Arch Sex Behav (2012) 41:351361 DOI 10.

1007/s10508-011-9830-5

ORIGINAL PAPER

Family Environment and Premarital Intercourse in Bandjoun (West Cameroon)

Zacharie Tsala Dimbuene Barthelemy Kuate Defo

Received: 18 March 2010 / Revised: 25 January 2011 / Accepted: 11 May 2011 / Published online: 9 September 2011 Springer Science+Business Media, LLC 2011

Abstract Family environment is one of the most inuential factors on youth sexual behavior but has received little investigation in sub-Saharan Africa. Yet, a comprehensive understanding of family inuences could improve the efciency of reproductive health (RH) interventions. Using retrospective data from a population-based survey, life-table analysis was utilized to compute the median age at premarital intercourse among 1,182 youth aged 1224 years. Discrete-time hazard models were used in multivariate analysis to estimate the effects of family structures and parentchild interactions on premarital intercourse. Overall, 42% of participants had a premarital intercourse, and the median age at rst sex was 16.9 years. Participants in nuclear two-parent families had the highest median (17.7) compared with those in nuclear one-(16.7), extended one-(16.5), extended two-parent families (16.9) or other relatives (16.8). Youth from monogamous families had the highest median (16.9) compared to those from polygamous (16.3) and other families (16.0). Orphans and youth reporting family transitions were more likely to initiate rst sex at an earlier age compared with non-orphans and non-movers, with a median of 16.1 and 16.9 years, respectively. Multivariate results showed that living in extended families, being orphaned, and family transitions signicantly increased the risk of premarital intercourse. Polygamy showed marginal effects. Stronger parentchild relationships and higher levels of parental control decreased the risk of premarital intercourse. Unexpectedly, parentchild communication was
Z. Tsala Dimbuene (&) B. Kuate Defo PRONUSTIC Research Laboratory and Department of Demography, University of Montreal, C.P. 6128 Succursale al, QC H3C 3J7, Canada Centre-Ville, Montre e-mail: z.tsala.dimbuene@umontreal.ca B. Kuate Defo de Centre de Recherche du Centre Hospitalier de lUniversite al, Unite de Sante Internationale, Montre al, QC, Canada Montre

signicantly associated with a higher risk of sexual debut. Programmatically, family environment is an important resource that needs to be promoted when designing RH interventions in subSaharan Africa. Keywords Family structure Family processes Adolescence Premarital sexual intercourse Sub-Saharan Africa

Introduction Premarital sexual activity during adolescence and emerging adulthood leads to a wide range of adverse outcomes in subSaharan Africa (SSA), including unintended pregnancies, illegal abortions, sexually transmitted infections (STIs), and HIV/ AIDS (Harrison, Cleland, Gouws, & Frohlich, 2005). Moreover, rst sex among adolescents and young adults in SSA is often unprotected (Garriguet, 2005; Sneed, 2009). As such, rst sex remains a major social problem and a serious public health issue (Clark, 2004; Cleland, Boerma, Carael, & Weir, 2004; Gage, 1998; Kuate Defo, 1998a). Whereas age at rst sex is almost stalling, recent estimates indicate that age at marriage is increasing (Mensch, Grant, & Blanc, 2006), yielding a lag of 2 years for women (Adair, 2008) and up to 8 years for men (Bankole, Singh, Woog, & Wulf, 2004) between sexual onset and rst marriage. This is likely to be detrimental for youth, especially in a context of low levels of condom use and contraception. Previous research showed a myriad of individual, familial, and community factors to be associated with sexual debut. By and large, family environment is the most inuential context related to rst sex which is widely examined in developed countries. In contrast, and drawing mainly on cross-sectional data, a few exceptions examined the relationship between family structure and sexual debut in SSA (Babalola, 2004; Babalola, Tambashe, &

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, 2005; Djamba, 2003; Ngom, Vondrasek, 2005; Diop-Sidibe Magadi, & Owuor, 2003; Rwenge, 2003; Tambashe & Shapiro, 1996; Thurman, Brown, Richter, Maharaj, & Magnani, 2006). However, these studies did not focus on the centrality of family environment and were mostly atheoretical. Additionally, crosssectional data have serious drawbacks because they rely on current individual and familial characteristics to explain past events (e.g., sexual debut). Thus, the observed associations can merely represent statistical artifacts. This study set out to contribute to the literature about family inuences by investigating the role parents and parent-like gures play in fostering sexual attitudes and acceptable behaviors among adolescents and young adults. Family Structure, Family Processes, and Sexual Initiation An extensive body of research, mostly based on U.S. data, has investigated the relationship between family environment and sexual debut among youth (for a review, see Miller, Benson, & Galbraith, 2001). These studies mainly focused on two nonexclusive areas, including family structure and family processes/ functioning (hereafter parentchild interactions), and provide avaluable conceptual tool which is also relevant in SSA. Most studies of the effects of family structure on sexual debut have supported at least one of three hypotheses: socialization, social control, and family instability and changes (Albrecht & Teachman, 2004; Wu & Thomson, 2001). Socialization hypotheses posit that individuals learn how to interact in dating relationships through conscious and unconscious observations of the relationships around them during childhood and adolescence, particularly those between parents or parentlike gures (Wu & Thomson, 2001). Youth from unmarried homes witness their parents dating or cohabitation while they are learning to deal with their own romantic relationships and may model their own patterns of sexual activity after those of parents (Davis & Friel, 2001). Most of these studies have uncovered similar results either in developed or developing countries: living in two-parent families, compared with neither- or one-parent families, was associated with lower rates of sexual debut. With respect to parental marital status, anthropological literature contends that polygamy is the most distinguishing characteristic of the African family (Kayongo-Male & Onyango, 1984; Omariba & Boyle, 2007). Therefore, a thorough analysis of the effects of family environment on sexual debut in SSA should integrate this specic component in research. Empirical evidence in SSA showed that polygamous families were associated with higher rates of sexual initiation (Slap et al., 2003); however, the mechanisms which potentially increase these risks still remain unknown. Even though two-parent households are often associated with lower rates of premarital intercourse, youth in polygamous families may differ from those in monogamous families for at least three reasons. First, the economic deprivation approach considers that a high number of women in polygamous unions increases the number of children (Amoran, Onadeko, & Adeniyi,

