International Journal of Nursing & Care

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1 Research Article Research Article International Journal of Nursing & Care ISSN Predictors of Early Initiation of First Sex among Youth: Comparison Study Among Cameroonian and Gabonese Youth Aged Years Minet Tesfai Hadish 1,2, Jing Mao 1*, Guilan Gong 1, Berhe Tesfai Hadish 3, Eyasu Habte Tesfamariam 4, Afewerki Weldezghi Tesfay 5, Okbamichael Tekle Zewde 2, Andom Yohannes Ghebray 2, and Teame Russom Hadgu 6,2 1 School of Nursing, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China. 2 School of Nursing, Asmara College of Health Sciences, Asmara, Eritrea. 3 Hospital Massawa, Zoba Semenawi Keyh Bahri, Ministry of Health, Massawa, Eritrea. 4 School of Public Health, Asmara College of Health Sciences, Asmara, Eritrea. 5 School of Public Health, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China. * Correspondance: Jing Mao, MD. Ph.D. Dean, School of Nursing, Tongji Medical College of Huazhong University of Science and Technology, 13Hang Kong Rd, Hankou, Wuhan, Hubei, China , Tel: ; Fax: ; maojing@hust. edu.cn. Received: 16 September 2017; Accepted: 05 October School of Nursing, Faculty of health Sciences, Erciyes University, Kayseri, Turkey. Citation: Minet Tesfai Hadish, Jing Mao, Guilan Gong, et al. Predictors of Early Initiation of First Sex among Youth: Comparison Study Among Cameroonian and Gabonese Youth Aged Years. Int J Nur Care. 2017; 1(5): ABSTRACT Background: In Cameroon and Gabon, the most highly HIV prevalent West African countries, adolescents are sexually active before age of 15. The main complications of early and unsafe sexual intercourse are mentioned as unwanted pregnancy, many sexually transmitted infections, death, abnormal sexual behaviors, and long-lasting or even lifelong mental and physical health consequences. Therefore, the aim of this study was to determine the predicting factors of early initiation of sex among aged Cameroonian and Gabonese youth. Methods: This study used nationally representative datasets from Demographic and Health Surveys (DHS) of Cameroon (2011) and Gabon (2012). A total of 14,880 youth, of which 9511(63.91%) from Cameroon and 5369(36.08%) from Gabon were taken. SPSS version 22 was used to run a binary multivariate logistic regression. Result: About 70% of Cameroonian and 80% of Gabonese youth had a history of sexual intercourse before the survey. Abstinence among youth was very low that 29.8% of Cameroonian and 44.2% of Gabonese youth were lost their virginity before their 15th birthday. Their first sex was very early, ranged from their 5th to 24th years old with a mean age of ± 7.69 years in Cameroon and ± 6.32 years in Gabon. Premarital sex was also very high among Cameroonian (51.5%) and Gabonese (78.4%) youth. Age at first marriage among youth was ranged from 8 to 24 years with the mean age of ± 2.74 years in Cameroon and ± 2.78 years in Gabon. First marriage before age 15 was high among Cameroonian (36.1%) and Gabonese (25.6%) youth. On multivariate analysis, age, place of residence, educational level, religion, marital status, wealth index, occupation, comprehensive knowledge and attitude of respondents were significantly associated with most of the sex before age 15, premarital sex and marriage before 15years. Comparing by gender, Cameroonian and Gabonese males were more likely to have higher premarital sex and sex before age 15. However, males of both countries were less likely to be married before age 15 than their female counterparts. Volume 1 Issue 5 1 of 11

2 Conclusion: In this study, the initiation of sex among youth was found to be very early. So, reproductive health education to young adolescents as well as parents and school collaboration are suggested as a fundamental tool to prevent the early initiation of sex among youth. Keywords Cameroon, Gabon, HIV/AIDS, Initiation of early sex, Predictors, Youth. Background Globally, the first sexual initiation among youth today is believed to be at their younger ages than in the past [1,2] and it is earlier in females compared to their male counterparts [3]. The United Nations Children s Fund (UNICEF) on its report, based on 2005 to 2010 Demographic and Health Surveys (DHS), 14% of girls and 11% of boys aged as well as 17% of females and 9% of males aged had sex before their age of 15 years [3]. That estimate may vary in different regions of the world. For example, the estimate of sex before age 15 among years old adolescent girls was 22% in Latin America, 8% in South Asia, 12% in Eastern and Southern Africa, and 16% in West and Central Africa [3]. Hence, early sex before the age of 15 was higher in West and Central Africa compared to the Eastern and Southern Africa. In Cameroon and Gabon, among the most HIV prevalent West and Central African countries with unwavering HIV epidemic [4-7], youth are sexually active at their younger ages [8-10]. Despite the decline of the new HIV infection by 41% in sub-saharan Africa between 2000 and 2014, in Cameroon, HIV/AIDS prevalence has shown increment from 4.3% in 2011 to 4.8% in 2014 [4,5] and Gabon has displayed minimal decrement from 4.1% in 2012 to 3.9% in 2014 [6,7]. More specifically, in Cameroon, 2.7% of young women and 0.5% of young men were living with HIV in 2011 [11] and in Gabon, the percentage of young people aged 15 to 24 who were living with HIV was 1.5% in 2012 [12]. Early sexual debut among youth is a sign of various failures in protection and care by the community towards youth, which exposes them to violence, exploitation, abuse and neglect [3]. There are many pieces of evidence that in some settings adolescents are pressured into early marriage and childbearing [13]. In developing countries, for example, 38% of girls marry before the age of 18, and 14% before the age of 15 [1]. As a consequence, among the years old mothers in the developing countries, more than onethird marry before their 18th birthday [14]. Even though marriage is a legal tie, adolescents are prone to exploitation and