 1.03 0.54; 1.96 0.89 0.32; 2.45 JSS 0.97 0.73; 1.29 0.72 0.41; 1.27 1.22 0.62; 2.39 1.59 0.58; 4.33 SSS & Higher 1.07 0.76; 1.51 0.41* 0.21; 0.81 1.51 0.75; 3.05 2.29 0.82; 6.38 Ethnicity Kassem 1.00 1.00 1.00 1.00 Nankam 0.63* 0.53; 0.75 0.81 0.56; 1.17 1.05 0.69; 1.60 1.11 0.61;2.01 Other 0.81 0.57; 1.14 1.12 0.58; 2.15 0.77 0.38; 1.57 0.81 0.34; 1.96 Co-residence Living with both 1.00 1.00 1.00 1.00 Living with father 0.82 0.60; 1.12 0.68 0.35; 1.33 0.56 0.24; 1.31 1.10 0.39; 3.11 Living with mother 1.22* 1.01; 1.47 1.00 0.69; 1.45 1.13 0.74; 1.70 1.35 0.75; 2.43 Living with neither 1.14 0.90; 1.43 1.03 0.63; 1.68 1.05 0.62; 1.78 1.36 0.67; 2.75 Sex Male 1.00 1.00 1.00 1.00 Female 0.75* 0.63; 0.88 0.30* 0.21; 0.43 0.80 0.54; 1.19 0.63 0.36; 1.09 Wealth Index Poorest 1.00 1.00 1.00 1.00 Poorer 1.30 0.99; 1.71 1.84* 1.04; 3.27 1.46 0.68; 3.11 0.59 0.19; 1.88 Poor 1.34* 1.03; 1.74 1.20 0.69; 2.08 1.73 0.84; 3.58 1.22 0.45; 3.28 Less poor 1.31 0.98; 1.75 0.82 0.45; 1.50 1.26 0.58; 2.77 0.98 0.34; 2.86 Least poor 1.19 0.85; 1.67 1.23 0.63; 2.40 1.30 0.55; 3.04 1.57 0.53; 4.67 Discuss with father Never 1.00 1.00 1.00 1.00 Ever 1.71* 1.11; 2.62 1.12 0.54; 2.31 0.93 0.40; 2.15 1.23 0.44; 3.46 Discuss with mother Never 1.00 1.00 1.00 1.00 Ever 2.03* 1.48; 2.79 1.22 0.69; 2.14 1.55 0.88; 2.70 1.64 0.80; 3.38 Place of Residence Rural 1.00 1.00 1.00 1.00 Urban 1.26 0.93; 1.73 1.26 0.69; 2.30 1.71 0.93; 3.12 1.23 0.59; 2.58 Religion Christian 1.00 1.00 1.00 1.00 Muslim 1.62* 1.20; 2.18 0.90 0.52; 1.56 1.48 0.83; 2.62 1.62 0.79; 3.33 Traditional/other 0.90 0.70; 1.16 0.86 0.51; 1.46 0.73 0.36; 1.46 0.90 0.33; 2.46 No religion 0.62* 0.43; 0.91 1.61 0.71; 3.66 1.79 0.78; 4.08 1.88 0.58; 6.05 N 6409 867 942 942 Note: *: Significant at 5% ^: This is a coefficient and not Odds ratio. 1.00: This is the reference category 29 When early sexual initiation was considered, there were very few explanatory variables that had a significant association. Only age, education level and respondent?s sex were significantly associated with initiation of sex before the age of 16. All other factors were not significant. Among all the explanatory variables investigated for sexual activity in the three months preceding the survey, only age had a significant association. All other variables were not significant. Condom use was significantly associated with age only (see Table 3.3). When regression models were fitted while disaggregated by sex (see Tables 3.4a & b), some differences were noted for the factors associated with the outcomes. Among females, age was associated with ever having had sex and early initiation of sex. In contrast, age was associated with all outcomes among males. 30 Table 3.4a Adjusted Odds Ratios from logistic regression models fitted by sex of respondent Ever Had sex Early Sexual initiation Female Male Female Male Variable OR 95% CI OR 95% CI OR 95% CI OR 95% CI Age ^0.53* 0.47; 0.59 ^0.32* 0.29; 0.36 '^-0.51* -0.67; -0.35 -^0.42* -0.51; Education No Education 1.00 1.00 1.00 1.00 Primary 0.78 0.49; 1.22 0.99 0.70; 1.42 0.98 0.35; 2.70 0.95 0.46; 1.93 JSS 0.88 0.55; 1.40 0.86 0.58; 1.27 0.47 0.17; 1.32 0.94 0.44; 2.00 SSS & Higher 0.67 0.38; 1.18 0.89 0.56; 1.42 0.43 0.12; 1.56 0.60 0.25; 1.41 Ethnicity Kassem 1.00 1.00 1.00 1.00 Nankam 1.01 0.74; 1.38 0.47 0.37; 0.58 1.47 0.70; 3.09 0.70 0.44; 1.13 Other 1.25 0.71; 2.20 0.68 0.42; 1.09 0.71 0.19; 2.65 0.99 0.41; 2.39 Co-residence Living with both 1.00 1.00 1.00 1.00 Living with father 1.52 0.91; 2.54 0.64* 0.42; 0.96 0.85 0.25; 2.88 0.57 0.23; 1.39 Living with mother 1.25 0.89; 1.76 1.12 0.89; 1.42 1.15 0.51; 2.56 1.13 0.71; 1.81 Living with neither 1.76* 1.21; 2.55 0.81 0.58; 1.12 1.76 0.71; 4.35 0.86 0.43; 1.71 Wealth Index Poorest 1.00 1.00 1.00 1.00 Poorer 1.47 0.88; 2.46 1.26 0.90; 1.77 4.01* 1.15; 13.98 1.88 0.90; 3.95 Poor 1.61 1.00; 2.57 1.23 0.88; 1.72 1.87 0.58; 5.98 1.17 0.57;2.39 Less poor 1.20 0.71; 2.03 1.55* 1.08; 2.23 0.88 0.23; 3.32 0.73 0.34; 1.57 Least poor 1.13 0.62; 2.05 1.50 0.97; 2.30 1.01 0.25; 4.10 1.26 0.53; 3.00 Discuss with father Never 1.00 1.00 1.00 1.00 Ever 0.79 0.37; 1.72 2.55* 1.46; 4.47 4.87 0.96; 24.65 0.85 0.36; 1.99 Discuss with mother Never 1.00 1.00 1.00 1.00 Ever 1.82* 1.15; 2.87 2.30* 1.37; 3.86 1.52 0.57; 4.10 1.01 0.47; 2.19 Place of Residence Rural 1.00 1.00 1.00 1.00 Urban 1.63 0.98; 2.71 1.19 0.77; 1.83 1.16 0.36; 3.78 1.38 0.62; 3.08 Religion Christian 1.00 1.00 1.00 1.00 Muslim 1.23 0.67; 2.26 1.74* 1.21; 2.50 6.90* 1.64; 29.01 0.69 0.37; 1.31 Traditional/other 1.10 0.60; 2.03 0.95 0.71; 1.27 0.35 0.04; 3.31 1.05 0.56; 1.96 No religion 1.06 0.41; 2.71 0.61 0.39; 0.93 1.25 0.05; 31.99 1.75 0.69; 4.45 N 2935 3474 314 553 Note: ^: This is a coefficient and not Odds Ratio *: Significant at 5% 1.00: This is the reference category 31 Table 3.4b Adjusted Odds Ratios from logistic regression models fitted by sex of respondent Condom use Had sex in last three months Female Male Female Male Variable OR 95% CI OR 95% CI OR 95% CI OR 95% CI Age ^0.09 -0.08; 0.26 ^0.20* 0.07; 0.32 ^0.06 -0.06; 0.18 ^014* 0.05; 0.22 Education No Education 1.00 1.00 1.00 1.00 Primary 1.40 0.26; 7.52 0.91 0.26; 3.14 1.12 0.37; 3.37 0.89 0.39; 2.03 JSS 1.38 0.25; 7.43 1.51 0.42; 5.36 1.24 0.41; 3.72 1.12 0.47; 2.67 SSS & Higher 2.09 0.40; 10.96 2.01 0.54; 7.44 1.77 0.57; 5.52 1.44 0.57; 3.62 Ethnicity Kassem 1.00 1.00 1.00 1.00 Nankam 0.82 0.31; 2.17 0.96 0.45; 2.05 1.20 0.59; 2.41 0.97 0.56; 1.67 Other 1.20 0.37; 3.87 0.77 0.25; 2.38 1.14 0.36; 3.60 0.76 0.29; 1.98 Co-residence Living with both 1.00 1.00 1.00 1.00 Living with father 0.98 0.19; 5.11 1.02 0.26; 3.95 0.65 0.17; 2.46 0.60 0.19; 1.86 Living with mother 1.52 0.54; 4.29 1.14 0.56; 2.30 1.06 0.49; 2.29 1.14 0.69; 1.89 Living with neither 1.80 0.64; 5.03 0.94 0.36; 2.43 1.70 0.78; 3.70 0.62 0.28; 1.36 Wealth Index ? Poorest 1.00 1.00 1.00 Poorer 0.23 0.38; 3.97 1.18 0.32; 4.40 1.69 0.66; 4.35 Poor 0.96 0.46; 4.31 1.15 0.33; 3.98 2.20 0.89; 5.47 Less poor 0.63 0.37; 4.14 0.90 0.23; 3.50 1.53 0.58; 4.05 Least poor 1.31 0.63; 8.02 0.67 0.15; 2.94 1.94 0.67; 5.62 Discuss with father Never 1.00 1.00 1.00 1.00 Ever 1.01 0.15; 6.72 1.25 0.35; 4.46 0.81 0.17; 4.01 0.86 0.31; 2.38 Discuss with mother Never 1.00 1.00 1.00 1.00 Ever 2.69 0.91; 7.97 0.94 0.33; 2.68 2.24 0.96; 5.26 1.11 0.50; 2.47 Place of Residence Rural 1.00 1.00 1.00 1.00 Urban *3.30 1.26; 8.62 1.13 0.44; 2.93 3.27* 1.22; 8.73 1.09 0.49; 2.46 Religion ? Christian 1.00 1.00 1.00 Muslim 1.78 0.78; 4.07 0.73 0.20; 2.67 1.86 0.97; 3.54 Traditional/other 1.10 0.37; 3.29 0.35 0.04; 2.87 0.86 0.40; 1.87 No religion 2.46 0.71; 8.59 1.15 0.12; 10.95 2.24 0.90; 5.55 N 361 587 355 587 Note: ^: This is a coefficient and not Odds Ratio *: Significant at 5% ?: Variable left out of the model due to categories with no observations 1.00: This is the reference category. 32 Discussion with the father was not significant for all outcomes among females while it was associated with increased likelihood of ever having had sex among males. For both males and females, discussion with the mother was significantly associated with increased likelihood of ever having had sex. Residing in the urban area was associated with an increased likelihood both of having been sexually active in the three months prior to the survey as well as condom use among females while among males, no such relationship was observed. Co-residence with parents was for most of the outcomes not a significant factor; however among females, living with neither parent was significantly associated with an increased likelihood of initiation of sex while for males, living with the father only was significantly protective for the same outcome. In summary, the results revealed that sexual behaviour is predicted by individual and family factors. One?s age, place of residence and religion were associated with sexual behaviour. Females were less likely than males to have had sex and also less likely to have initiated sex before the age of 16. Family factors that were found to predict sexual behaviour included living with the father only and living with neither parent as well as ever having discussed sexual matters with parents. 33 CHAPTER 4 4.0. Discussion The main objective of this study was to investigate if co-residence with biological parents had an influence on the sexual behaviour of adolescents. The results show that living with the father only is associated with less likelihood of having ever had sex among males. This may be linked to the authority that fathers, who are mostly the household heads, have over their children, thus they are able to exert this authority over their adolescent children?s sexual behaviour. A similar finding was reported in studies carried out in Cameroon and Nairobi (15, 17). However a study in Ivory Coast did not find this protective factor but rather found an increased likelihood of engaging in risky sexual behaviour if one lived with the father. While this finding is not in the expected direction where males might be expected to be more likely to have had sex, it nevertheless exposes likely gender bias in the socialization of adolescents regarding sexual matters within the home. Perhaps fathers are more open about their disapproval of sexual activity with their sons but not with their daughters. Since parental attitude towards sex is crucial in development of behaviour it is possible that sensing a lack of disapproval from their fathers may spur females to initiate sex. Other societal norms regarding sexual issues and local context of gender relationship might be worth looking into to answer the underlying reason for a higher likelihood of females than males to initiate sex if they live with their fathers as observed in this study. 