2005; Slap et al., 2003), essentially reducing the per capita resources within the home (Omariba & Boyle, 2007), and hence increases the risk of early sexual debut. Second, polygamous fathers may lack time to supervise a high number of children, leaving each mother nearly alone to oversee her children, similar to neither- or one-parent households. To the extent that one parent (the mother) provides adolescents and young adults with lesser supervision than do two parents, youth from polygamous families may be at a higher risk of premarital intercourse. Third, Elbedour, Bart, and Hektner (2007) conjectured that high levels of family conict within polygamous families may explain why youth from those families exhibit poor outcomes, including early sexual debut. From a socialization viewpoint, the quality or closeness of the parentchild relationship plays an important role in fostering proper and acceptable behaviors (Markham et al., 2010). Studies found that youth, particularly females who reported close relationships with parents or guardians, were likely to be less sexually active (Slap et al., 2003). Parentchild communication is another central factor in socialization. Higher levels of parent child communication are likely to cultivate a more supportive familial environment (Markham et al., 2010) and foster higher levels of self-condence and self-image among youth, which are associated with later age at rst sex (Dittus & Jaccard, 2000). In SSA, researchers often reported low levels of parentchild communication about sexuality (Boileau, Rashed, Sylla, & Zunzunegui, 2008). Empirically, ndings about the relationship between communication about sexual matters and sexual activity are mixed. Indeed, studies reported a weak relationship with sexual initiation (Karim, Magnani, Morgan, & Bond, 2003) and current sexual activity (Kumi-Kyereme, Awusabo-Asare, Biddlecom, & Tanle, 2007), whereas others found no consistent effects of parentchild communication (Adu-Mireku, 2003; Fatusi & Blum, 2008). Social control hypotheses posit that adolescents from twoparent families have fewer opportunities to engage in sexual activity due to higher levels of parental supervision and monitoring compared with neither- and one-parent families (Hogan & Kitagawa, 1985; Miller, Forehand, & Kotchik, 1999; Thompson, Hanson, & McLanaham, 1994). During this developmental period, parents and family members are critically inuential on the decisions adolescents and young adults make over sexual matters (Cohen et al., 2005). In SSA, parents, particularly fathers, play an important role in disciplinary rules within the home (Nsamenang, 2000; Verhoef, 2005). Father-child relationships in SSA are often vertical rather than horizontal (Ngom et al., 2003); therefore, father absence may lead to a lack of home discipline, resulting in a faster transition to sexual initiation (Roche et al., 2005; Simons, Chen, Simons, Brody, & Cutrona, 2006). Empirical evidence from SSA supports this assumption. Higher levels of parental monitoring were found to be negatively and signicantly associated with current sexual activity among Ghanaian youth (Kumi-Kyereme et al., 2007). Because

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African societies have different expectations for males and females about sexuality, the effects of parental control can vary by gender. For instance, premarital sexual intercourse in Bandjoun (West Cameroon) is strictly prohibited for females whereas it is sometimes encouraged or not sanctioned for boys (Kuate Defo, 1998b). Family instability and change hypotheses suggest that the instability brought on by marital disruption or parental death, and subsequent transitions, account for an earlier sexual activity in single-parent households (Albrecht & Teachman, 2004; Wu & Martinson, 1993). Greater conict and less warm relationships between parents during and after divorce adversely affect parentingstylesandyouthpsychological development,resultinginavariety of problematic behaviors, including early sexual debut, future patternsofsexual relationships,andunintendedpregnancies (Amato, 1987). Parental death is also a strong, traumatic, and stressful event which is associated with negative outcomes such as school dropouts (Case, Paxson, & Ableidinger, 2004; Gertler, Levine, & Ames, 2004) or sexual activity (Thurman et al., 2006). Finally, it has been proposed that the three perspectives can be viewed as complementary rather than competing (Wu & Thomson, 2001). Demographic events, like divorce or parental death, lead to family instability and changes (Bicego, Rutstein, ller, 2005; Thur& Johnson, 2003; Sarker, Neckermann, & Mu man et al., 2006). These changes thereafter bring stressful situations for both parents and children, and subsequently affect parentchild bonds such as the effectiveness of parental control due to the decrease in the number and types of parents within thehome.A new family environment requiresnew adaptation emotionally, psychologically, and economically; thereby, it may impede socialization processes. Social control and socialization processes are also linked in several ways (Wu & Thomson, 2001). If strong networks were developed within the communities, parents or parent-like gures would be very likely to share the same norms, values, and attitudes about sexuality. Therefore, youth will be more likely to behave in accordance with social frames and scripts parents provide them, which signicantly limit youths opportunities to engage in premarital intercourse. Likewise, the quality of parentchild relationships can reinforce more effective control over children because they are more likely to internalize familial values and attitudes about sexuality within a stable and caring environment. In Bandjoun, parent child relationships vary depending on parents gender. Fatherchild relationships, especially for daughters, are mostly vertical ones whereas motherchild relationships are rather horizontal and characterized by companionship, condentiality, and exibility with respect to the acceptance or rejection of normative behaviors (Kuate Defo, 1998a). Even though father gures provide more disciplinary rules within home, mothers may exert more effective control over children due to the elevated amount of time they spend with them.

