Background
The connection of teen births with an array of adverse outcomes, such as early neonatal death, low birth weight, anemia, postpartum hemorrhage, puerperal endometritis and high caesarean section rate, has been consistently documented [
1‐
4]. In Nicaragua, 20 % of the total population are adolescents [
5]. The fertility rate was estimated 89 per 1000 girls aged 15 to 19 years in 2014—the second highest rate in Latin America [
5] and teenage girls account for approximately 25 % of births and about half of those births are unintended [
6]. The prevalence of sexual debut before 15 years is 13 % [
7], consequently heightening the incidence of sexually transmitted diseases and unintended pregnancy [
8]. This high fertility occurs in a socio-cultural environment that applauds men with high number of sexual partners and where abortion is illegal [
9]. Although adolescent sexual and reproductive behavior are context-sensitive [
10,
11], until now most of existing research in this field has mainly provided evidence concerning the effect of individual-level characteristics, as highlighted in recent systematic reviews [
12‐
14].
Findings from prior nationwide representative studies supporting the existence of contextual effect on adolescent reproductive outcomes in Nicaragua are manifested in urban –rural differentials in sexual debut among adolescents [
9,
15]. Aside from residence area, smaller geographical units such as neighborhood are of interest for policy decision since they represent a proximate environment where adolescents commonly spend spare time out of their households and create new relationships [
16]. Recognizing the neighborhood-based homogeneity in social network, resource, relationship, and norms, an increasing attention has been paid to the potential role and mechanism of neighborhood attributes on teenage reproductive health, especially in high income countries [
16]. Among the neighborhood-level factors linked with population health outcomes, social capital is one of the commonly reported neighborhood characteristics [
16‐
20].
The theory based on social capital posits that the interplay of social processes (e.g., social connections and social interaction) will have impact on individual health through the provision of resources and the formation of norms, values, and beliefs [
21]. Given its potential malleability, social capital is of relevance to policy makers [
22‐
24]. Nevertheless, the available results pertaining to the connection between social capital and sexual and reproductive health amongst young people were rather mixed, probably due to variation in analytical approach and measure. Several studies in the United States had adopted the ecological study approach [
19,
20,
25]. One study reported a negative correlation between social capital (e.g., measures of organizational life, involvement in public affairs and social trust) and teen pregnancy [
19], and some suggested that social capital (measured by group membership and social trust) may serve as a mediator for income inequality on teen births [
20] and the link between social capital and teen births may be moderated by neighborhood’s ethnic composition when social capital is measured through collective efficacy (a composite scale based on social cohesion and social control) [
25]. A noteworthy point is that studies of ecological design are often limited in disentangling the contextual effect from compositional effect [
26]. To address this limitation, some scholars have turned to the multilevel approach. A study from the U.K. found that social capital (defined as social cohesion and social control) at neighborhood level is negatively associated with teen birth [
17], whereas a study from U.S. reports an insignificant association between neighborhood social capital (defined as social cohesion/trust and social control) and ever having sexual intercourse [
18].
In order to address the abovementioned gaps in the literature, the current study used the latest Demographic and Health Surveys (DHS) to examine whether social capital is associated with sexual onset and teen birth in Nicaragua. In this paper we adopted the multilevel approach to tackle potential effects of three perspectives of community-level social capital: social network, social norms, and resource [
27]. Social network, indexed by residential stability and religious affiliation [
28,
29], reflects the attachment and social interaction with community as well as the degree of participation in community affairs and membership in community organizations [
30]. Social norms, which define the acceptability of behaviors and can be viewed as the basis to build and maintain trust [
31,
32], were measured by percentage of childbearing women with sex behaviors or already having a child. For resource accessibility, we used the percentage of residents with higher education to index the access to information and material resources for collective efforts [
27,
33].
Results
This study included a total of 2 766 young females aged below 20 years. Table
1 portrays the baseline characteristics. Among the entire surveyed sample, the mean year of education attainment is 7.75, the majority (54.6 %) has less than 7 years of education and has the lowest median time to first sexual experience. People from the lowest wealth index (21.0 %) and those with no religion (15.4 %) have the shortest (16 years) median time to sexual debut. Regarding the subsample of female youth who ever had sex (
n = 1 247), the median survival time is prominently longer in the following variables: high education (30 months), being in the richer wealth index (34 months), unmarried (30 months), or residing in urban setting (30 months).