34 Living with neither of the biological parents is associated with an increased likelihood of reporting ever having had sex among females. This could point perhaps to a diminishing influence of the extended family on the upbringing of children especially in the education of adolescents regarding sexual issues. In a community where the extended family lives within the same compound, it is expected that relatives other than the biological parents will play a role in the upbringing of children within the compound. The impact of the extended kinship is expected to be seen in the sexual lives of adolescents who culturally were educated on sexual issues by the extended family. However there is no such observation since the study found that those living with neither parent were more likely to report ever having had sex compared to those living with both parents and with the father. The observed negative effect of residing with neither biological parent on reported sexual initiation is in line with findings from a national survey conducted in Ghana which found that living with neither parent was a predictor of sexual behaviour among females (10). Another finding from this study is that those adolescents who reported to have ever discussed sexual issues with either their fathers or mothers appear to have an increased likelihood of reporting ever having had sex, after controlling for co-residence type. Though this study cannot establish the sequence of events, it raises a concern about the content and timing of these discussions. Perhaps these discussions took place when parents started suspecting that their children were sexually active or the discussions were in the negative (36). This would not confer to adolescents the expected benefits for example postponing sexual initiation or abstaining altogether. This finding contradicts 35 findings from the USA which have consistently shown a protective role of discussing sexual issues between adolescents and their parents, especially mother-adolescent communication. Religion was found to be significant for initiating sex before the age of 16 among females while it was significant for ever having had sex among males; with Muslims in both cases being more likely to report the outcome compared to Christians. While the Muslim faith teaches abstinence from sex before marriage, it is surprising to see that those reporting Islam as their religion were more likely to initiate sex before age 16 and to ever have had sex among females and males respectively. This may point to possible rebellious behaviour among adolescents who may find the religious prescription on abstinence too difficult to adhere to. The apparent decline in condom use is a worrying trend which needs to be addressed. In the face of HIV/AIDS and high prevalence of unwanted pregnancies among adolescents in sub-Saharan Africa, there is need to empower adolescents who are sexually active to be able to negotiate safe sex practices. This is especially very critical for females who had a low proportion among those who ever had sex reporting use of condoms during the last sexual encounter. Low contraceptive usage has been documented as a concern in sub-Saharan Africa where high levels of adolescent sexual activity are not accompanied by corresponding contraceptive usage (8, 15). Our results suggest that, residing with the father only has a protective effect while residing with neither parent has a negative effect on the sexual behaviour of adolescent males and females respectively. Also discussing sexual matters with parents appear to 36 have a negative effect on sexual initiation. These findings have implications on interventions aimed at both parents and the unmarried adolescent population in the district. 37 CHAPTER 5 5.0. Conclusion and Recommendations. 5.1. Conclusion The study finds that the family structure in which adolescents live has an influence on their sexual behaviour. However given the small proportions of both female and male respondents reporting they ever discussed with fathers and the negative effect it has on sexual behaviour, it remains unclear through what mechanism the father?s presence operates to reduce the likelihood of sexual initiation among adolescents. Overall however the presence of the father has been shown to be an important protective factor in the sexual behaviour of adolescent children in this community. It would therefore be important to involve parents in the education and guidance of their children in order to achieve improvements in the sexual and reproductive lives of adolescents. 5.2. Recommendations The findings on the effect of co-residence with parents on sexual behaviour have implications on interventional programs aimed at adolescents in the district. There are very low proportions of adolescents who reported ever having had discussions with their parents on sexual and reproductive health matters. Therefore, interventions should be planned with parents as a target group to provide them with communication skills and relevant information regarding sexual and reproductive issues. This will enable them to hold timely discussions with their children and therefore help protect their children from early sexual activity, and also guide them in making the right choices with regard to their sexual and reproductive health. 38 Adolescents who live in a home where the father is present are less likely to have had sex; this points to a likely role of fathers in deterring sexual activity among adolescents. Perhaps programs can tap into this role and disseminate the benefits to other adolescents living in different family structures. It would be more applicable if interventions are designed bearing in mind that the different family structures in which adolescents live impact their sexual behaviour differently. Therefore, it would not be beneficial to lump all interventions into one but rather fragment them to suit the co-residence circumstances of adolescents. Since one of the main aims of adolescent sexual and reproductive health programs is the reduction of risks such as pregnancies and STIs including HIV/AIDS, there is an urgent need to make available reproductive health services to young people. This study has unveiled a very low usage of contraceptives particularly condoms which offer double protection. Therefore it would be of great importance to incorporate education on sexual and reproductive health especially before or during the initiation period. This would provide adolescents with vital information that would help them make informed decisions with regards to sex and the use of contraceptives. Provision of contraceptives such as condoms to young people should also be part of any planned interventions. Finally, it would be more insightful if the Center would take advantage of the longitudinal platform (DSS) to carry out longitudinal qualitative studies to get details on parental attitudes towards adolescent sexual behaviour. Such a study would also be able to provide information on the roles parents play in the sexual and reproductive lives of their adolescent children. These qualitative studies should be done hand in hand with 39 quantitative surveys which not only target adolescents but their parents as well. A longitudinal study would help identify the causal relationships between sexual behaviour and other variables. 40 References 1. Meekers, D. Sexual Initiation and Premarital Childbearing in sub-Saharan Africa. Population studies 1994; 48(1): 47-64. 2. Mturi, A.J. Parents? Attitudes to Adolescent Sexual Behaviour in Lesotho. African Journal of Reproductive Health, 2003; 7(2):25-33. 3. Meekers, D. and Ahmed G. (1997). Adolescent Sexuality in Southern Africa: Cultural Norms and Contemporary Behavior. 4. Mturi, A. J. and Moerane, W. Premarital Childbearing among Adolescents in Lesotho. Journal of South African Studies: Special Issue on Fertility in Southern Africa 2001; 27 (2): 259-275. 5. The International Encyclopaedia of Sexuality: Ghana. [Accessed on 09/03/ 2006]. 6. Taffa, N., Haimanot, R., Desalegn, S., Tesfaye, A., and Mohammed, K. Do Parents and Young People Communicate on Sexual Matters? The Situation of Family Life Education (FLE) in a Rural Town in Ethiopia. Ethiopian Journal of Health Development 1999; 13(3):205-10. 7. Lithur, N.O., (2003). Ghana?s Education Policy Framework and Adolescent Reproductive Health: A Perspective. [Accessed on 28/02/2006] 8. Zabin, L.S., Kiragu, K. The Health Consequences of Adolescent Sexual and Fertility Behaviour in Sub-Saharan Africa. Studies in Family Planning 29 ;( 2) Adolescent Reproductive Behaviour in the Developing World (1998), 210-232. 9. New Survey Findings, The Reproductive Revolution Continues, Population Reports. [Accessed on 27/10/2005]. 10. Karim, A.M., Magnani, R. J., Morgan, G.T. and Bond, K.C. Reproductive Health Risk and Protective Factors among Unmarried Youth in Ghana. International Family Planning Perspectives 2003; 29(1): 14-24. 11. UNFPA, 1997 Annual Report. Program Priorities: Adolescent Reproductive Health [Accessed on 12/04/2005]. 12. Kiragu, K. and Zabin, L.S. The Correlates of Premarital Sexual Activity Among School-Age Adolescents in Kenya. International Family Planning Perspectives, 1993; 19(3): 92-97 & 109. 13. Resnick, M.D., Bearman, P.S., Blum, R.W., Bauman, K.E., Harris, K.M., Jones, J., et al. (1997). Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health. Journal of the American Medical Association 278(10): 823-32. 42 14. Blum, R.W., Beurhing, T., Rinehart, P.M., (2000). Protecting Teens: Beyond Race, Income and Family Structure. Center for Adolescent Health, University of Minnesota, 200 Oak Street SE, Suite 260, Minneapolis MN. 15. Rwenge, M. Sexual Risk Behaviour Among Young People in Bamenda, Cameroon. International Family Planning Perspectives 2000; 26(3): 118-123 &130. 16. Blum, R.W., (2002). Mothers? Influence on Teen Sex: Connections That Promote Postponing Sexual Intercourse, Center for Adolescent Health and Development, University of Minnesota. 17. Ngom, P., Magadi, M.A., and Owuor, T. Parental Presence and Adolescent Reproductive Health among the Nairobi Urban Poor. African Population and Health Research Center: Working Papers, 2003, No. 28. 18. Afenyandu, D. and Goparaju, L., (2003). Adolescent Sexual and Reproductive Health Behaviour in Dodowa, Ghana. [Accessed on 27/05/2005] 19. Brown, K.M. Social Cognitive Theory. [Accessed on 29/08/2005]. 43 20. Miller, K., Forehand, R., and Kotchick, B.A. Adolescent Sexual Behaviour in Two Minority Samples: The Role of Family Variables. Journal of Marriage and the Family, 1999; 61(1): 85-98. 