Hypotheses The literature presented above leads to a number of relevant hypotheses in SSA. Family environment, especially biological parents, is a primary factor in youth sexual behavior. Family structure is expected to have an indirect effect, whereas family processes or parentchild interactions are important intervening variables which have direct effects on sexual onset. Weak relationships with parents orguardians andrejection ofparental authority may increase the likelihood of sexual intercourse. Closer parental relationships, higher levels of parental support, warmth within homes, and open communication create stable emotional family contexts which reduce youths desires to seek alternative intimate relationships from peers or unrelated adults. In this study, it is expected that youth from two-parent families, those who reported higher levels of (1) parentchild relationships, (2) parentchild communication, and (3) parental control had a later age of premarital intercourse. Conversely, orphans and youth who experienced family changes were expected to have early age of premarital intercourse.

Method Participants Data were drawn from a random representative sample of Cameroon Family and Health Survey carried out between December 1996 and March 1997 (CFHS-1996/97), under the auspices of the Population Observatory in Socioclinical Epidemiology (POSE) in Bandjoun, a semi-urban area in the province of West Cameroon among individuals aged 10 years and older in the 75 localities of Bandjoun (Kuate Defo, 2005). Each locality used probability samples in which all individuals aged 10 years and older have a nonzero chance of inclusion. The sampling procedure was designed to produce comparable locality-level estimates for the general population. The CFHS-1996/97 employed a selfweighted proportional design; the proportions of randomly selected households in 75 localities forming the Bandjoun in the sample equal to the same proportion in the general population. A total of 2,377 females and males were interviewed using forced-choice questions and face-to-face technique. For the purpose of this study, a sub-sample of 1,182 youth of both sexes aged 1224 years was utilized. The survey collected retrospective data on family histories at ages 6 and 12, which represent two important transitions for youth in Cameroonian society. The former is referred to as the inception of primary school whereas the latter represents adolescence and the transition from primary school to high school, which often coincides with puberty. Using these two markers limited the recall biases inherent to retrospective data.

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Procedure Trained interviewers administered in local languages a detailed questionnaire which consisted of sociodemographic characteristics, sexuality, contraception, HIV/AIDS knowledge, birth history, and health. Information about family structures, parental marital status, parentchild communication about sexuality, and household assets (including lighting mode at home, possession of a radio or TV) at ages 6, 12, and at the time of the survey was collected for youth aged between 10 and 29 years. When a household was selected, all individuals aged 10 years and over were given a number ranging from 1 to the maximum of individuals in the household, and one person was randomly selected for the interview. This sampling technique provided uncorrelated observations. Finally, due to the sensitivity about sexual topics, a statement about the condentiality of responses was read to participants, and an oral consent was obtained before each interview. Measures Dependent Variable: Timing of Premarital Intercourse The dependent variable was the waiting time to premarital intercourse. Participants reported age at rst intercourse (recorded in whole years). From an event history perspective, the occurrence of premarital intercourse at each age was dened as a single event and the nonoccurrence of sexual initiation was dened as censoring in the last interval (e.g., young people who were not sexually experienced at the time of interview but might experience transition to sexual initiation in the future). In practice, the probability of sexual debut in each interval of time (a year) was estimated using a binary outcome taking the values 1 if the premarital intercourse occurred in the interval and 0 otherwise. Participantswereasked two questions:Haveyou everhad sexual intercourse? (yes/no), and How old were you when you had sexual intercourse? for those who experienced sexual intercourse. Additionally, it was possible to determine whether sexual debut occurred within or before marriage using two questions about age at rst marriage:Have you ever been married?(yes/ no) andHow old were you when you rst got married? Family Structure Family structure was constructed with an emphasis on biological parents. This approach differs from other structural aspects of families, such as family size, number of siblings, parental education, and the number of generations living in the household. These latter approaches are somewhat more difcult to reconstitute due to recall biases and participants self-reported information about family congurations when he/she was younger. This is particularly true for young adults aged 20 years or older. In SSA, family structure in previous studies were derived from the variablerelationship with the head of householdavailable

in censuses and the rst generation of Demographic and Health Surveys (DHS). This variable does not allow determining participants co-residence with his/her biological parents. To address these shortcomings, subsequent DHS asked additional questions:Does the biological mother/father live in this household? which easily allow determining parental co-residence. In the CFHS-1996/97 survey, 10 dichotomous questions were used to capture family congurations at a given age t (referred to as ages 6 and 12) about the members of a typical African family in a semi-urban area: With whom did you live at age t ? Responses included father, mother, brother/sister, cousins, uncle/ aunt, grandfather/grandmother, friend, playmate, in institution, and alone. Only few participants chose the last four items (friend, playmate, institution, and alone); so they were excluded from subsequent analyses. The remaining six questions were used to build ve mutually exclusive categories of the most common types of families in SSA, including nuclear one-parent, extended one-parent, nuclear two-parent, extended two-parent, and other relatives for those living with parent-like gures (brother/sisters, uncles/aunts,grandparents). One-parent families(mother-only and father-only) were collapsed into the same category due to small cases, as well asother relatives. Likewise, it is important to note that youth living with biolog ical parents may reside with brothers/sisters, cousins or relatives. Prior to assigning participants to other relatives category, we ensured that they were not living with any biological parent. If the participant resided with one or two biological parents, the items cousins, uncle/aunt, and grandfather/grandmotherwere used to determine that the participant was living in an extended family. Parental Marital Status Participants were askedWhat was the marital status of parents/ guardians at age t? This variable is hereafter referred to as parental marital status. Responsesincluded single, married monogamous, married polygamous, separated, divorced, widowed. A new variable was created to distinguish youth who lived in monog amous and polygamous families or other (single, separated, divorced, and widowed). Family Processes Family processes previously identied as mediators of the effects of family structure on sexual initiation are described below. Quality of parentchild relationships at age t was captured with the question How did you see the quality of your relationships with your parents/guardian at age t? Reponses ranged from 1 = very good to 5 = difcult or bad. This variable was reversely recoded so that a high score indicated a higher quality of parentchild relationships. ParentChild Communication Five yes/no questions captured parent/guardian-communication:Did you ever have conversations