Table 1
Descriptive statistics of female participants aged 15 to 19 years
Women’s education (years) | 7.75 (0.08) | | | 6.90 (0.11) | | | |
Low (0 to 7 years) | | 54.6 | 16 | <0.001 | | 57.6 | 25 | 0.02 |
High (8 to 16 years) | | 45.3 | 19 | | | 42.3 | 30 | |
Wealth index quintiles |
Poorest | | 21.0 | 16 | <0.001 | | 26.1 | 24 | 0.001 |
Poorer | | 16.6 | 17 | | | 20.6 | 33 | |
Middle | | 26.5 | 18 | | | 24.2 | 31 | |
Richer | | 18.4 | 17 | | | 19.5 | 34 | |
Richest | | 17.3 | 19 | | | 9.60 | 31 | |
Marital status |
Unmarried | | 44.4 | | | | 36.5 | 30 | 0.0001 |
Married | | 55.5 | | | | 63.4 | 25 | |
Woman’s religion |
No religion | | 15.4 | 16 | <0.001 | | 20.5 | 25 | 0.50 |
Catholics | | 44.7 | 18 | | | 40.7 | 26 | |
Protestants | | 37.5 | 17 | | | 37.3 | 28 | |
Residence area |
Urban | | 54.9 | 18 | <0.001 | | 48.9 | 30 | 0.002 |
Rural | | 45.0 | 17 | | | 51.0 | 24 | |
Age of sexual debut (years) |
15 or under | | | | | | 62.5 | 27 | 0.80 |
16–19 | | | | | | 37.4 | 25 | |
Have you ever had abortions? |
Yes | | | | | | 14.5 | 27 | 0.91 |
No | | | | | | 85.4 | 27 | |
Table
2 shows the distribution of the community variables. The mean percentage of inhabitants that have lived for less than 10 years in the community is 17.7 %, although between-community variation was observed as denoted by the standard deviation (SD) of 13.3 and the interquartile range (IQR) of 9.3 to 23.1. The mean percentage of Catholics at community level is 46.4 % (SD = 23.9, IQR =26.6–64.7), and the average proportion of respondents with no religion in the community is 14.9 % (SD = 10.6, IQR = 7.1, 21.4). The community average proportion of having experienced sexual debut among women with childbearing ages at the time of survey is 85.5 % (SD = 8.05, IQR = 80.6, 91.3), and on average 71.9 % (SD = 11.0, IQR = 64.7, 80) of women aged 15 to 49 years in the community have had at least a child.
Table 2
Distribution of community variables (N = 356)
Percentage of community inhabitants that have lived in the same community 10 or less years | 17.7 | 13.3 | 14.8 | 9.3–23.1 |
Percentage of community inhabitants that are Catholic | 46.4 | 23.9 | 44.4 | 26.6–64.7 |
Percentage of community inhabitants with no religion | 14.9 | 10.6 | 13.3 | 7.1–21.4 |
Percentage of community inhabitants with secondary school or higher | 43.1 | 27.0 | 40.7 | 18.5–64.5 |
Percentage of childbearing aged females with onset sexual debut (age 15 to 49 years) | 85.5 | 8.05 | 85.7 | 80.6–91.3 |
Percentage of childbearing age women currently having a child (age 15 to 49 years) | 71.9 | 11.0 | 72 | 64.7–80 |
Table
3 exhibits the results of three models of survival analysis predicting transition to sexual onset. As indicated in model 1, all community capital variables appeared to be statistically significant except for community inhabitants with no religion. However, with all individual variables adjusted (model 2), only social norms variables remained significant. Finally, model 3, including both community- and individual-level variables, showed that one social norms (i.e., community-onset sexual debut; adjusted Hazard Ratio [aHR] = 1.47, CI 95 % = 1.39–1.56) and social resource (aHR = 1.16, CI 95 % = 1.02–1.33) may increase the girls’ hazard to have sexual onset. As for individual-level variables, the hazard is reduced by 17 % per 1 year of education (95 % CI = 0.81–0.85), 30 % for richest wealth index (
p < 0.001), and 25 % for Catholics and Protestants (all
p < 0.05).