21. National Population Council (2000). Republic of Ghana Adolescent Reproductive Health Policy. [Accessed on 27/05/2005]. 22. Mayhew, S. Sexual and Reproductive Health in Ghana and the Role of Donor Assistance. [Accessed on 30/11/2005]. 23. Awusabo-Asare, K., Abane, A.M., and Kumi-Kyereme, K. Adolescent Sexual and Reproductive Health in Ghana: A Synthesis of Research Evidence, Occasional Report, New York: The Alan Guttmacher Institute, 2004, No. 13. 24. GUS. Ghana (General Remarks). [Accessed on 30/11/2005]. 25. World Health Organization (WHO). Child and Adolescent Health and Development [Accessed on 21/03/2006]. 44 26. UNAIDS (2004). Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. [Accessed on 31/05/2005]. 27. Adongo, P. B., Phillips, J. F., Kajihara, B., Fayorsey, C., Debpuur, C. and Binka, F. Cultural Factors Constraining the Introduction of Family Planning Among the Kassena- Nankana of Northern Ghana. Social Science and Medicine, 1997; 45 (12):1789-1804 28. Adongo, P. B., Phillips, J. F., and Binka F. The Influence of Traditional Religion on Fertility Regulation among the Kassena-Nankana of Northern Ghana. Studies in Family Planning, 1998; 29(1):23-40 29. Ghana Regions: Districts of Ghana. [Accessed on 17/06/2006] 30. Mensch, B.S., Bagah, D., Clark, W.H., and Binka, F., (1998). The Changing Social Environment for Adolescents in the Kassena-Nankana District of Northern Ghana: Implications for Reproductive Behavior. [Accessed on 02/03/2006] 31. Jackson, E. F., Akweongo, P., Sakeah, E., Hodgson, A., Asuru, R. and Phillips, J. F. Women?s Denial of Having Experienced Female Genital Cutting in Northern Ghana: Explanatory Factors and Consequences for Analysis of Survey Data. Studies in Family Planning 2003; 34(3): 200?210 45 32. Mensch, B.S., Bagah, D., Clark, W.H., and Binka, F. The Changing Nature of Adolescence in the Kassena-Nankana District of Northern Ghana. Studies in Family Planning 1999; 30(2): 95-111 33. Niagia, S. (2005). Innovative Strategies for Bridging Health Inequality Gaps. [accessed on 17/06/2006]. 34. Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Research (NMIMR) and ORC Macro (2004). Ghana Demographic and Health Survey 2003. Calverton, Maryland: GSS, NMIMR and ORC Macro. 35. World Bank. Measuring Living Standards: Household Consumption and Wealth Indices. [Accessed on 12/04/ 2006]. 36. Babalola, S., Tambashe, B.O. and Vondrasek, C. Parental Factors and Sexual Risk- Taking among Young People in C?te d'Ivoire. African Journal of Reproductive Health, 2005; 9(1): 49-65. 46 Appendices Appendix A1 Questionnaire used in the Collection of the Primary Data. NAVRONGO HEALTH RESEARCH CENTRE KASSENA-NANKANA DISTRICT ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH SURVEY-2003 FEMALE QUESTIONNAIRE IDENTIFICATION NAME OF INTERVIEWEE: FNAME COMPOUND NAME/ID. FCMPNUM PERMANENT ID OF RESPONDENT FPERMID DATE OF INTERVIEW FDAINT FIELDWORKER CODE FFWCODE FIELD SUPERVISOR CODE FFSCODE RESULT OF INTERVIEW: COMPLETE, LISTED INTERVIEWEE 1 FRESULT COMPLETE, NEW INTERVIEWEE 2 INCOMPLETE, DIED 3 INCOMPLETE, MIGRATED 4 INCOMPLETE, REFUSED 5 INCOMPLETE, TOO YOUNG/TOO OLD 6 INCOMPLETE, NOT MET AFTER THREE REVISITS 7 INCOMPLETE, WRONG SEX 8 INCOMPLETE, WRONG NAME 9 INCOMPLETE, NOT KNOWN IN COMPOUND 10 INCOMPLETE, OTHER___________________________________ (SPECIFY) 11 47 SECTION 1: BACKGROUND and related information NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO HOUR ????????? FHSTART 101 RECORD TIME AT BEGINNING OF INTERVIEW MINUTES ???????. FMSTART 102 In what month and year were you born? MONTH????????... DK MONTH???????99 YEAR?????????? DK YEAR??????.99 FMONTH FYEAR 103 How old were you at your last birthday? CROSS-CHECK WITH 102 AND CORRECT IF INCONSISTENT AGE IN COMPLETED YRS?.. DON'T KNOW?????.99 FAGE 104 Have you ever attended school? YES ...............................................1 NO.................................................2 FSCHOOL 109 105 Are you still attending school? YES ...............................................1 NO.................................................2 NA.................................................8 FCSCH 106 (IF STILL IN SCHOOL) What is the highest level of school you are attending? (IF NOT IN SCHOOL) What is the highest level of school you attended? PRIMARY.....................................1 JUNIOR SECONDARY (JSS) ......2 SENIOR SECONDARY (SSS) .....3 TECHNICAL/COMMERCIAL/VOC ATIONAL?????4 POST SECONDARY?..???...5 TERTIARY _________________6 (SPECIFY) NA.................................................8 FLEVEL 107 (IF STILL IN SCHOOL) What is the highest class/form/year you have completed at that level? (IF NOT IN SCHOOL) What is the highest class/form/year you completed at that level? CLASS/FORM/YEAR...... NA...............................................88 FYEARC 108 (IF NOT IN SCHOOL ASK:) Why did you stop attending school? GRADUATED............................01 WANTED TO FIND A JOB........02 FINANCIAL CONSTRAINTS .........................................???03 PARENTS NEEDED HELP........04 LACK OF INTEREST.................05 PREGNANCY.............................06 GOT MARRIED..........................07 PROLONGED ILLNESS ............08 DISMISSED/SACK???..09 OTHER____________________10 (SPECIFY) NA...............................................88 DK...............................................99 FRSTOPSC 109 Have you ever received any vocational or apprenticeship training? YES................................................1 NO..................................................2 FVOCPT 111 48 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 110 What type of vocational or apprenticeship training have you received? DRESSMAKING/WEAVING...01 COOKING/CATERING........?..02 CARPENTARY/MASONRY /METALW ORK?..???03 ELECTRICIAN.......?????04 AUTO MECHANIC??....05 PLUMBING.......................??.06 COMPUTER/TYPING/SECRETARI AL TRAINING??...07 HAIRDRESSING.......????.08 OTHER________________09 (SPECIFY) NA??????????88 FTPVOCT 112 111 If you had the opportunity to receive vocational or apprenticeship training, which would you prefer? DRESSMAKING/WEAVING ....................................???.?01 COOKING/CATERING ...........................?????.?.02 CARPENTARY/MASONRY /METALWORK??.??03 ELECTRICIAN...........????04 AUTO MECHANIC?.....05 PLUMBING...........?????.06 COMPUTER/TYPING/SECRETARI AL TRAINING?...07 HAIRDRESSING...........???.08 OTHER_______________ 09 (SPECIFY) NA??????????88 FMVOCTP 112 What is your religion? CATHOLIC??????01 PRESBYTERIAN???..02 METHODIST.........?????.03 ANGLICAN........??????04 PENTECOASTAL???..05 OTHER CHRISTIAN.........??.06 MOSLEM???????08 TRADITIONAL..????09 NO RELIGION??.??..10 OTHER________________11 (SPECIFY) FRELIG 114 113 How often do you attend religious services? MORE THAN ONCE A WEEK?????????1 ONCE A WEEK?????2 ONCE A MONTH????.3 MORE THAN ONCE A MONTH??.??????4 ON SPECIAL OCCASIONS??????..5 NOT AT ALL?..????...6 OTHER 7 (SPECIFY) NA??????????.8 DK??????????.9 FFRQSV 114 What is your ethnic origin? KASSEM????????1 NANKAM?.??????.2 BULSA????????...3 OTHER 4 (SPECIFY) FETHIC 115 Now I have some questions about work? Have you ever worked for pay? YES??????????1 NO??????????.2 FWORK 119 116 Are you currently working for pay? YES??????????1 NO??????????.2 NA??????????.8 FCURWK 119 49 117 What type of work do you mainly do? (PROBE FOR MAIN OCCUPATION) FARMING???????01 TEACHING?????.?02 RESEARCH FIELDWORK????.?03 TRADER?..?????..04 TYPIST/SECRETARIAL /DATA ENTRY????...05 HOUSEHELP????......06 CIVIL SERVANT????.07 OTHER 08 (SPECIFY) NA??????????88 FOCCUP NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 118 Who decides what to do with the money you earn? MYSELF????????1 MY BROTHER/SISTER?...2 MY MOTHER?????...3 MY FATHER??????4 MY SPOUSE??????.5 MY GRAND FATHER/MOTHER???..6 MYSELF & SPOUSE???.7 MYSELF &SIBLINGS??..8 MYSELF & PARENTS?.?.9 MYSELF & OTHER??.....10 MYSELF & FRIEND???11 OTHER________________12 (SPECIFY) NA??????????.88 FDECIDM 119 Now I will like to ask you some questions about your family. Is your biological father alive? YES?????????.1 NO?????????..2 FRLIVE 125 120 Does he live in the same house with you? YES?????????.1 NO?????????..2 NA?????????..8 FFHCMP 121 Has your biological father ever been to school? YES?????????1 NO?????????.2 NA?????????.8 DK?????????.9 FFSCHOL 122 What type of work is your biological father currently doing? (PROBE FOR MAIN OCCUPATION) UNEMPLOYED????01 FARMING??????02 PUBLIC/ CIVIL SERVANTS??...??....03 TRADER???????04 TYPIST/SECRETARY??05 WATCHMAN/LABOURER???. ?..06 OTHER________________07 (SPECIFY) NA??????????88 FFWORK 123 Do you find it very easy, somewhat easy or not easy at all to talk with your biological father about things that are important to you? VERY EASY??????.1 SOMEWHAT EASY.???2 NOT EASY AT ALL???3 NA??????????.8 FFDCUS 124 Have you ever discussed sex-related matters with your biological father? If YES often or occasionally? OFTEN????????...1 OCCASIONALLY????.2 NEVER???????.?.3 NA??????????.8 FDCUSEX 125 Is your biological mother alive? YES??????????1 NO??????????..2 FMULIV 131 126 Does she live in the same house with you? YES?????????....1 NO??????????.2 NA??????????.8 FMHCMP 127 Has your biological mother ever been to school? YES??????????1 NO??????????.2 NA??????????.8 FMSCHOL 50 DK??????????.9 128 What type of work is your biological mother currently doing? (PROBE FOR MAIN OCCUPATION) UNEMPLOYED/ HOUSEWIFE?????.?1 FARMING??????.?2 PUBLIC CIVIL SERVANTS??...????3 TRADER????????4 TYPIST/SECRETARY??..5 OTHER 6 (SPECIFY) NA????????? ?8 FMWK 129 Do you find it very easy, somewhat easy or not easy at all to talk with your biological mother about things that are important to you VERY EASY??????.1 SOMEWHAT EASY???2 NOT EASY AT ALL???3 NA??????????.8 FMDCUS 130 Have you ever discussed sex-related matters with your biological mother? If YES Often or occasionally? OFTEN????????...1 OCCASIONALLY??? ?2 NEVER????????...3 NA??????????..8 FMDCSEX NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 131 Now I will like to talk to you about marriage. Are you currently married or living with a man? YES, CURRENTLY MARRIED???.???...1 YES, LIVING WITH A MAN.?????????.2 NO, NOT IN UNION???.3 FCURRMAR 133 132 Have you ever been married or lived with