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with your parents/guardians puberty, sexual education, STDs/ HIV/AIDS, pregnancies, and alcohol or drugs at age t?These items were summed; the scores ranged from 0 to 5 (Cronbachs a was .64 and .86 at age 6 and 12, respectively). Parental Monitoring This study used direct measures of parental supervision at age t, which indicated whether parents were aware of youths activities outside home:Were your parents/guardians controlling your leisure at age t? Responses ranged from 1 = a lot to 5 = not at all. Responses were reversely recoded to produce a gradient, higher score indicating higher levels of parental monitoring. Parental Survival The questionWhat was the main reason why you werent living with your biological parents at age t? captured parents survival status. Responses were mother and father died, father died, mother died, school, and other. This variable was coded 1 if at least one parent was deceased and 0 otherwise. Change in Family Congurations This was a crude measure indicating changes in family congurations between ages 6 and 12. This variable was coded 1 if family congurations changed between these two times and 0 otherwise. Economic deprivation was a set of three variables. First,What was the lighting mode that you were using in the home at age t? Responses were electricity, lamp, candle, and other. This variable was coded 1 if the lighting mode was electricity and 0 otherwise. Second,thepresenceofradioortelevisionathomewascapturedby the questionDid you have a radio or a television at home at age t? coded 1 = yes and 0 = otherwise. Third, the educational attainment of parents/guardians measured by the following question: What was the education level of the person in charge of you at age tResponses were recorded as follows: 0 = none, 1 = primary, 2 = high school, and 3 = university. These three items were summed to construct a proxy of socioeconomic status (SES) of the household (range 05), higher scores indicating higher economic situation. Data Analysis Bivariate and multivariate analyses were performed with STATA software, release 9. KaplanMeier life tables were employed to determine the median age at premarital intercourse. For this purpose and subsequent analyses, the key independent variables were considered time-varying covariates because information was available at ages 6 and 12. For multivariate analyses, discrete-time hazard modeling was used because the timing of premarital intercourse can be viewed as an age-dependent process. Using the person-age observation (in a person-year le) as the unit of analysis, multivariate discrete-time models (Allison, 1984) were conducted to estimate the effects of family structure,

parental marital status, and family processes on the risk of premarital intercourse. The odds of premarital intercourse were parameterized using logistic regression. The estimated odds ratios (OR) represent the effects that being in a variable category had on the risk of premarital intercourse relative to remaining virgin. This analytic strategy was appropriate because the events occurred in discrete time intervals, since premarital intercourse was captured in completed years. First, gross effects for each independent variable were estimated using bivariate logit models. Second, four models were performed to test each set of hypotheses enunciated above. Models 13 display the effects of the key independent variables linked to the socialization, social control, and family instability hypotheses, respectively. The full model (Model 4) was used to assess the effects of family environment, controlling for the identied mechanisms and other covariates. Additional analyses were undertaken to test interactions between gender and age, and family environment, including family structure, socioeconomic status, quality of parent/guardian-child relationships, parent/guardian-child communication, and parental supervision. These latter analyses revealed no signicant interaction terms between gender and age and the key independent variables. Thus, ndings presented here were limited to additive models.

Results Descriptive Statistics Table 1 provides descriptive statistics of demographic characteristics, family structure, and family processes at ages 6 and 12. Participants included 1,182 youth (52% of females). They ranged in age from 12 to 24 years (M = 17.3; SD = 3.4). The distribution of family structures at different ages indicated that twoparent families (both nuclear and extended) predominated. For instance, young people were mostly living in extended twoparent families at age 6 (54%) and 12 (43.4%). A noticeable proportion of youth were living in nuclear one- or extended oneparent families at ages 6 and 12, respectively, and this increased with age. Taken together, 12% and 15% of participants were living in one-parent families at ages 6 and 12. Whereas 13% of youth lived with other relatives at age 6, this percentage reached almost 25% at age 12. Most parents/guardians (over 85% at each age) were married both in monogamous and polygamous marriages. Polygamy was not uncommon in Bandjoun: more than one-third of parents/ guardians were polygamous. This is in line with national trends indicating that about 30% of married women were living in polygamous unions. As participants age increased, the likelihood of living in a household headed by an unmarried parent/ guardian increased. Many youth reported high quality of parentyouth relationships (M = 3.13 and 3.1 at ages 6 and 12, respectively; range = 05). In contrast, the levels of parent/guardian-

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356 Table 1 Descriptive statistics of the sample, and median age at rst sex, Bandjoun

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Family-related variables and demographic characteristics Family structure Nuclear one-parent Extended one-parent Nuclear two-parent Extended two-parent Other relatives Marital status of P/G Married monogamous Married polygamous Other (single/separated/divorced/widowed) Quality of parentchild relationships (range, 14)b Parentchild communication (range, 15)b Socioeconomic status of HHb Parental monitoring (range, 15) Parental survival Both alive One or two parents deceased Change in family congurations between age 6 and 12a No Yes Gendera Male Female Age (range, 1224 years)a,b Ever had sexual intercourse Sample size (N)
a b