abuse once they enter into a stable relationship which increases their risk to be contracted by HIV [12,15-17]. The younger the adolescent is in a stable relationship, the devastating the exploitations and abuses are, as it often becomes challenging for them to insist on prevention precautions. As a result, HIV infection rates among married young females are significantly higher than among singles. In Zimbabwe among females aged 15-24, for example, HIV prevalence among those currently married or in union was 14.2% compared to 6.2% among never had married youth [18]. And in another study, the incidence of HIV infection among couples was 45.3% compared to the 35.9% among sex workers [11]. Young people up to the age of 18 years, especially young adolescent girls, are often victims of different types of sexual abuses, coercion or even violence [1,19]. United Nations reports have evidenced that up to 45% of the first sexual experiences of the young females were forced and less likely to get contraceptives at their first sexual intercourse [1,14,20]. According to the review from World Health Organization (WHO), the percentages of types of sexual abuses in children and young people up to the age of 18 years were, noncontact sexual abuse (3.1% boys, 6.8% girls), contact sexual abuse (3.7% boys, 13.2% girls), penetrative sexual abuse (1.9% boys, 5.3% girls) and any sexual abuse (8.7% boys, 25.3% girls) [1]. The younger the youth (especially females) is at first sex, the greater the possibility that the sexual initiation is abuse and devastating the complications are [1]. Abuse by its nature is most likely to be unprotected sex as it happens without a plan which intensifies the consequences of the complications of early sex among the helpless young people. Complications of early and unsafe sexual intercourse are many as unwanted pregnancy, numerous sexually transmitted infections (HIV/AIDS, STDs, STIs) among high epidemic areas, death, abnormal sexual behaviors, and long-lasting or even lifelong mental and physical health consequences [1,21]. Communicable diseases including HIV/AIDS are important causes of death, especially in Africa among youth [1]. The number of AIDS-related deaths among adolescents rose by 50% between 2005 and 2012 [22]. Globally, the single leading risk factor for death and disability in women of reproductive age in low- and middle-income countries is unsafe sex [1,14]. In general, sexually transmitted infections are more common among the youth, and almost half of all infected persons worldwide are aged years [1]. Similarly, adolescent birth rates remain high in Africa in which about 16 million births by adolescent girls occur every year [3]. Initiation of early sexual activity among youth leads them to engage in behaviors that are at high risk for negative health outcomes; increased the likelihood of having multiple sex partners [21,23,24]. Even in the early married youth, significant relationship of higher risk sexual behavior development in later ages was found related to early initiation of sex and marriage below age 15 years [21]. In this context, youth are at high risk of such complications due to the early initiation of sex. Nevertheless, the specific needs of adolescents and young people are often overlooked during the development of national HIV strategies, policies, and budget allocations. As a result, young people living with HIV/AIDS often have inadequate access to health and social support services and face considerable stigma and discrimination [18]. Likewise, in Cameroon and Gabon adolescents are sexually active before age 15 [8,9]. However, no study has been done to investigate the predictors of early initiation of sex among youth. Therefore, this study was aimed at presenting an epidemiological study Volume 1 Issue 5 2 of 11

3 that could evidently alleviate this gap by investigating the level of early sexual behaviors and assessing the predicting factors of early sexual initiation among aged male and female youth in Gabon and Cameroon. Method and Design Data Source This study used DHS, conducted in Cameroon (2011) and Gabon (2012) which are the most recent available DHS data of the two countries as of January 2017 [25]. Selection of the countries in this study was determined by the availability of comparable data on risk sexual behaviors and being among the most HIV prevalent Central and West African countries. The DHS is a nationally representative household survey, conducted based on multistage cluster sampling method and by probability proportional to size which provides an internationally accepted, comparable and consistent data among countries [26]. The data collection method in DHS is defined and published elsewhere [26,27]. Variables of early initiation of sex were selected and re-categorized based on the MEASURE DHS online tools for HIV/AIDS survey indicators database [27]. Measures Independent Variables: The explanatory variables of the survey respondents like the level of education, place of residence, and wealth index were taken as they appeared in the DHS data files. The study used only the first two age groups, and 20-24, from the seven 5-year groups created in the data. Marital status was grouped into six categories in the DHS data files, and was recategorized into three; never married/in union, currently in union (married and living with partner), formerly in union (widowed, divorced and separated or no longer living together). The religion of the respondents was grouped into categories which varied between the two countries. Hence, it was recoded into four groups: Christian - (Catholic, Protestant, Methodist, Evangelical and Other Christians), Muslim, Other religion - (Animist and other religions) and No religion. The various categories of occupation in the two countries were re-grouped to working (involving in different works) and not working. Definition of Dependent Variables: Early sexual behaviors among youth included in this study were premarital sex, sex before the age 15 and 18 as well as marriage