a man? YES, PREVIOUSLY MARRIED???????.1 YES, LIVED WITH A MAN?????????..2 NO, NEVER IN UNION?????.???..3 NA??????????..8 FEVERMAR 137 201 133 Is your husband/partner living with you now or is he staying elsewhere? LIVING WITH SPOUSE????????..1 SPOUSE ELSEWHERE?.?2 NA?????.?????.8 FHEWHER 134 Does your husband/partner have any other wives/partners beside yourself? YES??????????1 NO??????????.2 NA?.?????????.8 DK?.?????????.9 FWIVES 137 135 How many other wives/partners does he have? NUMBER????????. NA????????..?.88 DK????????...?.99 FNWIVES 136 Are you the first, second, ?Wife/partrners? RANK?????????.. NA?????????..88 FRANK 137 How old were you when you started living with your first husband/partner? AGE????????? NA?????????..88 DK?????????..99 FAGEMAR 138 (ASK Q. 138 & 139 OF ONLY THOSE WHO ARE CURRENTLY MARRIED OR LIVING WITH A MAN) AGE??????? FAGLHUB 51 How old was your current husband/partner when you started living with him? NA?????????.88 DK?????????.99 139 What is the educational level of your current spouse? NO EDUCATION?.?.?..1 PRIMARY?.????.?..2 MIDDLE??????.?..3 SECONDARY.?????.4 HIGHER???????..5 OTHER 6 (SPECIFY) NA??????????8 FSPEDU SECTION 2: REPRODUCTIVE HEALTH KNOWLEDGE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 201 Has any member of your family ever talked to you about A. The menstrual cycle B. How pregnancy occurs C. Family planning methods D. Sexually transmitted diseases E. HIV/AIDS YES NO NOT SURE 1 2 9 1 2 9 1 2 9 1 2 9 1 2 9 FEDMENS FEDPREG FEDUFP FEDSTDS FEHIVDS 202 Young people learn about puberty, that is the ways in which boys? and girls? bodies change during the teenage years. What has been the major source of information for you on this topic? SCHOOL TEACHER???????...?01 PARENTS/GUARDIANS??..02 SIBLINGS??..??...???.03 OTHER RELATIVES?.??...???..04 FRIENDS/SCHOOL MATES????????....05 DOCTOR/HEALTH WORKER???????...06 BOOKS/MAGAZINES???07 FILMS/VIDEOS?????...08 TV???????????.09 RADIO?..????????10 DURBAR/COMMUNITY MEETINGS???????..11 RELIGIOUS LEADER??.....12 OTHER 13 (SPECIFY FPUBTY 203 From whom or where would you prefer to receive more information on this topic? SCHOOL TEACHER???????.??01 PARENTS/GUARDIANS.??....02 SIBLINGS??????.??....03 OTHER RELATIVES?.?...?????.04 FRIENDS/SCHOOLMATES??.05 DOCTOR/HEALTH WORKER?.06 BOOKS/MAGAZINES?.???..07 FILMS/VIDEOS??????.?08 TV????????????...09 RADIO??????????...10 DURBAR/COMMUNITY MEETINGS????????...11 RELIGIOUS LEADER ??...?.12 OTHER 13 (SPECIFY FINFSPB 204 When girls mature, they start to menstruate. At what age did you get your first menstrual period? AGE ?????????? NOT STARTED FAGEMENS 52 MENSTRUATING????..96 DK/UNSURE??????...99 205 Now think about how pregnancy occurs. What has been your major source of information on this topic? SCHOOL TEACHER?????01 PARENTS/GUARDIANS??....02 SIBLINGS??..??...???....03 OTHER RELATIVES?..???.04 FRIENDS/SCHOOL MATES??05 DOCTOR/HEALTH WORKER?????????..06 BOOKS/MAGAZINES????..07 FILMS/VIDEOS??????.?08 TV????????????...09 RADIO??.????????..10 DURBAR/COMMUNITY MEETINGS?????????.11 RELIGIOUS LEADER ????..12 OTHER 13 (SPECIFY) FREPRO NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 206 From whom or where would you prefer to receive more information on this topic? SCHOOL TEACHER?.???...01 PARENTS/GUARDIANS?.??02 SIBLINGS?????????.03 OTHER RELATIVES?..???.04 FRIENDS/SCHOOL MATES.?..05 DOCTORS/HEALTH WORKER?????????...06 BOOKS/MAGAZINES??..??07 FILMS/VIDEOS?.?????...08 TV?????..???????.09 RADIO.???.???????10 DURBAR/COMMUNITY MEETINGS?????????11 RELIGIOUS LEADER????.12 OTHER 13 (SPECIFY) FINFSRP 207 Now think about relationships between boys and girls. What has been your major source of information on this topic? SCHOOL TEACHER????...01 PARENTS/GUARDIANS???02 SIBLINGS?????????.03 OTHER RELATIVES???..?.04 FRIENDS/SCHOOL MATES??05 DOCTORS/HEALTH WORKER??????????06 BOOKS/MAGAZINES??...??07 FILMS/VIDEOS?????..?...08 TV????????..????.09 RADIO?.???.?????.?10 DURBAR/COMMUNITY MEETINGS?????????11 RELIGIOUS LEADER ????.12 OTHER 13 (SPECIFY) FRELNPS 208 From whom or where would you prefer to receive more information on this topic? SCHOOL TEACHER????...01 PARENTS/GUARDIANS???02 SIBLINGS?????????.03 OTHER RELATIVES??..??.04 FRIENDS/SCHOOL MATES?...05 DOCTORS/HEALTH WORKER?????????..06 BOOKS/MAGAZINES?..???07 FILMS/VIDEOS????..??...08 TV???????????..?.09 FINFSRL 53 RADI.O???.???.???....10 DURBAR/COMMUNITY MEETINGS?????????11 RELIGIOUS LEADER ???.?12 OTHER 13 (SPECIFY) 209 CHECK Q.104 AND ASK ONLY FOR THOSE WHO HAVE BEEN TO SCHOOL Have you ever had a class or lesson in school on: a. The menstrual Cycle b. How pregnancy occurs c. Family Planning Methods d. Sexually Transmitted Diseases e. How boys and girls relate to each other f. Personal hygiene g. HIV/AIDS YES NO DK 1 2 9 1 2 9 1 2 9 1 2 9 1 2 9 1 2 9 1 2 9 NA????????????.?8 FSCLMC FSCLPG FSCLFP FSCSTD FSCGEN FSHYG FSHIVDS 210 Do you think schools should teach lessons about: a. Family planning, b. Prevention of sexually transmitted diseases (STDs) c. HIV/AIDS YES NO DK 1 2 9 1 2 9 1 2 9 FAPSCH FSCHPSTD F CHVADS 211 When during the menstrual cycle is a woman most likely to become pregnant? RIGHT BEFORE HER PERIOD??????????...1 DURING HER PERIOD????..2 RIGHT AFTER HER PERIOD??3 ABOUT HALF WAY BETWEEN HER PERIODS????????.4 ANYTIME DURING THE MONTH??????????....5 OTHER 6 (SPECIFY) DK/UNSURE??????.??...9 FPRGOC NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 212 Can a woman get pregnant the very first time that she has sex? YES????????????...1 NO??????????.???2 DK????????????.?9 FPREG 213 In your opinion, is there anything you can do or use to avoid getting pregnant? YES???????????..?..1 NO???????????..?2 DK?????????..??...9 PKNWN 217 YES NO PILL 1 2 INJECTION 1 2 CONDOM 1 2 OTHER MODERN METHODS 1 2 WITHDRAWAL 1 2 RHYTHM/PERIODIC ABST 1 2 PROLONGED ABSTINENCE 1 2 HERBS 1 2 NON-PENETRATIVE SEX 1 2 AVOID SEX 1 2 OTHER (SPECIFY) 1 2 214 What are the things you can do or use to avoid getting pregnant? (PROBE AND CIRCLE ALL MENTIONED) NA????????????8 FPILLPV FINJTPV FCDMPV FNOPLPV FWHDPV RPABTPV PRABTPV FHERBPV FNPENPV FAVIOD FOTHPV 215 Where can you obtain any of these methods? (For the Rhythm, Withdrawal, Prolonged YES NO HOSPITAL/CLINIC/HEALTH CENTRE 1 2 FHTLCTR 54 Abstinence, Non-penetrative sex, etc) ASK: How did you learn to use this method? (CIRCLE ALL MENTIONED) OUTREACH CLINIC 1 2 DOCTOR/HEALTH WORKER 1 2 TRADITIONAL HEALER 1 2 MARKET 1 2 CHEMICAL SHOP 1 2 DURBAR 1 2 FRIENDS/SCHOOL MATES 1 2 RELATIVES 1 2 PARTNER OBTAINS 1 2 OTHER (SPECIFY) 1 2 NA?????????????8 DK?????????????9 FOURCH FDHTHWK FTRADHL FMARKET HCHMSOP FDURBAR FREDMTES FRELTVES FPARTNE FOTHER YES NO PARENTS/GUARDIANS 1 2 SIBLINGS 1 2 OTHER RELATIVE 1 2 BOYFRIEND 1 2 FRIEND/SCHOOLMATE 1 2 TEACHER 1 2 DOCTOR/HEALTH WORKER 1 2 PASTOR 1 2 IMAM 1 2 OTHER 1 2 (SPECIFY) 216 If you wanted to find out more about ways to avoid getting pregnant who would you talk to? (PROBE ?ANYONE ELSE?? CIRCLE ALL MENTION ED) NA????????????..8 FTKPG FTKSIBL FTKORL FTKBYS FTFSMTE FTKTCH FTKNSE FTKPST FOTHIF FOTHIF1 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 217 Are there any persons with whom you can easily discuss sex-related matters? IF YES: Who are these people? PROBE: ANY OTHER PERSON? (CIRCLE ALL MENTIONED) YES NO NO PERSON TO DISCUSS 1 2 BROTHER 1 2 SISTER 1 2 AUNT 1 2 UNCLE 1 2 TEACHER 1 2 HEALTH WORKER 1 2 RELIGIOUS LEADER 1 2 FRIEND 1 2 SCHOOL MATE 1 2 PARENTS 1 2 GRAND PARENTS 1 2 SPOUSE/PARTNER 1 2 OTHER (SPECIFY) 1 2 NA??????????????8 FNOSXD FSXDBRO FSXDSIS FSXDUNT FSXDUNCL FSXDTECH FSXDHWK FSXRELDR FSXDFRED FSXDSMTE FSXDPRTS FSXDGDPT FSXDSPSE FSXDOTHR 218 Do you know of any reasons why pregnancy/childbirth should be avoided while you are a teenager? YES ......??????????.1 NO...???????????..2 DK???????????..9 FTENPG 220 YES NO MOTHER COULD DIE 1 2 CHILD COULD DIE 1 2 BABY COULD BE UNHEALTHY 1 2 MOTHER CAN?T CARE FOR CHILD 1 2 219 What are these reasons? (PROBE: ?ANYTHING ELSE?? CIRCLE ALL MENTIONED) FATHER CAN?T CARE FOR CHILD 1 2 FMUDIE FCHDIE FBYHTY FMUNCR FFHNCR 55 AFFECTS MOTHER/FATHER?S EDUCATION 1 2 WOMAN NOT MATURE 1 2 OTHER (SPECIFY) 1 2 NA???????????.?8 FAFFECT FWMATU FOTHRE 220 Are there any good things about having a child while you are a teenager? YES?????????????.....1 NO??????..?????..??..2 DK?????????????..9 FCHILD 301 221 What are the good things about having a child while you are a teenager? (PROBE: ?ANYTHING ELSE?? CIRCLE ALL MENTIONED) PROVE YOUR FERTILITY SHOW YOU?RE MATURED GETTING MARRIED EARLY HAVING A CHILD TO LOVE PEOPLE RESPECT YOU MOVING OUT OF PARENT?S HOUSE SOMEONE TO TAKE CARE OF YOU WHEN YOU ARE OLD OTHER (SPECIFY) NA???????...8 YES 1 1 1 1 1 1 1 1 NO 2 2 2 2 2 2 2 2 FPFERT FMATURE FMEARLY FCHLOVE FRESPECT FLHOME FSECURE FOTHRES SECTION 3: SEXUAL BEHAVIOR, PREGNANCY AND CONTRACEPTIVE USE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 301 Now I will like to talk to you about some personal information so we can better understand reproductive health. How old were you when you had sex for the first time? AGE?????????????? NEVER HAD SEX???????????.96 DON?T KNOW??????..?????....99 FFSEX 327 302 At the time you had sex for the first time was your sexual partner older or younger than you or about the same age as you? OLDER???????????..?1 YOUNGER?????????.?..2 SAME AGE??????????...3 NA?????????????.?8 DON?T KNOW??.???????9 FAGSXPT 303 How would you describe your relationship with that person at the time? HUSBAND??..???????01 BOYFRIEND???.?????.02 SCHOOL MATE.??????...03 OCCASSIONAL PARTNER??..04 SUGAR DADDY?...???.??..05 TEACHER??????..???....06 COUSIN/BROTHER??..???....07 STRANGER?????????. 