Age 6

Age 12

Median age at rst sex

6.9 5.1 21.2 53.6 13.1 58.6 36.1 4.3 3.13 (.69) 0.12 (.56) 1.76 (1.33) 3.89 (1.34) 95.3 4.7 71.2 28.8 48.4 51.6 17.3 (3.38) 42.0 1,182

8.1 6.9 17.6 43.4 24.3 52.3 32.5 14.2 3.07 (.71) 0.43 (1.14) 1.73 (1.34) 3.87 (1.30) 79.7 20.3

16.7** 16.5 17.4 16.9 16.8 16.9** 16.3 16.0 n/a n/a n/a n/a 16.8** 16.1 17.6** 16.9 17.0 16.8 n/a

Note: Median age at premarital intercourse is calculated for categorical time-varying covariates. Signicance testing is based on Wilcoxon test for homogeneity across survival strata. Source: CFHS (1996/97) ** p\.05 These variables do not refer to referenced time in Table 1, namely age 6 and 12
b a

16.9

For continuous variables, mean and SD (in parentheses)

child communication were quite low (e.g., M = .40 at age 12; range = 05). On average, parental monitoring was high with an average of 3.9 at ages 6 and 12. Concerning parental death, the proportion of one- or double-orphans increased with age from 5 to 20% at ages 6 and 12, respectively. These gures were an undeniable indication of changes in family living arrangements between childhood and adolescence as a result of parental death. Likewise, almost 30% of participants reported another family conguration at 12 compared with that of age 6. Table 1 also displays the proportion of sexually experienced youth. Overall, 42% of adolescents and young adults had had premarital intercourse. Median age at premarital intercourse was 16.9 years. These gures were similar to national trends. Indeed, ndings from CDHS-1998 and CDHS-2004 showed that age at sexual debut among young adults aged 2029 years ranged between 15.9 years and 18 years. Bivariate and Multivariate Results Table 2 presents unadjusted and adjusted odds ratios (OR) of discrete-time logit models. Findings in column 2 show bivariate

associations of selected variables with premarital intercourse. Overall, these associations operated in the expected direction except for parent/guardian-child communication. Although living in family congurations other than nuclear two-parent families was associated with a higher risk of premarital intercourse, only two family structures reached statistical signicance. The risk of premarital intercourse was signicantly higher in extended families (one- or two-parent) compared with nuclear two-parent families. Surprisingly, parental marital status was not signicantly associated with premarital intercourse. Orphanhood was another factor which signicantly increased the risk of premarital intercourse. Indeed, the risk of premarital intercourse was 86% higher among orphans compared with non-orphans. Changes in family congurations between ages 6 and 12 were also associated with premarital intercourse. The risk of premarital intercourse was 36% greater among youth who reported changes in family congurations between ages 6 and 12. Parentchild interactions, including higher quality of parentchild relationships and parental monitoring, decreased signicantly the risk of premarital intercourse. In fact, a one-point increase in the quality of parentchild relationships and parental monitoring decreased by 16% and 17%

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Arch Sex Behav (2012) 41:351361 Table 2 Odds ratios (OR) of the effects of family structure, marital status, and family processes on premarital intercourse Variable Unadjusted OR Adjusted OR Model 1 Family structure Nuclear two-parent Nuclear one-parent Extended one-parent Extended two-parent Other relatives Marital status Married monogamous Married polygamous Other (single/separated/divorced/widowed) Parent/guardianchild relationships Parent/guardianchild communication Parental monitoring Parental survival Both parents alive At least one parent deceased No Yes Gender Male Female Age N Pseudo-observations LL Pseudo-R2 (%) Source: CFHS (1996/97) * p\.10, ** p\.05, *** p\.01 1.00 0.88 2.25*** 1,182 11, 445 n/a n/a 1.00 0.84* 2.29*** 1,182 11, 445 -2,038.27*** 22.5 1.00 0.89 2.27*** 1,182 11, 445 2,057.95*** 21.3 1.00 0.87 2.29*** 1,182 11, 445 -2,064.10*** 21.9 1.00 0.84* 2.27*** 1,182 11, 445 1.00 1.86** 1.00 1.36** 1.00 1.00 1.00 1.67** 1.00 1.31** 1.00 1.49** 1.00 1.25* 1.00 1.52 1.89*** 1.34* 1.28 1.00 1.16 1.30 0.84** 1.17*** 0.83** 1.00 1.39 1.73*** 1.23* 1.16 1.00 1.22* 1.11 0.85** 1.15*** 0.86** 1.00 1.43 1.77*** 1.34** 1.38* 1.00 1.16 1.11 1.00 1.38 1.69** 1.25* 1.27 1.00 1.22* 1.08 0.84** 1.16*** 0.89** Model 2 Model 3 Model 4