Table 3
Individual and community characteristics predicting the transition to sexual onset among females aged 15 to 19 years
Community social capital (z-score) |
% of community inhabitants that have lived in the same neighborhood less than 10 years | 1.13 (1.04–1.22)** | 1.06 (0.99–1.14) | 1.01 (0.94–1.09) |
% of community inhabitants that are Catholics | 0.88 (0.81–0.95)** | 0.92 (0.85–1.00) | 0.98 (0.89–1.07) |
% of community inhabitants with no religion | 1.07 (0.99–1.15) | 1.04 (0.97–1.11) | 1.02 (0.95–1.10) |
% of females in the community with onset sexual debut (aged 15 to 49 years) | 1.52 (1.43–1.61)*** | 1.47 (1.39–1.56)*** | 1.47 (1.39–1.56)*** |
% of females in the community aged 15 to 49 years currently having a child | 1.33 (1.25–1.43)*** | 1.14 (1.06–1.24)*** | 1.07 (0.99–1.16) |
% of community inhabitants with secondary school or higher | 0.75 (0.70–0.81)*** | 0.98 (0.85–1.12) | 1.16 (1.02–1.33)** |
Individual characteristics |
Women’s education (years) | 0.81 (0.79–0.82)*** | | 0.83 (0.81–0.85)*** |
Wealth index quintiles |
Poorest | 1 | | 1 |
Poorer | 0.76 (0.63–0.92)*** | | 0.93 (0.76–1.14) |
Middle | 0.66 (0.52–0.83)*** | | 0.96 (0.74–1.23) |
Richer | 0.59 (0.49–0.72)*** | | 0.84 (0.66–1.06) |
Richest | 0.39 (0.31–0.48)*** | | 0.70 (0.54–0.91)*** |
Woman’s religion |
No religion | 1 | | 1 |
Catholics | 0.53 (0.45–0.62)*** | | 0.75 (0.63–0.90)** |
Protestants | 0.64 (0.54–0.75)*** | | 0.75 (0.62–0.89)** |
Residence area |
Urban | 1 | | 1 |
Rural | 1.52 (1.33–1.74)*** | | 0.93 (0.71–1.22) |
The association estimates for community- and individual- characteristics predicting the transition from sexual debut to the first birth occurrence were summarized in Table
4. With all variables adjusted, we found that a higher percentage of female-onset sexual debut and of residents with higher education may reduce the hazard to have the first birth by 38 % (95 % CI = 0.53–0.70) and 11 % (95 % CI = 0.78–0.99), respectively; whereas a higher percentage of females having a child may elevate the hazard by 76 % (95 % CI = 1.52–2.02). At individual-level variables, women who were married have 36 % (95 % CI = 1.12–1.67) greater hazard of birth occurrence while this hazard was decreased by 5 % per year of education, and was 27 % lower for the poorer wealth index group (95 % CI = 0.54–1.00,
p = 0.051).
Table 4
Individual and community characteristics linking transition from sexual debut to first birth among females aged 15 to 19 years
Community social capital (z-score) |
% of community inhabitants that have lived in the same neighborhood less than 10 years | 1.10 (1.01–1.20)** | 1.06 (0.97–1.16) | 1.04 (0.94–1.14) |
% of community inhabitants that are Catholics | 1.00 (0.91–1.10) | 0.99 (0.89–1.10) | 1.03 (0.91–1.16) |
% of community inhabitants with no religion | 1.02 (0.93–1.11) | 1.02 (0.93–1.12) | 1.01 (0.91–1.12) |
% of females in the community aged 15 to 49 years with onset sexual debut | 0.93 (0.85–1.02) | 0.89 (0.81–0.98)** | 0.62 (0.53–0.70)*** |
% of females in the community aged 15 to 49 years currently having a child | 1.13 (1.04–1.22)*** | 1.23 (1.12–1.36)*** | 1.76 (1.52–2.02)*** |
% of community inhabitants with secondary school or higher | 1.14 (1.06–1.24)*** | 0.94 (0.83–1.06) | 0.89 (0.78–0.99)** |
Individual characteristics | | | |
Women’s education (years) | 0.94 (0.91–0.96)*** | | 0.95 (0.92–0.99)** |
Age of sexual onset |
< 15 years | 1 | | |
16 to 19 years | 0.92 (0.74–1.15) | | 1.20 (0.95–1.52) |
Wealth index quintiles |
Poorest | 1 | | 1 |
Poorer | 0.68 (0.52–0.89)** | | 0.73 (0.54–1.00) |
Middle | 0.62 (0.45–0.87)** | | 0.74 (0.50–1.10) |
Richer | 0.65 (0.50–0.86)** | | 0.80 (0.56–1.16) |
Richest | 0.71 (0.53–0.94)** | | 1.03 (0.68–1.54) |
Woman’s religion |
No religion | 1 | | 1 |
Catholics | 0.92 (0.73–1.16) | | 0.89 (0.68–1.15) |
Protestants | 0.84 (0.66–1.05) | | 0.84 (0.65–1.09) |
Residence area | | | |
Urban | 1 | | 1 |
Rural | 1.46 (1.22–1.74)*** | | 1.11 (0.82–1.49) |
Marital status |
Unmarried/no cohabitation | 1 | | 1 |
Married | 1.51 (1.25–1.84)*** | | 1.36 (1.12–1.67)** |
Have you ever had abortions |
No | 1 | | 1 |
Yes | 1.05 (0.82–1.34) | | 1.05 (0.81–1.35) |
Discussion
On the basis of population-based survey in Central America, our results demonstrated that social capital, manifested in the social norm and resource perspectives, may play an important role in shaping teenage girls’ timing of sexual debut and first birth. The prevailing social norms of female-onset sexual debut and resources may increase the hazard of sexual onset by 47 and 16 %, respectively, yet reduce the hazard of having the first birth by 38 and 11 %.