08 OTHER 09 (SPECIFY) NA??????????????88 311 FTYPRL 304 What was the main reason you decided to have sex the first time? (Do not read list) TO SHOW LOVE TO MY PARTNER /IN LOVE????.???????.01 THREATENED/FORCED/RAPED ????????????.???.02 TRICKED/CONVINCED WITH MONEY OR GIFTS???????.03 SWEET TALKED BY MY PARTNER ?.??????????????..04 PRESSURE FROM PEERS?.???.05 TO FIND OUT WHAT IT WAS FRSEX 56 LIKE/EXPERIMENTING?????06 PROMISE OF MARRIAGE????.07 PREMARITAL SEX IS FASHIONBLE ???????????????...08 DESIRE SEX/AROUSED???...?..09 FUN/ENJOYMENT/PLEASURE?.?10 OTHER 11 (SPECIFY) REFUSED TO ANSWER?????12 NA??????????????88 DK??????????????99 305 When you had sex for the first time, did either you or your partner drink alcohol before you had sex? I DRUNK (MY PARTNER DID NOT).??..??????????..1 MY PARTNER DRUNK (I DID NOT) ???????????????...2 YES, WE BOTH DRUNK.???....?3 NO, NEITHER ONE OF US DRUNK?..?????????.......4 NA????????????.?....8 DK/CAN?T REMEMBER???..?...9 FSESALCO 306 When you had sex for the first time, did either you or your partner take drugs before you had sex? I TOOK DRUGS (MY PARTNER DID NOT)?.................................................1 MY PARTNER TOOK DRUGS (I DID NOT..?????????????..2 YES, WE BOTH TOOK DRUGS..?....3 NO, NEITHER ONE OF US TOOK DRUGS....???????????..4 NA??????????.??...?..8 DK/CAN?T REMEMBER?????..9 FSEXDRUG 307 The first time you had sex with your partner would you say (PROBE): A. You forced him to have sex B. He forced you to have sex C. You persuaded him to have sex D. He persuaded you to have sex E. We were both willing to have sex I FORCED HIM?????????1 HE FORCED ME????????..2 I PERSUADED HIM?.??????3 HE PERSUADED ME??.?.??.?4 BOTH WILLING???..?.????5 NA????.?.?????????8 FSXFRCI 308 And would you say it was planned or unplanned? PLANNED?????????..?.?1 UNPLANNED...?????????..2 NA?????...????????.?8 FSEXINT 309 Did you regret having intercourse on that first occasion? YES, REGRETTED?...?????.?.1 NO, NOT REGRETTED ??????2 NA??????????...?.???8 FRGTSEX NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 310 When you had sex for the first time, did you want to have sex at that time in your life, or would you have preferred to wait? WANTED TO HAVE SEX?????1 WANTED TO WAIT???????.2 NA??????????..????8 DK/CAN?T REMEMBER???.??9 FSXDLAY 311 At the time you had sex for the first time were you concerned that you might get pregnant? YES????????????.?..1 NO??????????????2 NA??????????????8 DK/CAN'T REMEMBER?????9 FPRGCNC 312 On that first time did you or your partner do anything to prevent a pregnancy? YES??????.???????.1 NO?..??????????..2 NA??????????..??....8 FPRVENT 314 313 What method did you use/What did you do? CONDOM????????.??01 PILL??????????.??.02 INJECTION???????.??.03 OTHER MODERN METHOD??.04 WITHDRAWAL??????.?..05 SAFE PERIOD????????..06 FPMTHD 57 OTHER 08 (SPECIFY) NA????????????..?88 314 On the first time you had sex were you ever concerned that you might contract the HIV virus or another sexually transmitted disease from your partner? IF YES, very or somewhat? VERY CONCERNED???????.1 SOMEWHAT CONCERNED????.2 NOT CONCERNED????????3 NA???????????????8 FADSTD 315 Did you do anything to reduce the risk of infection? YES?????????????..1 NO?????????????2 NA?????????????8 FSTDS 318 316 What did you do? Probe! USED CONDOMS????????..1 TOOK MEDICINES??????.?...2 OTHER 3 (SPECIFY) NA?????????????...?8 FPVSTD 317 Who decided on the method? Was it mainly your decision, your partner?s decision or a joint decision? MY DECISION???..????....1 PARTNER?S DECISION????....2 JOINT DECISION???????...3 NA??????????????8 FDECIDE 319 318 What is the main reason you or your partner did not use anything to prevent pregnancy or disease? DIDN?T EXPECT TO HAVE SEX THEN???????????..?01 NO KNOWLEDGE OF FP METHODS??????..??..?..02 WANTED TO HAVE A CHILD?.....03 WASN?T THINKING ABOUT IT??04 THOUGHT IT WAS BAD FOR MY HEALTH??????????..?05 DIDN?T KNOW WHERE TO GET METHOD??????????.?06 THOUGHT I COULDN?T GET PREGNANT??????????07 IT WAS MY PARTNER?S RESPONSIBILITY??????.?.08 PARTNER DID NOT WANT TO?..09 RELIGIOUS REASONS?????.10 PERCEIVED NO RISK?????..11 OTHER 12 (SPECIFY) NA??????.??????..?.88 DON?T KNOW????..???.????.99 FRPRVNT 319 Did you have sex during the last 3 months? YES????????.???..?...1 NO????????????..?.2 NO RESPONSE??????.?.?3 NA????????????.?..8 FLSTSX 327 320 During the last 3 months how many different people did you have sex with? NUMBER???????? NA????????????.?.88 DON?T KNOW/ NOT SURE???..99 FNOSXP 321 On the last occasion that you had sex did you or your partner do anything to avoid pregnancy? YES????????????......1 NO???????????..??.2 NA????????????..?.8 FPRGPVT 323 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 322 What did you do? PILL????..???.???..?.01 INJECTION??????.???.02 CONDOM??????????.03 OTHER MODERN METHOD??..04 WITHDRAWAL????????05 RHYTHM/PERIODIC ABST???06 PROLONGED ABSTINENCE .??.07 OTHER______________________ 08 FMETHD 324 58 (SPECIFY) NA?????????????..88 323 What is the main reason you or your partner did not use anything to prevent pregnancy? DIDN?T EXPECT TO HAVE SEX THEN??????????.??.01 NO KNOWLEDGE OF FP METHODS???????.??02 WANTED TO HAVE A CHILD??.03 WASN?T THINKING ABOUT IT?..04 THOUGHT IT WAS BAD FOR MY HEALTH??????????.....05 DIDN?T KNOW WHERE TO GET METHOD???????.06 THOUGHT I COULDN?T GET PREGNANT??????.?...??07 IT WAS MY PARTNER?S RESPONSIBILITY??..?.??.......08 PARTNER DID NOT WANT TO??09 BOTH DID NOT WANT TO???...10 RELIGIOUS REASONS?????...11 PERCEIVED NO RISK??????12 OTHER 13 (SPECIFY) NA?????????????....88 DON?T KNOW????????.?.99 FRPREVENT 324 On the last occasion that you had sex did you or your partner do anything to avoid STDs? YES?????????..????1 NO??????????.???..2 NA??????????.???..8 FSTDPVT 326 325 What did you do? USED CONDOM???...???......1 TOOK MEDICINES?????..?..2 OTHER 3 (SPECIFY) NA??????????????8 FMETHD1 326 What is the main reason you or your partner did not use anything to prevent STDs? DIDN?T EXPECT TO HAVE SEX THEN????????????..01 NO KNOWLEDGE OF FP METHODS??????????.02 WASN?T THINKING ABOUT IT?.03 THOUGHT IT WAS BAD FOR MY HEALTH?.........................................04 DIDN?T KNOW WHERE TO GET METHOD???????????.05 IT WAS MY PARTNER?S RESPONSIBILITY??????.....06 PARTNER DID NOT WANT TO?..07 BOTH DID NOT WANT TO?..?...08 RELIGIOUS REASONS????....09 PERCEIVED NO RISK?????..10 OTHER 11 (SPECIFY) NA??????????????88 DON?T KNOW?????????99 FPREVENT NOW I WANT TO ASK YOU ABOUT OTHER FORMS OF SEXUAL CONTACT THAT YOU MAY HAVE EXPERIENCED. 327 (CHECK Q.307): IF R HAS BEEN FORCED TO HAVE SEX SKIP TO 328 Some young people are forced to have sexual intercourse against their will by a stranger, a relative, a friend or an older person. Have you ever been forced to have sex against your will? YES??????????????1 NO??????????????.2 NA??????????????.8 FOCSEX 330 59 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 328 [REFER TO Q. 307 (IF R HAS BEEN FORCED) AND ASK 328, 329] Would you say this happens to you often, sometimes, or rarely? OFTEN???????????.?..1 SOMETIMES?????.?????2 RARELY????.???????..3 NA????????.??????8 FRGHSS1 329 Did you or the sexual partner do anything to avoid a pregnancy the last time you were forced to have sex? YES??????????????1 NO??????????????.2 NA??????????????.8 FPVPRGFS 330 Some young females are touched on the breast, buttocks, waist or some other part of the body when they do not want to be, by a stranger, a relative, a friend or an older person. Has this ever happened to you? YES??????????????1 NO???????..??????.2 NA???????..??????.8 FHASEX 332 331 Would you say this happens to you often, sometimes, or rarely? OFTEN????????????.1 SOMETIMES?????.????..2 RARELY???????????..3 NA??????????????8 FRGHSS 332 Some young people have ?occasional sex?, perhaps after a party or after drinking. Has this ever happened to you? YES?????????????1 NO?????????????.2 NA?????????????.8 FOCCSEX 336 333 Would you say this happens to you often, sometimes, or rarely? OFTEN????????????..1 SOMETIMES?????.????..2 RARELY???????????..3 NA?????????????....8 FRGOSX 334 Did you or your sexual partner do anything to avoid a pregnancy the last time you had occasional sex? YES????????..????.?1 NO????..?????????..2 NA?????????????.?8 FOCSPRV 335 Did you or your sexual partner do anything to avoid an STD the last time you had occasional sex? YES??????????????1 NO??????????????.2 NA??????????????.8 FOCSTD 336 Some young people receive money, gifts or other favours in exchange for sex. Have you ever received anything in exchange for sex? YES??????????????1 NO??????????????.2 NA??????????????.8 DK/CAN?T REMEMBER?????.9 FEXCSEX 340 337 Would you say this happens to you often, sometimes, or rarely? OFTEN????????????..1 SOMETIMES?????????...2 RARELY???????????...3 DK??????????????.4 NA??????????????.8 FRGOEXS X 338 Did you or your sexual partner do anything to avoid a pregnancy the last time you received money, gifts or favours in exchange for sex? YES??????????????1 NO??????????????.2 DK??????????????.3 NA??????????????.8 FPVPRG 339 Did you or your sexual partner do anything to avoid an STD the last time you received money, gifts or favours in exchange for sex? YES???????????..??.1 NO??????????????2 DK??????????????3 NA??????????????8 FPVSTDS 340 Have you ever given money or gifts to someone to get that person to have sex with you? YES????????????..?1 NO??????????????2 NA??????????????8 DK/CAN?T REMEMBER?????9 FEXCSEX2 341 REVIEW 301, 327, 332, 336, 340 AND TICK APPROPRIATE BOX Respondent has not Respondent has reported sexual reported sexual Intercourse Intercourse FNOSEX 343 342 I want to make certain that I have the correct information. Have you ever had sexual intercourse in your whole life? YES???????????????1 NO??????????????2 NA???????????????.8 FEVSEX 360 1 2 60 343 Now I would like to talk to you about pregnancy Have you ever been pregnant? YES????????????1 NO????????????.2 NOT SURE?????????9 NA????????????.8 FPREG 356 344 How old were you when you first became pregnant? AGE IN YEARS NA???????????????...88 DK???????????????...99 FAGEPRE G NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 345 Did your first pregnancy affect your life in any way? YES???????????????1 NO?????????????..2 NA?????????????..8 FPRGFCT 347 346 How did it affect your life? STOPPED SCHOOL??????..?.....1 FORCED TO MARRY EARLY?????2 STOPPED APPRENTICESHIP TRAINING?.???????????.3 AFFECTED HEALTH ????????4 OTHER 5 (SPECIFY) NA??????????????..?.8 FRPGFCT 347 At the time you first became pregnant, were you using anything or trying in any way to delay or avoid getting pregnant? YES?????????????..?1 NO??????..?????..?..2 NA?????????????..?.8 FUFPPREG 349 348 What were you using or doing to delay or avoid getting pregnant? PILL?????????????.?..01 INJECTION .???????????..02 CONDOM?.???....???????.03 OTHER MODERN