before age 15. The variables were binary response variables coded 0 for youth those who answered NO and 1 otherwise. Statistical Analysis The study used the Predictive Analytic Software-PASW (SPSS version 22) to analyze the DHS data. Descriptive statistics was used to assess the level of risk sexual behaviors and results of the two countries were displayed using tables. Binary logistic regression was used for multivariate analysis to examine the associations among selected potential correlates of risk sexual behaviors and to compare the risk sexual behaviors by gender and country. Odds ratio and 95% confidence interval was used to observe the associations and comparisons. In the analyses, P-values less than 0.05 were taken as significant. Results Descriptive statistics of the explanatory variables of the survey Descriptive statistics of the Socio-demographic characteristics and other selected explanatory variables of the survey respondents are presented in table 1. Data of a total of 14,880 youth; 4765(32.0%) males and 10,115(68.0%) females, of which 9511(63.9%) from Cameroon and 5369(36.1%) from Gabon was sorted and analyzed. The age group of the respondents was similar in the two countries in which the age groups were slightly dominant, where 53.5% females and 57.5% males from Cameroon, 53.8% females and 60.8% males from Gabon. The urban-rural ratio in Gabon was higher than in Cameroon in both gender groups. Regarding the educational level of the study participants, the majority were secondary in all the gender groups of both countries. However, participants with no education were considerably high (11.5%) among Cameroonian female youth. The religious affiliations of youth in both countries had some differences where the dominant religion was Christianity in all gender groups of both countries, ranged from 74.4% in Gabonese males to 87.4% Gabonese females followed by Muslim in Cameroon and no religion in Gabon. In both countries, never in union youth were dominant followed by currently married youth. In relation to wealth index of participants, opposite pattern was observed between the two countries. In Cameroon, an increasing pattern of percentage was observed from the poorest to the richest, whereas, a decreasing pattern of percentages was observed in Gabon, from poorest to the richest. Regarding the working status of the participants, there exists a big difference in which Cameroonian youth were more engaged in different works than Gabonese youth. Half of Cameroonian female youth were working, but only less than one-quarter of Gabonese female youths were working. Similarly, around three quarter (71.2%) Cameroonian males were working compared to less than half (44.5%) of Gabonese males that participates in different works. Descriptive statistics of the dependent variables of the survey The descriptive statistics of the dependent variables of the survey participants are presented in figure 1. Most of the youth, 67.9% in Cameroon (female=71.2%, male=59.9%) and 81.0% in Gabon (female=81.8%, male= 79.6%), had history of sexual intercourse before the survey. Age at first sex of the study respondents was as early as their fifth birthday to their 24th with a mean age of ± 7.69 in Cameroon and ± 6.32 in Gabon. First sex before age 15 years old was considerably high among youth which was 29.8% in Cameroon (32.3% of females and 23.8% of males) and 44.2% in Gabon (40.6% of females and 50.2% of males). Above 30% of Cameroonian and 32% of Gabonese youth started sexual intercourse within their 15th and 18th birthdays. Only, 7.2% of Cameroonian and 3.9% of Gabonese youth had their first sex after their 18 years old. The majority of the youth, 58.7% of Cameroonian and 75.2% of Gabonese, had sex before age 18 years. Generally, abstinence among youth was very low in which only 48.5% of Cameroonians and 21.6% of Gabonese youth did not had sex before their first marriage or cohabitation. Premarital sex Volume 1 Issue 5 3 of 11

4 Variables CAMEROON GABON Female (N=6708) N(%) Male (N=2803) N(%) Female (N=3407) N(%) Male (N=1962) N(%) Age (53.5) 1612 (57.5) 1834 (53.8) 1192 (60.8) (46.5) 1191 (42.5) 1573 (46.2) 770 (39.2) Type of residence Urban 3585 (53.4) 1561 (55.7) 2476 (72.7) 1403 (71.5) Rural 3123 (46.6) 1242 (44.3) 931 (27.3) 559 (28.5) No education 771 (11.5) 134 (4.8) 76 (2.2) 44 (2.2) Educational status Primary 1984 (29.6) 754 (26.9) 872 (25.6) 492 (25.1) secondary 3698 (55.1) 1770 (63.1) 2374 (69.7) 1389 (70.8) Higher 255 (3.8) 145 (5.1) 85 (2.5) 37 (1.9) Christian 5072 (75.8) 2066 (74.5) 2975 (87.4) 1459 (74.4) Religion Muslim 1340 (20.0) 570 (20.6) 150 (4.4) 97 (4.9) Other religion 172 (2.6) 28 (1.0) 33 (1.0) 24 (1.2) No religion 110 (1.6) 108 (3.9) 247 (7.3) 381 (19.4) Never in union 3637 (54.2) 2511 (89.6) 2188 (64.2) 1752 (89.3) Marital status Currently in union 2834 (42.2) 261 (9.3) 1083 (31.8) 174 (8.9) Formerly in union 237 (3.5) 31 (1.1) 136 (4.0) 36 (1.8) Poorest 865 (12.9) 368 (13.1) 1156 (33.9) 681 (34.7) poorer 1254 (18.7) 471 (16.8) 817 (24.0) 494 (25.2) Wealth index Middle 1395 (20.8) 584 (20.8) 555 (16.3) 281 (14.3) Richer 1638 (24.4) 679 (24.2) 478 (14.0) 253 (12.1) Richest 1556 (23.2) 701 (25.0) 401 (11.8) 253 (12.1) Occupation Not working 3428 (51.1) 808 (28.8) 2598 (76.3) 1088 (55.5) Working 3280 (48.9) 1995 (71.2) 809 (23.7) 874 (44.5) Table 1: Socio demographic variables. Religion, marital status and Occupation are re-categorized. Cameroon Gabon Variable Female Male Female Male OR 95% CI P OR 95% CI P OR 95% CI P OR 95% CI P Age (Ref=15-19) < < < <0.001 Place of Residence (Ref=Rural) Highest Education level (Ref=No Education) Religion (Ref=No religion) Marital Status (Ref=Never in Union) Urban Primary < < Secondary < < <0.001 Higher < < Christian Muslim < Other Currently married Formerly married < Wealth Index (Ref=Poorest) Occupation (Ref=Not Working) Comprehensive knowledge (Ref=No) Acceptance attitude (Ref=No) Poorer < < Middle < < < Richer < < < Richest < < < Working < < Yes Yes Table 2: Adjusted Odds Ratios (AOR) of Premarital sex against selected variables among y all youth: Cameroon and Gabon. Volume 1 Issue 5 4 of 11