The lack of significant association for social network suggested that social interactions and social cohesiveness generated within community organizations may have little influence on both sexual debut or early childbearing of very young women [
29,
45]. As compared with other religious groups such as Protestants, the Catholicism may be less active in neighborhoods or villages (for example: having fewer churches and offering fewer worship services), which may undermine its influence at the geographical level [
46]. Given that religious-affiliated people are known to be more willing to participate in community affairs [
47], it is also possible that our measure of religion-related social network did not capture the extent to which community members are actively participating, interacting with each other and eventually creating bonds that allow them to cope with adverse situations [
29]. Nevertheless, our study may not be directly comparable with some prior multilevel studies conducted in Kenya, Philippines, and U.S., where different indicators of social network, unit of geographical aggregation (e.g., counties instead of a proxy of neighborhood), and statistical techniques were used [
37,
48‐
50]. Finally, individual-level religion was found to delay the timing of sexual debut, indicating the possibility that religion-related social network (particularly the Catholics) on sexual intercourse may be operated indirectly through individual religious affiliation; for example, this influence could be exerted by inculcating teachings that encourage female adolescents to remain a virgin until marriage [
51].
Prevailing social norms at community-level predict sexual onset and transition to the first birth: high community percentage of female- sexual onset exerts an opposite influence on sexual debut and transition to adolescent motherhood. It is possible that the first sexual encounter was a consequence of male counterpart pressure, sporadic, and not part of a plan to build a family [
52]. Relationships with those characteristics likely end up in disarray and subsequent abandonment and stigma (for losing virginity) [
9] and may make it difficult for girls to build future family or successfully transit to motherhood. Even though no separation occurred after first sexual intercourse, the unmarried girls (as 36.5 % of our analytical sample) may opt for avoiding having a child out of wedlock and being stigmatized [
53]. Living in a community with high percentage of females currently having a child predicts faster transition to first birth which may be an expression of social pressure to start motherhood while still young and being able to cope with physical demanding activities associated with motherhood [
31,
32].
Our community education variable was shown to influence both sexual onset and first birth. Communities with high percentage of inhabitants with secondary school and higher education are expected to have higher levels of social development [
54]. Prior research has established that more developed areas are less likely to follow conservative and traditional lifestyle, thus the observed positive association of community education with sexual onset may reflect departure from traditional norms (e.g., delayed sexual debut) [
9,
37]. More developed communities may also offer adolescents more opportunities such as easier access to schooling, employment, or healthcare that may contribute to deter adolescent childbearing [
13,
55]. This observation, echoing the individual-level findings that higher education may delay the time to having the first birth, highlighted the importance of education, both individually (a form of human capital) and collectively, in young population in order to have healthy development [
56].
This paper has several limitations. First, since the DHS offers a limited set of social capital related-variables, we were unable to use more comprehensive social capital measures used in prior research [
19]. Second, although the quality of data collection from DHS is known to be high, social desirability or recall bias may arise when date of sexual debut was collected. Third, due to the cross-sectional design of our study, no temporal sequence can be established. For example, our measurements of community social capital reflect the characteristics of the current place where the respondent live and not necessarily the characteristics before the outcome occurred. Finally, our results from the subsample of adolescents who have ever had sexual encounters should be interpreted with caution since the younger respondents (e.g., 15-years) are more vulnerable to be right censored even if they had the first sexual debut at the same age with those of the 19-year old.
In spite of these limitations, this paper is one of the first studies examining the role of community social capital on adolescent sexual behavior in the context of middle income countries. Further, the sampling procedures of the DHS would ensure the interpretation with national representativeness. Finally, our multilevel analytical strategy allows us to vividly comprehend the effect each level exerts on sexual debut and teen birth, which help fill gaps in current literature mainly based on single-level studies (individual-level or ecological).
Acknowledgments
We are grateful to Taiwan International Cooperation and Development Fund (ICDF) for scholarship provided for some of the authors. We are also indebted to National Yang Ming University and its International Health Program (IHP) for varied opportunities given to complete the study. We address many thanks to ICF International that provided the datasets used in this study.