357

Change in family congurations between age 6 and 12

-2,046.25*** 23.7

the risk of premarital intercourse, respectively. Parentchild communication unexpectedly increased the risk of premarital intercourse by 17%. Models 13 (Table 2) tested the three sets of hypotheses outlined in the conceptual framework. Models 1 and 2 tested the socialization and social control hypotheses using two key independent variables: family congurations and parental marital status. The quality of parentchild relationships and parentchild communication are central for socialization whereas parental supervision is expected to mediate the effects of family environment in social control processes. When socialization mechanisms were introduced in Model 1, the effects of family congurations were nearly similar to those from bivariate analyses. In Model 1, the effects of living in extended families decreased by 9% the risk of premarital intercourse, indicating only a moderate mediation of the quality of parentchild relationships and parentchild communication. Furthermore, living in polygamous families in Model 1 marginally increased by 22% the risk of premarital intercourse,

compared with monogamous families. In Model 2, some family congurations remained statistically signicant. Living in extended families or marginally with other relatives was associated with a higher risk of premarital intercourse. Parental control showed a signicant negative effect, supporting the social control hypotheses that greater parental supervision would be associated with lower ratesofpremarital intercourse.Infact,when youthwerewell supervised, the risk of premarital intercourse decreased by 14%. The family instability and change hypotheses were tested considering parental survival and changes in family congurations as the key independent variables. Parental death was associated with a higher risk of premarital intercourse (see Model 3). The risk of premarital intercourse was 67% higher among orphans compared with non-orphans, and 31% higher among youth who reported changes in family congurations. Model 4 included all selected variables theoretically associated with premarital intercourse. The effects of family structure, parental marital status, family processes, and family changes

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observed previously in Models 13 persisted when all variables are included. From these ndings, Model 4 showed that family environment and parentchild interactions were important aspects of youths life, and further our understanding of why youth in SSA start sexual initiation at either earlier or later ages, and what role family conguration, especially parents or parent-like gures, can play to limit youths opportunities to engage in sexual intercourse.

Discussion An important goal of this study was to examine how family environment in SSA was associated with premarital intercourse drawing on an integrative theoretical framework not tested to date in African settings, including socialization, social control, and family instability hypotheses. In addition, the study examined how parentchild interactions (quality of parentchild relationships, parentchild communication, and parental supervision) mediated the effects of family congurations. The study provided limited support for each set of hypotheses. From socialization hypotheses, ndings showed that youth living in extended families, and marginally those who lived with other relatives, were far more likely to engage in premarital intercourse at an earlier age. Contrary to previous studies (Slap et al., 2003), polygamy showed only a marginal effect; youth from polygamous families reported a higher risk of premarital intercourse. Broadly speaking, polygamy in SSA is conceived of as a reection of high status and achievement (Karanja, 1994). If this argument was true, one would expect positive outcomes among youth from polygamous families. It is possible that polygamy affects everyone involved in this practice, from emotionally scarred children, to wives who think they would be better as single parents, and even husbands who recognize the stressful side of polygyny (Elbedour, Onwuegbuzie, Caridine, & AbuSaad, 2002). Youth from polygamous families, particularly females, may then perceive dating practices as an alternative to the lack of affection and psychological insecurity within home. These decits may therefore explain higher rates of premarital intercourse among youth raised within those families. For the socialization hypotheses to work well, one might expect that parentchild relationships and parentchild communication about sexuality would mediate the effects of family structure. First, although the effects of parentchild relationships were in the expected direction, only a moderate level of mediation was observed. Second, parentchild communication showed an unexpected effect: it increased signicantly the risk of premarital intercourse. Overall, these ndings provided partial support of socialization hypotheses. Even though living in two-parent families is often depicted as a strong protective precondition in Western literature, a family is neither protective nor at risk by the number of biological parentspresent withinhome.A numberofadditionalcriteria are needed (e.g., cohesion, commitment, adaptability, communication, spirituality, connectedness, efcacy) to enhance a

familys protective effect (Greeff & van Der Merwe, 2004). The extended families and the practice of polygamy can mean that fathers are less involved in childrearing and supervision; then, leading to early sexual initiation among youth. These specic traits of African families call for further theoretical exploration and empirical evidence. Unlike African societies, family nuclearization observed in Western countries extends the role of each parent in childrearing. Hence, the absence of one parent in the Western context entails dramatic socioeconomic changes such as a signicant decline of family income. In SSA, the effects of family structure per se may be less important than those of increasing poverty due to higher unemployment rates within many countries. Higher quality of parent/guardian-child relationships was signicantly associated with a lower risk of premarital intercourse as reported in previous studies (Amoran et al., 2005; Slap et al., 2003); however, the ndings need to be interpreted with caution. In this study, the quality of parentchild relationships represents participants self-reported perception of the degree of closeness with parents or guardians during childhood and adolescence. Because parentchild interactions are bidirectional, parents views should be important as well. To establish how parent child relationships differed between families, additional analyses were performed. Results (not shown) indicated that levels of parentchild relationships were higher in nuclear two-parent families compared with other types of families. These ndings suggest that two-parent families may be more likely to offer a more appropriate environment for childrens positive adjustment due to better parenting styles. Unexpectedly, parentchild communication increased signicantly the risk of premarital intercourse. One might argue that when parents are aware of youths sexual initiation, they are motivated to talk about sexual topics. This argument did not stand here because this study addressed parentchild communication prior to sexual initiation. The nature of the data (e.g., cross-sectional, retrospective or longitudinal) likely may explain the discrepancies observed in SSA concerning the links between parentchild communication and sexual initiation (Adu-Mireku, 2003). Indeed, cross-sectional data are not appropriate to examine the time-order issues: What comes rst, communication about sexuality or rst sex? Our data retrace past events and we cannot rule out the possibility of some mismatch between the timing of parentchild communication and the timing of sexual initiation from the participants recollections of both past events, which may have affected to some extent the association between parent child communication and sexual debut. Longitudinal investigations ensure precision of the timing of events and preclude misclassication of exposure and outcome variables. Findings on the relationship between parentchild communication and sexual behavior in SSA remain inconclusive; as such, the direction, magnitude, and signicance of this relationship need further investigation because for youth, parents are an important source of information about sexuality (WHO, 2007).