METHOD..?..?..?.04 WITHDRAWAL??????????05 RHYTHM/PERIODIC ABSTINENCE/ SAFE PERIOD???????????06 PROLONGED ABSTINENCE????.07 HERBS??????????????08 NON-PENETRATIVE SEX??????09 OTHER 10 (SPECIFY) NA????...?.?????????...88 DK??..?????????????.99 FMETHUS E 349 Are you pregnant now? YES???????????????.1 NO???????????????..2 NA???????????????..8 UNSURE/DON'T KNOW??????.9 FPRGCUR 350 Thinking of the most recent pregnancy (i.e. the last time you became pregnant), did you want to be pregnant at that time? YES?????????.??.???..1 NO??????.?????????2 NA??????.?????????8 FPRGPF 351 What happened to this pregnancy? (i.e. The most recent pregnancy) CURRENTLY PREGNANT????.?.1 ABORTED????????????.2 MISCARRIAGE??????????3 STILL BIRTH???????????4 LIVE BIRTH?????????.??.5 NA?????????????.??.8 FPRGOTC 352 Have you ever had any live born child? IF NO PROBE: Include any baby who cried or showed signs of life but survived only a few hours or days? YES???????????????...?1 NO?????????????????..2 NA???????????????.??.8 FBORN 354 353 How many living children do you have, including those who do not stay with you? (Please include children who were born alive but have died) CHILDREN ??????????. IF NONE WRITE 00 FCHOM 61 NA?????????????.?.88 354 Have you ever had a pregnancy that did not end in a delivery? YES??????????????..??.1 NO?????????????????..2 NA?????????.??????.?..8 FDELIVRY 356 355 How many of such pregnancies have you had NUMBER??????????? NA??????????????.....88 FNODELV 356 Have you ever used anything or tried in any way to delay or avoid getting pregnant? YES??????????????.??..1 NO?????.????????................2 NA?????...??????????..?8 FPUSED 401 357 Are you currently doing anything to delay or avoid getting pregnant? YES ?????????????????.?1 NO ???????????????...............2 NA (CURRENTLY PREGNANT)??????...?....8 FCONSTAT 401 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 358 What method are you using (or what are you doing) to delay or avoid getting pregnant? PILL????????????..?....01 INJECTION ????????????02 CONDOM???????..?????..03 OTHER MODERN METHODS???.....??04 WITHDRAWAL???????????05 RHYTHM/PERIODIC ABSTINENCE / SAFE PERIOD?????...?..????...06 PRO LONGED ABSTINENCE???????07 HERBS??...???????..????.08 NON-PENETRATIVE SEX??.???.??.09 OTHER 10 (SPECIFY) NA????..???????????88 DK????????????????99 FCCURU E 359 Is it easy or difficult for you to obtain this method? EASY?????.???????.................? 1 DIFFICULT???.??????????.?. 2 NA????????????????..?? 8 DK????????????????9 FDIFCULT 401 THE NEXT SET OF QUESTIONS (360-364) SHOULD BE ASKED OF THOSE WHO HAVE NEVER EXPERIENCED SEXUAL INTERCOURSE. CHECK Q. 301 360 Some Young people may have various reasons for not having sex. What are some of the reasons why you have not had sexual intercourse? (READ OUT) A. I have not thought about sex B. I don?t feel ready to have sex C. I have not had the opportunity to have sex D. I think that sex before marriage is wrong E. I am afraid of getting pregnant F. I am afraid of getting HIV/AIDS or another sexually transmitted infection. G. My parents disapprove of sex before marriage YES NO 1 2 1 2 1 2 1 2 1 2 1 2 1 2 NA?????????.???.?8 FNSXTHS FNREAD Y FNOPPT FPRESX FAFRPG FHIVDS FPDISAG 361 Do you feel any pressure from others to have sex? YES??????????????1 NO??????????..????...2 NA??????????..????...8 FSXPRSU 363 362 From whom do you feel the greatest pressure to have sex? FRIENDS OF SAME SEX??..??..01 FRIENDS OF OPPOSITE SEX???02 PARENTS???????????.03 OTHER RELATIVES??.???.?.04 FPSXPRS 62 WORK COLLEAGUES????.?..05 PARTNER/SPECIAL FRIEND..??..06 SCHOOL MATES????..???...07 TEACHERS???..??????.?08 OTHER 09 (SPECIFY) NA?????????????.?88 363 Have you ever received any encouragement or support to abstain from sex until marriage? YES???????.????????...1 NO????????..?????.??.... 2 NA????????????????.... 8 FABSTAI N 401 364 From whom do you receive the greatest encouragement/support to abstain from sex? FRIENDS OF SAME SEX????.....01 FRIENDS OF OPPOSITE SEX???..02 PARENTS????????.??..?03 OTHER RELATIVES??.?????04 WORK COLLEAGUES??????..05 PARTNER/SPECIAL FRIEND???..06 SCHOOL MATES????????..07 TEACHERS????.???.???..08 OTHER 09 (SPECIFY) NA????????.??????..88 FSABSTN SECTION 4: STDS/HIV/AIDS KNOWLEDGE & ATTITUDES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 401 Do you know of any disease a person can get from having sex? YES?????..??????????..1 NO????????????????..2 FHSTDS 410 YES N O SYPHILIS 1 2 GONORRHEA 1 2 HIV/AIDS 1 2 GENITAL WARTS 1 2 CHANCRIOD 1 2 HERPES 1 2 HEPATITIS B 1 2 CHLAMYDIA 1 2 TRICHOMONIASIS 1 2 OTHER 1 2 (SPECIFY) NA???????????????...8 402 Which diseases can people get from having sex? PROBE: ANY OTHER? (CIRCLE ALL MENTIONED) DK???????????????...9 FSYPLIS FGONOR FHIV/AD FGENIWT FCHANRD FHEPES FHEPATIS FCHLAMD FTRICHS FOTHER 403 Can a person get any of these diseases from having sex the first time? YES???????????????.1 NO??????.?????????..2 NA??????.?????????..8 DK??????..?????????..9 FSXSTD YES NO ABNORMAL VAGINAL BLEEDING 1 2 ABNORMAL VAGINAL DISCHARGE 1 2 GENITAL ITCHING 1 2 GENITAL LESIONS/SORES 1 2 LOWER ABDOMINAL PAIN 1 2 PAIN DURING INTERCOURSE 1 2 404 What signs and symptoms suggest that a person has an STD? PROBE: ANY OTHER? (CIRCLE ALL MENTIONED) URETHRAL DISCHARGE 1 2 FVGBLED FVGDCHE FGNIITCH FGENILES FABDOPIN FSXPAIN FUREDCH FPAINURI FWEGTLS FOTHERS 63 BURNING PAIN ON URINATION 1 2 LOSS OF WEIGHT 1 2 OTHER (SPECIFY) 1 2 NA????????????????.8 DK?????????????.???9 YES NO NEVER HAD A SYMPTOM 1 2 ABNORMAL VAGINAL BLEEDING 1 2 ABNORMAL VAGINAL DISCHARGE 1 2 GENITAL ITCHING 1 2 GENITAL LESIONS/SORES 1 2 LOWER ABDOMINAL PAIN 1 2 PAIN DURING INTERCOURSE 1 2 URETHRAL DISCHARGE 1 2 BURNING PAIN ON URINATION 1 2 LOSS OF WEIGHT 1 2 OTHER (SPECIFY) 1 2 405 Have you ever had any of these symptoms? (READ LIST) IF NEVER HAD A SYMPTOM SKIP TO 409 (CIRCLE ALL MENTIONED) NA????????????????8 FNSYMP F405ABVGB F405ABVGD F405GNIT F405GENI F405ABDO F405SXPA F405URE F405PAIN F405WEG F405OTH DK????????????????.9 406 The last time that you had any of these symptoms, did you seek treatment? YES????????????????...1 NO?????????????????.2 NA????????????????.....8 FTREAT 408 407 Where did you seek treatment? CHEMICAL SELLER/DRUG STORE???????????.?.. 01 HOSPITAL/CLINIC/HEALTH CTRE?????????????.02 DOCTOR/NURSE/MIDWIFE???..03 OTHER HEALTH WORKER?????.04 HERBALIST???????????..05 SOOTHSAYER??????????..06 SELF TREATMENT??.??????..07 OTHER__________________________ 08 (SPECIFY) NA??????????????..?8.8 DK??????????????..?.99 FPLACTR 409 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 408 What was the main reason you did not seek treatment? SERVICES TOO FAR AWAY/INACCESSIBLE???????.?..0 1 CANNOT AFFORD SERVICES??.???...02 DON?T KNOW WHERE TO GO FOR SERVICES?????..???...????.....0 3 AFRAID OF KNOWING THE RESULTS???................................................0 4 IT IS EMBARRASSING?????.???....05 DID NOT THINK IT WAS AN STD????...06 SYMPTOMS DISAPPEARED???????07 DRUGS NOT AVAILABLE????.???...08 OTHER FRESTR 64 09 (SPECIFY) NA?????????????..?..???. 88 YES N O CHEMICAL SELLER/DRUG STORE 1 2 HOSPITAL/CLINIC/HEALTH CENTRE 1 2 DOCTOR/HEALTH WORKER 1 2 HERBALIST 1 2 SELF TREATMENT 1 2 OTHER (SPECIFY) 1 2 NA????????????????.8 409 If your friend needed treatment for a sexually transmitted disease, where could he or she obtain such treatment? PROBE Any other places? (CIRCLE ALL MENTIONED) DK??????????????.??9 F409CDG F409HCTR M409DOC F409HERB F409SLTRT F4090THR YES N O RADIO 1 2 TV 1 2 NEWSPAPER/MAGAZINES 1 2 PAMPHLETS/POSTERS 1 2 HEALTH WORKERS 1 2 CHURCH/MOSQUE 1 2 SCHOOL TEACHERS 1 2 COMMUNITY MEETINGS 1 2 FRIENDS/RELATIVES 1 2 WORKPLACE 1 2 CLUBS/GROUPS/ORGANISAT IONS 1 2 NO KNOWLEDGE OF AIDS 1 2 OTHER (SPECIFY) 1 2 410 How did you first hear about HIV/AIDS? (CIRCLE ALL MENTIONED) IF R HAS NEVER HEARD OF AIDS SKIP TO NEXT SECTION NA????????????????.8 F410RADI F410TV F410NEWS F410POST F410HWOR F410CHUR F410SCHT F410COMM F410FREN F410WPLA F410CLGPS F410NKNHD F410OTHE DK/CAN?T REMEMBER???????.9 YES N O SEX WITH INFECTED PERSON 1 2 INJECTION WITH UNSTERILISED NEEDLES 1 2 DURING PREGNANCY AND DELIVERY 1 2 THROUGH BREAST MILK 1 2 FROM TRANSFUSIONS WITH INFECTED BLOOD 1 2 SHARING RAZORS 1 2 SHAKING HANDS WITH INFECTED PERSON 1 2 MOSQUITO BITES 1 2 SUPERNATURAL 1 2 OTHER (SPECIFY) 1 2 NA?????????????...??..8 411 How does one get HIV/AIDS? (CIRCLE ALL MENTIONED) DK????????????????.9 F411SEX F411INJE F411PGDV F411MILK F411BLOD F411RAZO F411HNDS F411MSQB F411SPNT F411OTHE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO YES N O SEVERE WEIGHT LOSS 1 2 THINNING OF HAIR 1 2 PERSISTENT DIARRHOEA 1 2 PERSISTENT COUGH 1 2 412 What are the possible signs and symptoms of HIV/AIDS? (CIRCLE ALL MENTIONED) DIFFICULTY IN SWALLOWING 1 2 F412LWEI F412HAIR F412DIAR F412TB F412SWAL F412SKINF F412ANEA 65 SKIN CONDITION 1 2 ANAEMIA 1 2 PERSISTENT FEVER 1 2 MANY DIFFERENT INFECTIONS 1 2 OTHER (SPECIFY) 1 2 NA??????????????.?..8 DK??????????????.?..9 F412FVER F412DIFFETS F412OTHE YES NO ABSTAIN FROM SEX/NO SEX 1 2 HAVE ONE SEXUAL PARTNER 1 2 USE CONDOMS 1 2 USE STERILISED SYRINGES/NEEDLES 1 2 NO SEX WITH PROSTITUTES 1 2 AVOID BLOOD TRANSFUSION 1 2 OTHER (SPECIFY) 1 2 NA???????????????8 413 How can people protect themselves from getting HIV infection? (CIRCLE ALL MENTIONED) PROBE: IS THAT ALL? IS THERE ANY OTHER MEANS? DK??????????????....9 F413ASEX F413SPAR F413COND F413SSYR F413SPROS F413BTRA F413OTHE YES NO ABSTAIN FROM SEX 1 2 USE CONDOMS 1 2 HAVE ONLY ONE SEX PARTNER 1 2 AVOID SEX WITH PROSTITUTES 1 2 NON-PENETRATIVE SEX 1 2 OTHER (SPECIFY) 1 2 NA????????????????.8 414 What does ?safe sex? mean to you? (CIRCLE ALL MENTIONED) DK????????????????.9 F414ABS F414COD F414ONEP F414AVDP F414NPEN F414THER 415 Is it possible for a healthy looking person to have the HIV virus? YES?..??????????..???...1 NO????????????????..2 NA????????????????..8 DK????????????????..9 FAIDSK1 416 Do you think your chances of getting HIV/AIDS are small, moderate, great, or that you have no risk? SMALL??????????????...1 MODERATE.????????????.2 GREAT???????.???????..3 NO RISK AT ALL???..???????4 HAS AIDS???.??????????.5 NA????????????????..8 DON?T KNOW???????????..9 FHIVRISK 417 Has your knowledge of HIV/AIDS influenced or