5 Variable Cameroon Gabon Female Male Female Male OR 95% CI P OR 95% CI P OR 95% CI P OR 95% CI P Age (Ref=15-19) < < Place of Residence (Ref=Rural) Urban Highest Education level (Ref=No Education) Religion (Ref=No religion) Marital Status (Ref=Never in Union) Wealth Index (Ref=Poorest) Primary Secondary Higher Christian Muslim <0.001 Other Currently married Formerly married < < < < Poorer Middle < Richer < Richest < Occupation (Ref=Not Working) Working Comprehensive knowledge (Ref=No) Yes Acceptance attitude (Ref=No) Yes Table 3: Adjusted Odds Ratios (AOR) for sex before age 15 among youth: Cameroon and Gabon. Religion, marital status and Occupation are recategorized. Variable Cameroon Gabon Female Male Female Male OR 95% CI P OR 95% CI P OR 95% CI P OR 95% CI P Age (Ref=15-19) < < Place of Residence (Ref=Rural) Urban Highest Education level (Ref=No Education) Religion (Ref=No religion) Marital Status (Ref=formerly in Union) Wealth Index (Ref=Poorest) Primary < Secondary < Higher Christian Muslim Other Currently in union Poorer Middle Richer Richest Occupation (Ref=Not Working) Working Comprehensive knowledge (Ref=No) Yes Acceptance attitude (Ref=No) Yes Table 4: Adjusted Odds Ratios (AOR) Marriage before age 15 against selected variables among y all youth: Cameroon and Gabon. Religion, marital status and Occupation are re-categorized. Volume 1 Issue 5 5 of 11

6 was common among youth that 51.5% of Cameroonian (48.9% of females and 57.8% of males) and 78.4% of Gabonese (77.8% of females and 79.4% of males) had sex before their first marriage or cohabitation. Surprisingly, the percentage of premarital sex among those who had sex before the survey was very high where 76.0% of Cameroonian (females 68.7% and males 96.7%) and 96.9% of Gabonese (females 95.2% and males 99.9%) of those who had sex before the survey had premarital sex. Figure 1: Descriptive statistics of risk sexual behavior output variables. Age at first marriage among youth was ranged from 8 to 24 years with the mean age of ± 2.74 years in Cameroon and ± 2.78 years in Gabon. First marriage before age 15 was high among Cameroonian (36.1%) and Gabonese (25.6%) youth. Especially among females, it was more exaggerated in both countries in which 38.7% of females against 9.6% of males in Cameroon and 28.7% of females against 7.6% of males in Gabon. The majority, 39.4% of Cameroonian and 41.6% of Gabonese youth, got married between their 15th and 18th birthday and 24.4% of Cameroonian and 32.8% of Gabonese youth were married after their 18th birthday. Predicting Factors of Risk sexual Behaviors among Youth: Cameroon and Gabon Premarital sex among youth: Cameroon and Gabon Adjusted Odds Ratios (AOR) of premarital sex against selected variables among Cameroonian and Gabonese youth are presented in table 2. A significant positive association was found between the age of the participants and premarital sex that the age groups were more likely than age groups to have higher premarital sex. However, urban resident Cameroonian females (AOR=0.72, p=0.008) and Gabonese males (AOR=0.63, P=0.009) were less likely to have premarital sex compared to their rural counterparts. On the other hand, no statistically significant association was observed between premarital sex and type of residence among Cameroonian males and Gabonese females. A significant increasing pattern of adjusted odds ratios of premarital sex was found in relation to increasing educational level in Cameroonian youth, but only secondary educated Gabonese males showed significant association comparing to participants with no education. With regard to the religious affiliation of the study participants, Muslim females from Cameroon (AOR= 0.36, p=0.001) and Gabon (AOR=0.09, p=<0.001) as well as Christian (AOR=0.60, p=0.006) and Muslim (AOR=0.37, p=0.007) males from Gabon were less likely to have premarital sex compared to youth with no religion. Regarding marital status, currently married youth from both countries and formerly married females from Gabon showed significantly higher positive odds of premarital sex compared to never in union youth. A considerable difference of adjusted odds ratios of premarital sex was observed between Cameroonian and Gabonese youth with regard to wealth index. Among Cameroonian youth, increasing odds ratio of premarital sex was observed with an increasing of wealth index from the poorer to the richest compared to the poorest, in contrary, the opposite was showed among Gabonese youth that increased wealth status was protecting factor to premarital sex. Working status of the participants and premarital sex was significantly associated in which that indicates working youth were more likely to have premarital sex compared to not working youth in both countries. In contrast, having comprehensive HIV/AIDS knowledge did not show significant association with respect to premarital sex, except in Cameroonian males (AOR=1.22, p=0.045), were more likely to have premarital sex compared to those who did not have comprehensive knowledge. Similarly, acceptance attitude was protective against premarital sex among Gabonese females (AOR=0.79, p=0.044) only. Sex before age 15 among youth: Cameroon and Gabon Adjusted Odds Ratios (AOR) of Sex before age 15 against selected variables among Cameroonian and Gabonese youth are presented in table 3. Sex before age 15 was found to be significantly associated with the age of the participants in which years old Cameroonian (AOR=0.67, p<0.001) and Gabonese (AOR=0.56, p<0.001) females were less likely to have sex before age 15 years compared to the age groups. However, urban residence did not show significant differences to a rural residence to have sex before age 15 years old. Related to educational status, Cameroonian female youth with primary (AOR=0.72, p=0.041), secondary (AOR=0.58, p=0.002) and higher (AOR=0.38, p=0.005) educational level, as well as Gabonese females with higher (AOR=0.31, p=0.014) educational