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Another intriguing nding with respect to Western contexts is the positive association of household socioeconomic status. Studies conducted in the U.S. revealed the benet of better-off households. In African settings, conicting evidence persists about the relationship between economic factors (e.g., poverty) and sexual behavior. Some studies reported a negative link (Madise, Zulu, & Ciera, 2007) whereas others have found a positive relationship (Djamba, 2003; Mishra et al., 2007; Msisha, Kapiga, Earls, & Subramanian, 2008). Djamba (2003) speculated that girls living in wealthier families can be less supervised. This also means that men with more economic resources tend to invest searchingformorefemale sexual mateswhereasdevotingless time to children (Djamba, 2003). The current study suggests another explanation based on social status and popularity among youth: higher socioeconomic status provides youth with higher social status and popularity. Male youth from better-off households are more attractive for females, and they also have more opportunities for sexual mates than their counterparts from disadvantaged households. Because dating often blends aspects of friendships, physical intimacy and material benets; youth from advantaged households in SSA are more likely to share gifts with boyfriends or girlfriends, or have enough money to attend parties. That may increase youths freedom for sexual initiation. Likewise, female youth from wealthier families may face more pressures than their counterparts from poor households due to a higher body image (e.g., they are well-dressed). For instance, male youth contend that dating a girl from a low socioeconomic status means an additional nancial burden. In the context of extreme poverty, even males expect gifts from girlfriends living in advantaged households. In this case, dating preferences will be given to female youth from wealthier families. Therefore, female youth from advantaged homes will be more likely to be exposed to sexual initiation than females from poor households. From the social control hypotheses, parental monitoring/ control was associated with lower rates of premarital intercourse. However, the effects of family congurations on premarital intercourse need to be interpreted with caution with respect to social control. In fact, researchers argued that the number of adults involved in youth supervision may have a negative effect on sexual debut; assuming that youth raised in one-parent families have a greater risk of premarital intercourse. Then, one might expect lower risk of premarital intercourse in extended one- or two-parent families according to social control due to the presence of additional adults within the home. This was not the case because youth raised in extended families had higher rates of premarital intercourse. Economic deprivation may partly explain these counterintuitive ndings. An analysis of variance showed that extended families had signicantly lower socioeconomic status compared with nuclear families. In contrast, extended families did not signicantly differ from nuclear oneor two-parent families in terms of parental supervision. From the family instability perspective, parental death was signicantly associated with a higher risk of premarital

intercourse. Besides biological parents, it is well known that other adults may care for youth after parental death; however, they will not necessarily provide them with an equivalent amount of affection or psychological support than biological parents do. Changes in living conditions, economic deprivation, and adaptation following parental death may explain the observed negative effects of orphanhood on premarital intercourse. Although forming intimate and sexual relationships may be an important coping mechanism for orphans during difcult times (Thornton & Camburn, 1987; Thurman et al., 2006), the effects of parental death on the risk of premarital intercourse may persist or sometimes augment due to orphans economic and psychological vulnerability. For instance, the pressing needs for material or nancial resources orphans face can lead to premarital intercourse at an earlier age, and put them in a feeble position to negotiate protected sexual relations. On another conceptual point, the current study addressed shortcomings identied in previous research (Wu & Thomson, 2001). For instance, Wu and Thomson stated that their analyses did not include several crucial intervening elements outlined in the framework. Therefore, the inclusion of parentchild interactions in this study, which are an important component of family functioning, provides a substantive contribution in SSA. That some family congurations on premarital sexual intercourse remained signicant after controlling for family processes (parent child relationships, parental supervision/monitoring) suggest that parents still remain important players in RH interventions targeting youth (WHO, 2007). Limitations This study used family antecedents during childhood and adolescence to further our understanding of how youth engage in premarital intercourse; however, there remain a number of methodological limitations to be addressed. The primary limitation comes from the nature of the data. While the efforts were taken to ensure the representativeness of the sample in this study and even though our sample was large, the fact that all participants were recruited from a homogeneous ethnic setting (98% of participants were from the same ethnic group) limits our ability to generalize the ndings to youth from other regions of Cameroon. Indeed, information at national level should likely provide different patterns of family environment and family processes. Another limitation stems on the multidimensionality of the family processes or parentchild interactions, including communication about sexuality, parental monitoring/supervision, and the quality of parentchild relationships. Data used here were designed to explore a set of RH outcomes, not necessarily to address the complexities of psychosocial constructs like parentchild relationships, parental control, and communication about sexuality in the ways they are documented in developed countries. Further research should closely look at these aspects to develop appropriate and context-specic instruments