changed your decisions about having sex or your sexual behavior? IF YES, PROBE: In what way? (CRICLE ALL MENTIONED) YES NO DID NOT START SEX 1 2 STOPPED ALL SEX 1 2 STARTED USING CONDOMS 1 2 RESTRICTED SEX TO ONE PARTNER 1 2 REDUCED NUMBER OF PARTNERS 1 2 STOPPED SEX WITH PROSTITUTES 1 2 OTHER 1 2 NO CHANGE IN SEXUAL BEHAVIOR 1 2 NA??????????????....8 DK??????????????....9 M418NOSX M418SXSTP M418CDMU M418ONPN M418RDPTS M418SXPRO M418OTHE M418NOCH 66 418 Do you know of anyone who is suffering from or has died of HIV/AIDS? YES?????????.?????..?1 NO??????.??????????2 NA?????.???????????8 FKPSAIDS NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 419 In the past year have you discussed STD/AIDS prevention with anyone? YES???????????????...1 NO?????????????.??2 NA?????????????.??8 FDISADS 421 420 With whom did you discuss STD/AIDS prevention? PROBE BY ASKING ?ANYONE ELSE?? (CIRCLE ALL MENTIONED) HUSBAND/PARTNER FATHER MOTHER SISTER BROTHER OTHER RELATIVE FRIEND/SCHOOL MATE HEALTH WORKER SCHOOL TEACHER RELIGIOUS LEADER OTHER (SPECIFY) NA ??????? YES 1 1 1 1 1 1 1 1 1 1 1 NO 2 2 2 2 2 2 2 2 2 2 2 8 FDISHUS FDISDAD FDISMOM FDISSIS FDISBRO FDISREL FDISFRI FDISHWK FDISTEA FDISRLE FDISOTH 421 Which of these is of greater concern to you; getting HIV/AIDS or becoming pregnant? GETTING HIV/AIDS?????.???..?.?1 GETTING PREGNANT?????????...2 DK??????????????????. ..3 NA?????????????????.? ..8 FPRGAIDS SECTION 5: SEXUALITY & GENDER NORMS NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO Young people have various views about relationships. I will read out some of these views to you. For each one, (in 501-521) please tell me whether you agree or disagree? 501 It?s alright for unmarried boys and girls of my age to have sex. AGREE??????????1 DON?T KNOW/NOT SURE?...2 DISAGREE?????.???.3 FDATES 502 It?s alright for boys and girls of my age to kiss, hug and touch each other. AGREE????????.??1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FROMNC 503 A girl of my age cannot refuse if her boyfriend asks her for sex? AGREE??????????.1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FBYFDSX 504 A girl of my age cannot refuse if a man who has already given her a gift ask her for sex? AGREE??????????1 DON?T KNOW/NOT SURE?...2 DISAGREE?????.???.3 FNGTSEX 505 Sometimes a boy has to force a girl to have sex if he loves her. AGREE??????????1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FFORSEX 506 A boy will not respect a girl who agrees to have sex. AGREE??????????1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FCHEAP 507 Most girls who have sex before marriage regret it afterwards. AGREE??????????.1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FRGRSEX 508 A boy and a girl should have sex before they marry to see whether they are suited to each other. AGREE??????????1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FPREMSX 509 A girl stops growing after she has had sex for the first time AGREE??????????1 DON?T KNOW/NOT SURE?...2 DISAGREE?????.???.3 FGROW 510 Girls should remain virgins until they marry. AGREE??????????1 FVRGINS 67 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 511 It is sometimes justifiable for a boy to beat his girlfriend. AGREE??????????.1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FVIOLCE 512 Most of my friends who have sex with someone use condoms regularly. AGREE??????????1 DON?T KNOW/NOT SURE?...2 DISAGREE????????.3 FCONDOM 513 I am confident that I can insist on condom use every time I have sex. AGREE??????????1 DON?T KNOW/NOT SURE?..2 DISAGREE????????.3 FCNFICDM 514 I would never contemplate having an abortion myself or for my friend AGREE??????????1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FABORT 515 It is mainly the girl?s responsibility to ensure that contraception is used regularly AGREE??????????1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FCNTRES 516 I feel I know how to use a condom properly AGREE??????????.1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FCNTUSE 517 I would refuse to have sex with someone who is not prepared to use a condom AGREE??????????.1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FRFSEXC 518 I think that you should be in love with someone before having sex with him AGREE??????????.1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FLVESEX 519 Men need sex more frequently than women. AGREE??????????1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FMLFGSX 520 Most of my friends have had sexual intercourse AGREE??????????.1 DON?T KNOW/NOT SURE??2 DISAGREE??????.??.3 FPEESEX 521 Many of my friends have had an abortion AGREE???????.???1 DON?T KNOW/NOT SURE??2 DISAGREE????????..3 FABORT1 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 522 What do you think is the ideal age for a girl to start having sex? AGE????????. ?? NA???????????.88 DON'T KNOW??????.99 FSXAGE1 523 What do you think is the ideal age for a boy to start having sex? AGE?????? ?.. NA??????????.88 DON'T KNOW?????.99 FSXAGE2 524 How old should a girl be before marrying? AGE????????. ?? NA???????????.88 DON'T KNOW????.??.99 FIDAGEM1 525 How old should a boy be before marrying? AGE???????. NA???????????.88 DON'T KNOW?????.?.99 FIDAGEM2 526 Do you approve of unmarried young people using family planning methods? YES ????????????1 NO.????????????.2 DK.????????????.9 FPAPUM 527 Do you approve of married couples using family planning methods? YES...???????????.1 NO....???????????..2 DK....???????????..9 FAPROVCM 68 528 Do you think it is easy or difficult for unmarried young people in this community to obtain contraceptives? EASY??????????...1 DIFFICULT?????????2 DK????????????9 531 FACESS 531 529 Why is it difficult for unmarried young people to obtain contraceptives? NO MONEY????????...01 DIFFICULT TO FIND???.??02 PROVIDERS/SELLERS DISAPPROVE??????.?..03 PARENTS DISAPPROVE????04 COMMUNITY DISAPPROVES .??????????...??.05 RELIGIOUS LEADERS DISAPPROVE ????.........................................06 SOCIAL DISAPPROVAL/ SHYNESS??????????...07 OTHER 08 (SPECIFY) NA???????????...88 DK.??...?????????99 FROBTFPD YES NO IMPROVE ECONOMIC STATUS OF YOUTH 1 2 REDUCE COST OF CONTRACEPTIVES 1 2 INCREASE SUPPLY POINTS 1 2 EDUCATE PUBLIC ON REPRODUCTIVE HEALTH 1 2 TRAIN YOUTH DISTRIBUTORS 1 2 CHANGE ATTITUDE OF FP PROVIDERS 1 2 OTHER (SPECIFY) 1 2 NOTHING?????????.7 530 What do you think should be done to make it less difficult for unmarried people in this community to obtain contraceptives? (CIRCLE ALL MENTIONED) NA??????????..??8 F530ESTA F530SUBS F530ACES F530RETR F530NTH F530CHAT F530OTHE 531 In your opinion, do you think discussing family planning with people of your age encourages them to have sex? YES????????????..1 NO??????.??????..2 DK???.?????????..9 FVFPFLIR SECTION 6: HEALTH-SEEKING BEHAVIOUR NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO NOW I WOULD LIKE TO ASK YOU A FEW QUESTIONS A BOUT HEALTH CARE. 601 In the past 12 months have you ever visited a hospital, health centre or CHC to receive services on a health problem? YES??????????????1 NO.????????????.2 FHOSPVIS 602 In the last six months, have you suffered from any health problem? YES???????????????1 NO?????????????..2 NA?????????????..8 FHPROB 613 603 What was the main problem? MALARIA?????????.... 01 FEVER???????????..02 COUGH.??????????....03 DIARRHOREA????????...04 SKIN CONDITION?????..?...05 STDS???????????....06 INJURIES??????????..07 PREGNANCY RELATED CONDITIONS?????????.08 OTHER 09 (SPECIFY) NA????????????. 88 MHPRO 69 DK?.???????????.99 604 Did you seek care for this problem during the six months period? YES????????????..1 NO???????????..?2 NA????????????...8 FVHOS6M T 612 605 What type of facility did you visit when you had the health problem, modern or a traditional facility? MODERN??????????...1 TRADITIONAL?????????2 SELF TREATMENT???????.3 OTHER 4 (SPECIFY) NA?????????????.8 DON?T KNOW?????????9 FFACVIS 612 606 How many times have you visited a hospital/health centre/CHC with this problem during the last six months? NUMBER OF TIMES???. NA????????????.88 DK?.???????????.99 FNTVHOS P 607 In your opinion, did you receive adequate services or information on this problem? YES..??...??????.??.1 NO????????????...2 NA????????????...8 DK???????????...9 609 FVHOSCA R 609 608 What would have made the services adequate? (CIRCLE ALL MENTIONED) YES NO FRIENDLY ATTITUDES OF HEALTH WORKERS 1 2 FASTER PROCESS IN ATTENDING TO PATIENTS/CLIENTS 1 2 AVAILABILITY OF A DOCTOR 1 2 MORE HEALTH WORKERS TO ATTEND TO PATIENTS/CLIENTS 1 2 HEALTH WORKERS PATIENTLY LISTENING TO COMPLAINTS 1 2 AVAILABILITY OF PRESCRIBED DRUGS/METHODS 1 2 ADEQUATE EQUIPMENT 1 2 OTHER (SPECIFY) 1 2 NA????????????.8 DK????????????..9 FATTI FFAST FDOCT FDOCT FPATIEN FDRUMHS FEQUIP FOTHER 609 Did you feel comfortable enough to ask questions? YES???????????????.1 NO..???????????????.2 NA????????????????8 FHSCNFT 611 610 Were the questions you asked answered adequately? YES????????????............... 1 NO????????????????. 2 NA?.???????????????. 8 FSATISF NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 611 Was there enough privacy at the facility? YES???????????????. ?1 NO????????????????. .2 NA????????????????. ..8 FPRIVATE 613 70 612 Why did you not visit a hospital, clinic or a CHC with this problem? LACK OF FUNDS?????..?..1 NOT SERIOUS??????..?...2 TOO FAR?????????......4 SHY/EMBARRASSED??..?...?5 OTHER 6 (SPECIFY) NA?????????????.8 FHYVISIT 613 Sometimes people have pain or unusual discharge/itching from the private part or the private part don?t feel normal. Have you ever suffered from an infection in your private part? YES????????????.?1 NO??????????????..2 NA???????????.8 FINFECTPP 701 614 Who did you first discuss this problem with? PARENTS/GUARDIAN?????.01 SIBLINGS???????????.02 OTHER RELATIVE ???????.03 BOYFRIEND??????????.04 TRADITIONAL HEALER?????.05 NURSE/DOCTOR????????..06 FRIEND/SCHOOL MATE??.???07 NO ONE????????..????.08 OTHER 09 (SPECIFY) NA?????????????...88 FPERDISC 615 Did you obtain treatment? YES??.?????????????1 NO??????.?????????..2 NA???????..????????.8 617 FSTDCURE 616 What was the main reason you did not obtain treatment? COULD NOT AFFORD?????..1 WAS DENIED BY PROVIDER???2 WAS TOO EMBARRASSED ???...3 DIDN?T THINK IT WAS IMPOR???????.?????4 SYMPTOMS DISAPPEARED?..??.5 OTHER 6 (SPECIFY) NA?????????????8 FNSTDCUR 618 617 Where did you obtain treatment? DRUG STORE?????????..1 FROM A FRIEND????????.2 HOSPITAL??????????..3 CLINIC/HEALTH CENTRE?????4 TRADITIONAL HEALER?????..5 PRIVATE PRACTITIONER?????6 OTHER (SPECIFY) 7 NA?????????????8 FPSTDCUR 618 Are you currently suffering from any infection in your private part? YES....?????.??????1 NO.....???.????????.2 REFUSED TO ANSWER ......????3 NA?????????.? ?? 