level, were less likely than youth with no education to have sex before age 15 years. However, secondary (AOR=2.66, p=0.004) educated Cameroonian males, secondary (AOR=2.62, p=0.014) and higher (AOR=4.27, p=0.006) educated Gabonese males were more likely to have sex before age 15years compared to youth with no education. Gabonese Christian (AOR=0.77, p=.030), and Muslim (AOR=0.39, p<0.001) males and other religion (AOR=0.19, p=0.001), as well as Gabonese Muslim females (AOR=0.55, p=0.022), were less likely than youth with no religion to have sex before age 15 years. However, Cameroonian youth did not show a significant association between religion and sex before age 15 years. Regarding marital status, currently married youth in both countries, and Cameroonian (AOR=3.45, p<0.001) and Gabonese (AOR=2.52, p<0.001) females who were formerly married were more likely to have sex before age 15 years when compared to never in union youth. The poorer Cameroonian females, as well as the poorer, middle, richer and richest Cameroonian males, Volume 1 Issue 5 6 of 11

7 were more likely to have sex before age 15 years compared to the poorest. However, the opposite was seen in Gabonese females that the poorer, middle, richer and richest were less likely to have sex before age 15years compared to the poorest. Moreover, no significant association was seen in Gabonese males between wealth status and sex before age 15years. Considering occupation, only Cameroonian females and males showed significant association in which working youth were more likely than not working to have sex before age 15 years. Similarly, Gabonese females and males with comprehensive HIV/ AIDS knowledge showed a significant positive association that the knowledgeable youth were less likely to have sex before age 15 years. However, no statistically significant association was found between the acceptance attitude of the participants and sex before age 15 years. Marriage before age 15 among youth: Cameroon and Gabon Marriage before age 15 against selected variables among all youth is presented in table 4. The year group Cameroonian youth (males AOR=0.38, p<0.001 and females AOR=0.19, p=0.001) and Gabonese females (AOR=0.31, p<0.001) were less likely to be married before age 15 compared to the age group. Primary, secondary and higher educated Cameroonian females as well as secondary educated females from Gabon were less likely to be married before age 15. Currently married Cameroonian female youth (AOR= 0.61, p=0.026) were less likely to be married before age 15 compared to the formerly married youth. The richer and richest Cameroonian females were less likely to be married before age 15. However, there was no significant association between the place of residence, religion, occupation, comprehensive Knowledge of HIV/AIDS as well as acceptance attitude and marriage before age 15. Comparisons by Country and Gender The comparison of sexual risk behaviors by country is presented in table 5. Gabonese males were (p<0.001), 3.19 (p<0.001), and 3.61 (p<0.001), times more likely to have premarital sex, sex before age 15, and sex before age 18 than Cameroonian males, respectively. Similarly, Gabonese girls were 6.62 (p<0.001), 1.51 (p<0.001), and 2.09 (p=<0.001), times more likely to have premarital sex, and sex before age 15 and sex before age 18 than Cameroonian females, respectively. However, marriage before age 15 did not show significant difference among Cameroonian and Gabonese youth. Variable GENDER Country OR 95%CI P Premarital sex Sex before age 15 Sex before age 18 Male Gabon (Ref=Cameroon) <0.001 Female Gabon (Ref=Cameroon) <0.001 Male Gabon (Ref=Cameroon) <0.001 Female Gabon (Ref=Cameroon) <0.001 Male Gabon (Ref=Cameroon) <0.001 Female Gabon (Ref=Cameroon) <0.001 Marriage before Male Gabon (Ref=Cameroon age 15 Female Gabon (Ref=Cameroon Table 5: Comparison by country. Comparing by gender (Table 6), Cameroonian males were 3.69 (p<0.001) times more likely to have premarital sex than Cameroonian females. Gabonese males were also (p<0.001), 1.89 (p<0.001), and 1.43 (p<0.001) times more likely to have premarital sex, sex before age 15 and sex before age 18 years than their female counterparts, respectively. On the other hand, Cameroonian males (AOR=0.23, p<0.001) and Gabonese males (AOR=0.20, p=<0.001) were less likely to be married before 15 than their female counterparts. However, to have sex before age 15 and 18 years did not show significant difference with respect to the gender difference in Cameroon. Variable Gender (Ref= Female) Cameroon Gabon OR 95% CI P OR 95% CI P Premarital sex Male < <0.001 Sex before age 15 Sex before age 18 Male <0.001 Male <0.001 Marriage Male < <0.001 before age 15 Table 6: Comparison by gender. Discussion Levels of early initiation of sex among Youth: Cameroon and Gabon In this study, the level of early sexual behaviors such as early first sex before age 15 and 18 years, premarital sex, early marriage before age 15 years were found to be very high. Consequently, abstinence among never-married youth was very low. The findings of the present study indicate that the percentages of early sexual initiation before age 15 of youth was higher than the reports from many regions of the world based on DHS data and the global estimate of early sexual intuition among youth [3] and other studies [21]. Causes of early initiation of sex are many like early marriage, sexual abuse, alcohol and drug influence and cultural and traditional beliefs. As the young adolescents enter to the stable relationship, they often get challenges in negotiation on a safer sex related to fear, partner objection and lack of information and even abuse, coercion or violence [12,14]. However, even though the minimum legal age for marriage in Cameroon and Gabon is 15 years [28], 36.1% in Cameroon and 25.6 % in Gabon married before they reach age 15. As a result, the chance of contracting HIV and other sexually transmitted diseases among youth may be increased as their partners could be sexually experienced and most probably infected [1]. Therefore, the rate HIV infection found to be higher in married female youth than never married youth [12,18] and even in some setting more than the prevalence in sex workers [11]. Young people up to the age of 18 years, both males and females, are often victims of different types of sexual abuses, exploitation, and violence which may increase the rate of early sexual initiation [1,14,20]. Sexual abuse is common even among the married couples who are at stable relationship [12]. Abuse by its nature Volume 1 Issue 5 7 of 11