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Arch Sex Behav (2012) 41:351361 Albrecht, C., & Teachman, J. A. (2004). Childhood living arrangements and the risk of premarital intercourse. Journal of Family Issues, 24, 867894. Allison, P. D. (1984). Event history analysis: Regression for longitudinal event data. Beverly Hills, CA: Sage Publications. Amato, P. R. (1987). Family processes in one-parent, stepparent, and intact families: The childs point ofview. Journal of Marriage and the Family, 49, 327337. Amoran, O. E., Onadeko, M. O., & Adeniyi, J. D. (2005). Parental inuence on adolescent sexual initiation. International Quarterly of Community Health Education, 23, 7381. Babalola, S. (2004). Perceived peer behavior and the timing of sexual debut in Rwanda: A survival analysis of youth data. Journal of Youth and Adolescence, 33, 353363. Babalola, S., Tambashe, B. O., & Vondrasek, C. (2005). Parental factors te dIvoire. African and sexual risk-taking among young people in Co Journal of Reproductive Health, 9, 4965. Bankole, A., Singh, S., Woog, V., & Wulf, D. (2004). Risk and protection: Youth and HIV/AIDS in sub-Saharan Africa. New York: Guttmacher Institute. Bicego, G., Rutstein, S., & Johnson, K. (2003). Dimensions of the emerging orphan crisis in sub-Saharan Africa. Social Science and Medicine, 56, 12351247. Boileau, C., Rashed, S., Sylla, M., & Zunzunegui, M. V. (2008). Monitoring HIV risk and evaluating interventions among young people in urban West Africa: Development and validation of an instrument. AIDS Education and Prevention, 20, 203219. Case, A., Paxson, C., & Ableidinger, J. (2004). Orphans in Africa: Parental death, poverty and school enrolment. Demography, 41, 483508. Clark, S. (2004). Early marriage and HIV risks in sub-Saharan Africa. Studies in Family Planning, 35, 149160. Cleland, J., Boerma, J. T., Carael, M., & Weir, S. S. (2004). Monitoring sexual behaviour in general populations: A synthesis of lessons of the past decade. Sexually Transmitted Infections, 80, ii1ii7. Cohen, B., Jessor, R., Reed, H., Lloyd, C., Behrman, J., & Lam, D. (2005). Conceptual framework. In National Research Council Institute of Medicine (Ed.), Growing up global: The changing transitions to adulthood in developing countries (pp. 3263). Washington, DC: The National Academies Press. Davis, E. C., & Friel, L. V. (2001). Adolescent sexuality: Disentangling the effects of family structure and family content. Journal of Marriage and the Family, 63, 669681. , N. (2005). Siblings premarital childbearing and the timing of Diop-Sidibe te dIvoire. International Family rst sex in three major cities of Co Planning Perspectives, 31, 5462. Dittus, P., & Jaccard, J. (2000). Adolescents perceptions of maternal disapproval of sex: Relationships to sexual outcomes. Journal of Adolescent Health, 26, 268278. Djamba, K. Y. (2003). Social capital and premarital sexual activity in Africa: The case of Kinshasa, Democratic Republic of Congo. Archives of Sexual Behavior, 32, 327337. Elbedour, S., Bart, W., & Hektner, J. (2007). The relationship between monogamous/polygamous family structure and the mental health of Bedouin Arab adolescents. Journal of Adolescence, 30, 213230. Elbedour, S., Onwuegbuzie, A. J., Caridine, C., & Abu-Saad, H. (2002). The effects of polygamous marital structure on behavioral, emotional, and academic adjustment in children: A comprehensive review of literature. Clinical Child and Family Psychology Review, 5, 255271. Fatusi, A. O., & Blum, R. W. (2008). Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC Public Health, 8. doi:10.118611471-2458-8-136. Gage, A. J. (1998). Sexual activity and contraceptive use: The components of the decision-making process. Studies in Family Planning, 29, 154166. Garriguet, D. (2005). Early sexual intercourse. Health Reports, 16, 918. Gertler, P., Levine, D. I., & Ames, M. (2004). Schooling and parental death. Review of Economics and Statistics, 86, 211225.

with a higher degree of internal validity. Therefore, no denitive statement is made about the inuences of parentchild interactions on premarital intercourse. For instance, parent-youth communication was measured using dichotomous items about ve topics (sexual education, puberty, pregnancy, STDs/HIV/AIDS, and alcohol/drug use), yet a Likert scale could provide a wider variation to better capture its associations with premarital intercourse. Likewise, the quality of parentchild relationships are self-reportedperceptionsonly. Parentsviewsmay provideanother face of parental involvement. Parental control and parentchild relationships consisted of one item on a 5-point Likert scale. Such measures may be unreliable or less appropriate to capture the complexity of parentchild interactions (Markham et al., 2010). Notwithstanding these caveats, ndings retrieved from the uniquely rich data at hand in the African context, provide a rationale for further investigations regarding family environment and youth sexual behavior in SSA, a relatively under-studied research area to date (Kuate Defo, 2011). The current study provides a clear indication that family environment should be a key component of RH interventions in Cameroon and other African societies; and how families can mitigate the negative effects associated with youth sexual behavior. Practitioners, policymakers and stakeholders need to work together with families, and broadly with communities to build strong networks to expect long-lasting effects on RH matters. Family transitions also appeared to be strongly associated with the risk of premarital intercourse in Bandjoun. Methodologically, more detailed information would be necessary to fully capture the effects of family transitions on premarital intercourse. Ideally, prospective studies should provide more detailed and accurate information about family transitions compared with retrospective data due to recall biases. However,prospectivestudiesareoftencostlyandtime-consuming;their feasibility in the context of SSA is very limited.
Acknowledgments This work was carried out as a part of the research program on Reproductive Behavior, Population Health and Nutrition in Africa of the PRONUSTIC Research Laboratory at the University of Montreal. The data collection and eldwork activities were supported by Rockefeller grants RF 97045 #82 and RF 97045 #90 to Professor Barthelemy Kuate Defo. The present study was supported by those grants and a doctoral fellowship grant from the Mellon Foundation to Dr Zacharie Tsala Dimbuene. We thank Ann Biddlecom, Justine Gibbings, Aldo Bongiorno, Christian Mbarga, and Keith Owre for comments and suggestions on earlier versions of this article presented to the 5th African Population Conference (Arusha, Tanzania, December 1014, 2007) and the 2009 Annual meeting of Population Association of America (Detroit, Michigan, April 30May 2, 2009). We are also grateful to three anonymous referees and the Editor for thoughtful and helpful comments on an earlier version of the article.

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