8 DON?T KNOW.....???.????.9 FINFECT 701 619 Can you describe the infection you have? ULCER/SORE ON PRIVATE PART?????????..?.....1 GENITAL DISCAHRGE?.???2 ITCHING IN PRIVATE PART??3 BURNING PAIN DURING URINATION.????????...4 VAGINAL BLEEDING?????5 OTHER_____________________ 6 (SPECIFY) NA???????????? ?8 FNMEINF SECTION 7: TIME USE, COMMUNITY CONCERNS AND EXPOSURE TO MEDIA 71 NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO YES NO PERFORMING HOUSEHOLD CHORES 1 2 HELPING OUT WITH MY SIBLINGS 1 2 WORKING TO EARN AN INCOME 1 2 HELPING MY PARENTS ON THE FARM 1 2 HELPING MY PARENTS IN THEIR BUSINESS 1 2 DOING NOTHING/IDLING 1 2 ATTEND SCHOOL 1 2 701 How do you spend a normal day? DO NOT READ LIST. PROBE (CIRCLE ALL MENTIONED) OTHER (SPECIFY) 1 2 FNORCHO FNORHEL FNORINC FNORHEP FNORHEB FNORNOT FNORMSC FNOROTH YES NO READ NOVELS /MAGAZINES 1 2 STUDY 1 2 WATCH TELEVISION 1 2 LISTEN TO THE RADIO/MUSIC 1 2 WATCH MOVIES 1 2 GET TOGETHER WITH FRIENDS 1 2 GO TO A SOCIAL CENTRE 1 2 GO OUT WITH MY BOYFRIEND 1 2 DRINK ALCOHOL/SMOKE 1 2 PLAY WITH MY CHILDREN 1 2 RELAX WITH MY HUSBAND 1 2 VISIT FAMILY 1 2 CHURCH ACTIVITIES 1 2 NOTHING 1 2 702 What do you like to do in your leisure time/when you are not engaged? DO NOT READ LIST. PROBE: Anything else? (CIRCLE ALL MENTIONED) OTHER (SPECIFY) 1 2 FLEIREAD FLEISTUD FLEIWTV FLEIRADI FLEIMOVI FLEIFREN FLEICENT FLEIBFRE FLEIALCO FLEIPCHN FLEIHUSB FLEIVFAM FLETCH FLEINOTH FLEIOTHE YES NO MARKET PLACE 1 2 CHURCH/MOSQUE 1 2 SCHOOL 1 2 WEDDING/ FUNERALS 1 2 BARS/DRINKING PLACES 1 2 AT THE BOREHOLE 1 2 AT MY HOME 1 2 AT MY FRIENDS HOME 1 2 AT MOVIE/VIDEO HOUSE 1 2 AT THE SOCIAL CENTRE 1 2 703 Where do you usually meet your friends of the same sex? DO NOT READ LIST. PROBE: Anywhere else? (CIRCLE ALL MENTIONED) NO FRIENDS OF SAME SEX 1 2 FMSSMARK FMOQCHU FMSCHOOL FMSWEDNG FMBRDRKSP FMSBRHL FMSSFHOM FMFRNHME FMSSMOVI FMSSCTR FMNOFRNS FMSSOTHE 72 OTHER (SPECIFY) 1 2 NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO YES NO MARKET PLACE 1 2 CHURCH/MOSQUE 1 2 SCHOOL 1 2 WEDDING/FUNERALS 1 2 BARS/DRINKING PLACES 1 2 AT THE BOREHOLE 1 2 AT MY HOME 1 2 AT MY FRIENDS HOME 1 2 AT MOVIE/VIDEO HOUSE 1 2 AT THE SOCIAL CENTRE 1 2 NO FRIENDS OF THE OPPOSITE SEX 1 2 704 Where do you usually meet with your friends of the opposite sex? DO NOT READ LIST. PROBE: Anywhere else? (CIRCLE ALL MENTIONED) OTHER (SPECIFY) 1 2 FMOSMARK FMOSCHU FMOSCHOOL FMOSWEDD FMOSBAR FMOSBORE FMOSHOME FMOSFHOM FMOSOVI FMOSOCIAL FMOSNONE FMOSOTHER YES NO NONE 1 2 DEBATING/DRAMA CLUB 1 2 RELIGIOUS GROUP 1 2 POETRY/LITERATURE CLUB 1 2 GIRL GUIDES/BOY SCOUTS 1 2 TRADITIONAL DANCE/DRUMING CLUB 1 2 SPORTS CLUB 1 2 MUSIC GROUP 1 2 YOUTH GROUP 1 2 AGRICULTURAL GROUP 1 2 INCOME GENERATING 8GROUP 1 2 705 What clubs, associations/social groups do you belong to? DO NOT READ LIST. PROBE: Any other? (CIRCLE ALL MENTIONED) IF NONE SKIP TO 707 OTHER (SPECIFY) 1 2 F705NONE F705DEBA F705RELG F705POET F705SCGDS F705DANC F705SPOR F705MUSI F705YOUT F705AGRI F705INCO F705OTHE 706 How often are you involved in the activities of the group(s) to which you belong? ONCE A WEEK????.?????1 MORE THAN ONCE A WEEK???.2 ONCE A MONTH??...?????.. 3 2-3 TIMES A MONTH???...???4 RARELY???..????????..5 OTHER 6 (SPECIFY) NA?????????..?????8 FGRPINVO 707 And now I have some questions about your social activities. In the last month did you go to clubs, parties, funerals, movies etc? IF YES. How many times? RECORD 00 IF NONE NUMBER OF TIMES NA??????????????88 NEV??????.???????96 DK/CAN'T REMEMBER?????99 FSOC 708 Do you drink alcohol? IF YES. On how many days in the last month did you drink alcohol? RECORD 00 IF R HAS NOT DRUNK ALCOHOL IN THE LAST MONTH NUMBER OF DAYS NA?????????????...88 NEVER???..????????.96 DK/CAN'T REMEMBER??.????.99 FALCOH 73 709 Do you smoke cigarettes or tobacco? IF YES. How many have you smoked in the last 7 days? RECORD 00 IF R HAS NOT SMOKED IN THE LAST 7 DAYS NUMBER OF CIGARETTES NA?????????..?????..88 NEVER???????????..?...96 DK/CAN'T REMEMBER??????.99 FSMOKE 710. In every community people tend to face some problems. I want to know about the problems that young people in this community face. What are some of the problems that young people in your community face? (CIRCLE (1) FOR EACH PROBLEM MENTIONED SPONTANEOUSLY, (PROBE BY ASKING ?ANYTHING ELSE?) THEN PROCEED TO READ OUT EACH PROBLEM NOT MENTIONED SPONTANEOUSLY AND CIRCLE (2) IF R AGREES IT IS A PROBLEM, CIRCLE (3) IF NOT MENTIONED. FOR THOSE MENTIONED SPONTANEOUSLY/PROMPTED ASK Q. 711? PROBLEMS FACING YOUNG PEOPLE 711. IS THIS A PROBLEM FOR YOU 1. POVERTY 1.YES SPONT. 2.YES PROMT. 3. NO F710PO V 1. YES 2. NO 8. NA F711POV 2. UNEMPLOYMENT 1.YES SPONT. 2.YES PROMT. 3. NO F710E MP 1. YES 2. NO 8. NA F711WOR 3. POOR PARENTAL GUIDANCE 1.YES SPONT. 2.YES PROMT. 3. NO F710PP G 1. YES 2. NO 8. NA F711PPG 4. DRUG ABUSE 1.YES SPONT. 2.YES PROMT. 3. NO F710G A 1. YES 2. NO 8. NA F711DA 5. ALCOHOL ABUSE 1.YES SPONT. 2.YES PROMT. 3. NO F710A A 1. YES 2. NO 8. NA F711AA 6. PEER PRESSURE/BAD FRIENDS 1.YES SPONT. 2.YES PROMT. 3. NO F710PP 1. YES 2. NO 8. NA F711PPF 7. POOR/NO RECREATIONAL FACILITIES 1.YES SPONT. 2.YES PROMT. 3. NO F710PR F 1. YES 2. NO 8. NA F711PRF 8. POOR/NO EDUCATIONAL FACILITIES 1.YES SPONT. 2.YES PROMT. 3. NO F710PE F 1. YES 2. NO 8. NA F711PEF 9. POOR/NO HEALTH SERVICES 1.YES SPONT. 2.YES PROMT. 3. NO F710HS 1. YES 2. NO 8. NA F711PHS 10. POOR/NO KNOWLEDGE ABOUT GROWING UP 1.YES SPONT. 2.YES PROMT. 3. NO F710PG 1. YES 2. NO 8. NA F711PKG 11.POOR/NO ACCESS TO INFORMATION 1.YES SPONT. 2.YES PROMT. 3. NO F710AI F 1. YES 2. NO 8. NA F711PAI 12. PRESSURE TO GET MARRIED 1.YES SPONT. 2.YES PROMT. 3. NO F710P M 1. YES 2. NO 8. NA F711PGM 13. PRESSURE TO HAVE SEX 1.YES SPONT. 2.YES PROMT. 3. NO F710PS X 1. YES 2. NO 8. NA F711PSE 14. RAPE/FORCED SEX 1.YES SPONT. 2.YES PROMT. 3. NO F710FS X 1. YES 2. NO 8. NA F711RFS 15. STEALING 1.YES SPONT. 2.YES PROMT. 3. NO F710FS T 1. YES 2. NO 8. NA F711RFS1 16. OTHER (SPECIFY) 1.YES SPONT. 2.YES PROMT. 3. NO F710OT H 1. YES 2. NO 8. NA F711OTH EXPOSURE TO MEDIA 712 How often do you listen to a radio? EVERYDAY????..??????...1 SEVERAL TIMES A WEEK?..??.?2 A FEW TIMES A WEEK???.??...3 ONCE A WEEK????.?????.4 NEVER????????????..5 OTHER 6 (SPECIFY) FFRADIO 717 74 NA???????????????8 713 Have you ever listened to any radio programme on youth related issues? YES??????????????? 1 NO???????????????.. 2 NA???????????????.. 8 FYRADPG 717 YES N O WEEKEND SURPRISE 1 2 CAMPUS REQUEST 1 2 FUN FACTORY 1 2 OUR VOICES 1 2 YOUTH IN DEVELOPMENT 1 2 WOMEN IN DEVELOPMENT 1 2 HOME ISSUES 1 2 YOUTH VIBES 1 2 BIRTHDAY LINE 1 2 MORNING SHOW 1 2 BREAKFAST SHOW 1 2 INSIGHT 1 2 OTHER (SPECIFY) 1 2 714 Which youth programmes have you ever listened to? (CIRCLE ALL MENTIONED) NA????????????.8 FWKDSUR FCMPRQT FFUNFACT FVIOCES FYOUDEV FWOMDV FHMISSU FYUHVBS FBRTHLIN FMORNSH FBRKFSHW FINSIGHT FYOTHER 715 During what time of the day do you listen to the radio? WEEK DAY MORNINGS????......1 WEEKDAY AFTERNOONS????..2 WEEKDAY EVENINGS???..?.?.3 WEEKENDS????????..??..4 OTHER 5 (SPECIFY) NA??????????.????..8 FRADTME NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 716 During what time of the day would you prefer to listen to youth programs on the radio? WEEK DAY MORNINGS???...1 WEEKDAY AFTERNOONS??...2 WEEKDAY EVENINGS????..3 WEEKEND MORNINGS????.4 WEEKEND AFTERNOONS???5 WEEKEND EVENINGS????..6 OTHER 7 (SPECIFY) NA?????????????.8 DON?T KNOW?????.???9 FRADPREF 717 During the past six months, did you hear or see anything about STDs/HIV/AIDS: On the radio? On the television? In a newspaper or magazine? From a poster? In a community meeting? RADIO TELEVISION NEWSPAPER/ MAGAZINE POSTER COMMUNITY MEETING YES 1 1 1 1 1 NO 2 2 2 2 2 FSTDRAD FSTDTV FSTDMAG FSTDPOST FSTDCOM 718 Would you like to receive information on STDs/HIV/AIDS? YES?????.??????..?..1 NO????????...?????2 FSTDINFO 720 75 719 How would you prefer to receive this information? TEACHERS IN SCHOOL?...?.?1 HEALTH WORKERS?????.2 IN DURBARS?????..???.3 FRIENDS/SCHOOLMATES..??..4 RELIGIOUS LEADERS??...??5 FROM PARENTS????..??...6 RADIO??????????.?.7 TELEVISION????????...8 NEWSPAPERS/MAGAZINES?...9 POSTERS??????????10 OTHER____________________ 11 (SPECIFY) NA????????..???.....88 FPREFSOU 720 RECORD TIME AT END OF INTERVIEW HOUR??????? MINUTE?????? FHEND FMEND THANK YOU VERY MUCH FOR TAKING THE TIME TO ANSWER THESE QUESTIONS. WE APPRECIATE YOUR CO-OPERATION AND PARTICIPATION IN THIS STUDY 76 Appendix A2 Ethical Clearance Certificate 77 Appendix A3 i) Proportion of adolescents who initiated sex at different ages Age at first sex Females Males Frequency Percentage Frequency Percentage Had sex at or below age 12 18 5.6 146 26.3 Had sex between age 13-15 62 19.4 129 23.2 Had sex between age 16-19 157 49.1 176 31.7 Had sex at age 20 and above 83 25.9 104 18.7 ii) Univariate results for all outcomes with co-residence status as the independent variable Ever had sex Early sexual initiation Condom use Sex in last 3 months OR 95% CI OR 95% CI OR 95% CI OR 95% CI Living with Both 1.00 1.00 1.00 1.00 Living with Father 1.05 0.80; 1.38 0.51* 0.29; 0.91 1.18 0.44; 3.16 0.63 0.28; 1.44 Living with Mother 1.49* 1.26; 1.75 0.91 0.67; 1.25 1.51 0.86; 2.62 1.25 0.84; 1.85 Living with Neither 1.37* 1.12; 1.67 0.67* 0.45; 0.99 1.80 0.96; 3.39 1.25 0.77; 2.02 N 6474 875 950 950 Log likelihood -2686.63 -586.68 -262.85 -422.38 iii) Contraceptive use during last sexual intercourse All Female Male Method Frequency Percentage Frequency Percentage Frequency Percentage Pill 1 0.11 0 0.00 0 0.00 Injection 4 0.42 3 0.83 1 0.17 Condom 82 8.66 25 6.93 1 0.17 Other modern 2 0.21 2 0.55 57 9.74 Rhythm method 1 0.11 1 0.28 0 0.00 Did not use 856 90.49 330 91.41 526 89.92 Total 946 100.00 361 100.00 585 100.00