8 is most likely to be unprotected as it happens without a plan and intensifies the consequences of the complications of early sex among the helpless young people. As research reveals, only a few young females get a chance to use a contraceptive of any kind at their first sexual exposure [20]. It may be aggravated by the influence of alcohol and drug use as they are predisposing factors to the initiation of early and unprotected sex among youth [21,24,29]. The dangerous cultural beliefs and misconceptions like Having sex with virgin cures you of AIDS! [30] and men should marry younger than women [31] can have a big contribution to the early initiation of sex. The magnitude of these cultural factors is worrisome, for example in a study done in South African young students, 69.6% believe that having sex with a virgin can cure you of HIV and 31.2% of females and 22.9% of males indicated that they had sex with someone above 30 years older than them [30]. This may put young adolescents to be victims of many hunters of child sex offenders and child marriage in sub-saharan African countries. On the other hand, there is ample body of research findings that indicate HIV infection is significantly associated with having sex with an older sexual partner [31]. Communities and even laws are not able to stand against these insane acts. The criminal justice of the countries towards protection of child marriage and sex offending is also shallow compared to other violent crimes. Not alone to the semi-legalized child marriage, but even for the sexual abusers, fewer are accused. Based on the study done by Finkelhor [32] of those convicted for child sexual abuse, only a few receive sentences longer than one year however up to around half of them (46%) serve no jail time. Communities with higher ethnic diversities were found to be significant associates of premarital sexual behavior [33]. Cameroon and Gabon are among the countries with the highest ethnic diversities and complex social and cultural variations in Africa in which Cameroon has 250 and Gabon has 40 ethnic groups [34-36]. Another reason could be internal migrations of young people for education or work as high residential mobility is significantly associated with premarital sexual behaviors [33]. Internal migration leads the young people to be away from their families and to get a chance to practice early sexual practices [37]. On the way, they may get a chance to involve in paid sex, which is a more significant contributor to HIV epidemic in Western, Central, and Eastern Africa [38]. Modernization and the fashionable globalization could also be another reason for the early initiation of sex among youth. The lack of information on HIV prevention and the inability to utilize that information in sexual relationships determine the degree of risk among youth [20]. Youth are not only restricted from access to contraception and reproductive services by their lack of knowledge, but most of the reproductive health services in developing countries are also intended to serve the needs of married individuals [1]. In particular, the needs of adolescents and young people are often ignored in many countries during the development of national HIV prevention programs, sexual and reproductive health policies and budget allocations [11,12,36,39-41]. Predicting factors of Risk sexual behaviors among youth: Cameroon and Gabon In this study, age, place of residence, higher educational level, religion, marital status, wealth index, occupation, Comprehensive HIV/AIDS knowledge, and acceptance attitude towards PLHA were significantly associated with premarital sex, sex before age 15 and marriage before age 15 among aged Cameroon and Gabon youth. A significant association was found between the age of the participants and premarital sex that the age groups were more likely than the age groups to have higher premarital sex in both countries and both gender groups. However, the years old Cameroonian and Gabonese females and Cameroonian males were less likely to have sex before age 15 and be married before age 15 compared to the age group which coincides with other reports that the younger youth were more sexually active and engaged in early marriage [8,15,21,42]. Studies suggested that the chances of initiation of first sex is reduced as age advances and reaches the twentieth [21]. Studies found that urban residents had higher premarital sex compared to rural residents [33,43,44]. But, in this study, urban residence was protective against premarital sex among Cameroonian females and Gabonese males. But there was no significant difference between the type of residence and early sex before age 15 and marriage before 15. This difference could be related to the privilege of the access of the urban residents to mass media that could boost their knowledge of HIV prevention [45-47] and thereby equip their behavior to avert early sex [48]. In this study, premarital sex and early sex before age 15 were significantly associated with increased educational level in Cameroon and the secondary educated male in Gabon. This finding was congruent with other similar studies that had reported an increased educational level was predicting factor of premarital sex and early sexual behaviors [33,38,43,44,49-52]. Education was found to be protective against early sex and marriage before age 15 among female youth. Similar results were reported from other studies that youth with primary or secondary level were less likely to have sex at their early ages and thereby lost their virginity at their older ages [53]. Generally, school enrollment and actively involving at school and being goal oriented with an ambition of achieving higher education could be protective against high-risk sexual behaviors [53-55]. In this context, school-based behavior change intervention programs can be sought as it has been evidenced from other countries to reduce sexual risk behavior [56]. On the other hand, poorly educated females are at high risk of getting married at their earlier ages [15]. In this study, religion was found to be protective against premarital sex, sex before age 15 but it was not associated with marriage before age 15. A similar finding was reported that youth who were Volume 1 Issue 5 8 of 11

9 active attendants of religious services were less likely to engage in early sex [54]. Currently married Cameroonian and Gabonese youth and formerly married females from Gabon were more likely to have premarital sex and sex before age 15 than never in union youth. This accords to the results of another study [48]. However, currently married Cameroonian females were less likely to be married before age 15 compared to the formerly married. From these results, we may suggest that being formerly married is a predicting factor of high-risk sexual behavior. Studies found that formerly married were more likely to be infected with HIV than currently married [57]. This could be due to poverty or limited access to high-quality health care which may lead them to engage in higher risk sex for exchange of drugs, money or to meet other needs among females [58]. Among men, separation and being away from home was associated with non-spousal sexual activities [59]. Wealth index was significantly associated with pre-marital sex and early sex before age 15 in Cameroonian youth. This finding was congruent with other similar studies in which youth from the higher wealth index were more likely than the poorest to engage to early sex [33, 43, 49-51, 54]. Hence, the highest prevalence of HIV was seen among the wealthiest quintiles and was increased as wealth increases [60]. Moreover, studies suggested that some wellto-do families may offer money to their youth which intern may contribute to experimenting sex at their early age [38]. The unsafe sexual behavior among wealthier youth may also be evidenced by the higher prevalence of HIV among the wealthiest quintiles and the increased rate of HIV with wealth [4,60]. However, the opposite was seen in Gabonese youth that it was negatively associated with premarital sex and early sex before age 15 and early marriage among Cameroonian females. Studies also indicate that low-income female youth married earlier than wealthy female youth [15]. Working youth were more likely to have pre-marital sex and sex before age 15 than not working youth however it was not significantly associated with early marriage before age 15. Similar studies found that youth who are involved in different works for a salary and away from home can have more rights and decisionmaking autonomy to engage in risky and early sex [21, 23]. In contrary, other studies suggested that youth who were engaged in different works were less likely to have sex at their early ages and thereby lost their virginity at their older ages [53]. Cameroonian males with comprehensive HIV/AIDS knowledge were more likely to engage in premarital sex. knowing about health risks of HIV alone could not lead people to change their behavior [57], concurrently information exposure, use of information and experience of that information were significantly associated with behavior change [61]. This indicates that interventional health education could be best recommended to behavior change. Lack of knowledge about HIV transmission and prevention among youth is well-noted by different researchers [8,47]. The lack of information and the power to use this information in sexual relationships, including in the context of marriage undermines youth to engage in safer sex practices [20]. On the other hand, Gabonese youth having HIV knowledge were less likely to be involved in sex before the age of 15. Nevertheless, HIV knowledge was not significantly associated with early marriage before age 15. Acceptance attitude towards PLHA was protective against premarital sex among Gabonese females. However, no statistically significant association was found between the acceptance attitude of the participants and sex before age 15 years and marriage before 15. Other studies reported similar results that there was no significant relationship found between acceptance attitude and sexual behaviors [62]. Comparison of sexual risk behaviors by country and gender When comparing the countries by controlling all other variables, Gabonese youth were more likely than Cameroonian youth to have premarital sex and sex before age 15. However, no significant difference was shown about marriage before age 15. Comparing by gender, Cameroonian and Gabonese males were more likely than females to have premarital sex. Similar studies reported that men were significantly more likely to have premarital sex than their female counterparts [33]. Gabonese males were more likely to engage in early sex before their 15th and 18th birthday. However, males of both countries were less likely to be married before age 15 than their female counterparts. Young women face higher health costs than men due to their greater use of health care yet they are more likely than their male counterparts to be poor and unemployed and are less considered in the prevention programs. For example, only one female condom is available for every 36 women in Sub-Saharan Africa [14]. Their access to contraception is limited secondary to lack of information and skills, and by the fact that most reproductive health-care services in developing countries are designed to serve the needs of married women of reproductive age [1]. Conclusion In this study, the level of early sex among youth was high. So, designing risk sexual and reproductive health focused on health education is crucial to address the different needs of males and females. Furthermore, female adolescents need to be able to access and use health services, particularly for sexual, reproductive and mental health care. Families and communities should work to change and provide a protective environment for children from the early marriage, exploitation, and abuse, including the prevention of intimate partner violence and sexual violence. It is also very important to investigate protecting, HIV testing and health care seeking behavior of those youth to tackle the HIV epidemic. Limitations of the study This study consists of some limitations related to the crosssectional nature of the study; it looks at associations not causes and effects. The DHS is a household-based survey and hence excludes significant non-household population groups, like those living on streets or in institutions, for example, prisons, colleges or boarding schools, military barracks, refugee camps, which could have more risk sexual behaviors than the household population. Similarly, as Volume 1 Issue 5 9 of 11

10 the questionnaire is designed to collect self-reported responses, there could be recall biases and socially desirable responses and the missing data in the data files may affect the results. Acknowledgments We would like to thank the Demography Health Surveys (DHS) Program, ICF International Rockville USA, for allowing us to use the raw data of this study. References 1. WHO. Women and health: today's evidence tomorrow's agenda. World Health Organization Slaymaker E, et al. Trends in age at first sex in Uganda: evidence from Demographic and Health Survey data and longitudinal cohorts in Masaka and Rakai. Sexually transmitted infections. 2009; 85: i12-i Unicef. Opportunity in crisis: preventing HIV from early adolescence to young adulthood. UNICEF L Institut National de la, S. and I.C.F. International. HIV Prevalence in Cameroon: Finding from the 2011 DHS-MICS UNAIDS. HIV and AIDS Estimates: Cameroon UNAIDS. HIV and AIDS Estimates: Gabon La Direction Générale de la, S. and I.C.F. International. Prévalence du VIH/sida au Gabon: résultats de l EDSG-II WHO. World Health Organization, Media Centre, Major UN Study Finds Alarming Lack of Knowledge About HIV/AIDS Among Young People Foumane P. Sexual activity of adolescent school girls in an urban secondary school in cameroon. Journal of Reproduction & Infertility. 2013; 14: Christiane NA. HIV/AIDS prevalence, knowledge, attitudes and related behaviors among young people in Libreville, Gabon. Journal of Humanities and Social Science. 2014; 19: Cameroun RD. Rapport national de suivi de la declaration politique sur le vih/sida cameroun, in global aids response progress (garp). Onusida Gabonaise R. Rapport National Sur La Reponse Au Vih/Sida 2014, Ministère de la Santé et de la Prévoyance Sociale Neal S. Childbearing in adolescents aged years in low resource countries: a neglected issue. New estimates from demographic and household surveys in 42 countries. Acta obstetricia et gynecologica Scandinavica. 2012; 91: UNAIDS. Every minute, a young woman is newly infected with HIV Nasrullah MR, Zakar MZ. Child marriage and its associations with controlling behaviors and spousal violence against adolescent and young women in Pakistan. Journal of Adolescent Health. 2014; 55: Bamiwuye SO. Odimegwu C. Spousal violence in sub-saharan Africa: does household poverty-wealth matter? Reproductive health. 2014; 11: Gómez AM, Speizer IS. Community-level intimate partner violence and the circumstances of first sex among young women from five African countries. Reproductive health. 2010; 7: Unicef. Eastern and southern Africa, HIV and AIDS, Preventing HIV infection among adolescents and young people. Available September Elveborg Lindskog E. Violent conflict and sexual behavior in Rwanda. Population, Space and Place UNWOMEN. Facts and Figures: HIV and AIDS: Prevalence and New Infections: Factors that fuel HIV and the Response to HIV Kumari A. Nair R. Predictors of high risk sexual behaviour among men in India. Journal of Family Welfare. 2012; 58: AVERT. Averting HIV and AIDS; Global information and advice on HIV & AIDS; YOUNG PEOPLE, ADOLESCENTS AND HIV/AIDS Uchudi, J, M. Magadi, and M. Mostazir, A multilevel analysis of the determinants of high-risk sexual behaviour in sub- Saharan Africa. Journal of biosocial science. 2012; 44: O'Donnell L, C.R. O'Donnell, Stueve A. Early sexual initiation and subsequent sex-related risks among urban minority youth: The reach for health study. Family planning perspectives. 2001; MEASUREDHS. The DHS Program, Demographic and Health Surveys. Available datasets. Available from: dhsprogram.com/data/available-datasets.cfm. 26. MEASUREDHS. STANDARD RECODE MANUAL FOR DHS 6, Demographic and Health Surveys Methodology, Demographic and Health Survey's DHS Toolkit of methodology for the MEASURE DHS Phase III project, implemented from MEASUREDHS. Measure DHS Online Tools. HIV/AIDS Survey Indicators Database. Program Areas and Indicators. 28. GULFNEWS. Legal age for marrriage around the world Stueve A, O donnell LN. Early alcohol initiation and subsequent sexual and alcohol risk behaviors among urban youths. American Journal of Public Health. 2005; 95: Peltzer K, Promtussananon S. HIV/AIDS knowledge and sexual behavior among junior secondary school students in South Africa. Journal of social sciences. 2005; 1: Gregson S. Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. The Lancet. 2002; 359: Finkelhor D. Current information on the scope and nature of child sexual abuse. The future of children. 1994; Uthman O. Does it really matter where you live? A multilevel analysis of social disorganization and risky sexual behaviours in sub-saharan Africa. DHS Working Papers. 2010: Gabon. Factbook, Index Mundi Cameroon. Factbook, Index Mundi Versteegh HP. Evaluation of HIV and AIDS knowledge in rural Cameroon men with the use of a questionnaire. The Pan Volume 1 Issue 5 10 of 11