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Comparing the awareness of and beliefs in sexually transmitted infections among university students in Madagascar and the United States of America
Abstract and Figures
Young adults have a higher risk of contracting sexually transmitted infections (STIs) than other age groups. This risk may be mediated by their social and cultural setting which can impact young adults’ awareness of, beliefs in, and risk of contracting STIs (including HIV/AIDS). In order to understand how these factors vary among young adults of different cultures, it is important to study these issues on a cross-cultural scale. This study aimed to increase understanding of the relationship between the culture of a place of study and: (1) STI awareness; (2) belief in STIs; and (3) self-reported STI prevalence in the study population. Survey data were collected from university students in Madagascar ( n = 242 surveys in 2013) and the United States of America ( n = 199 surveys in 2015). Compared to students at the American university, students at the Malagasy university: (1) did not appear to have a conclusively lower awareness of STIs; (2) did not differ in rates of belief in the existence of gonorrhea and syphilis, but had higher rates of disbelief in HIV/AIDS; and (3) were more likely to report having been infected with syphilis and gonorrhea, but not with HIV/AIDS. Students at the Malagasy university also listed different reasons than the students at the American university for why they believed in the existence of STIs. These findings highlight the need for further cross-cultural research to better adapt intervention strategies to different cultural settings.
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... nine in South Africa [24,27,29,34,37,42,46,82,84], five in each of Ghana [19,31,65,66,68] and Ethiopia [21,73,77,78,80], four in Uganda [13,55,72,75], three in Mozambique [22,26,30], two in each of Namibia [45,76]and Cameroon [59,67], one in each of Congo [25], Sudan [33], Senegal [39], Morocco [47], Gambia [50], Tanzania [53], Madagascar [71] and Egypt [74] while a Fig 2). Heterogeneity was high in all questions (I 2 more than 80%), except for the question "Is TB associated with HIV infection?" ...
... Adolescents and young people. The study participants' age were greater than 14and less than 25 years in thirteen HIV-related included studies, representing a total population of 5,908 participants; five studies were conducted in Nigeria [14,[16][17][18]63], three in Ghana [19,31,66], two in Mozambique [26,30], and one in each of Cameroon [59], Madagascar [71]and Uganda [72]. Majority of studies were toward students and adolescents (11/13) while two studies were conducted among pregnant women. ...
... Fourteen included studies assessed the awareness of 9,446 Africans in regard to HBV, three studies were conducted in each of Nigeria [61,62,64], Cameroon [20,40,58] and Ghana [12,15,28], two in Ethiopia [32,52], one in each of Kenya, Mozambique and Madagascar [26,57,71]. The oldest among the study included was conducted in 2010 while the newest was conducted in 2016 (Table 1). ...
Sexually Transmitted Infections (STIs) are ambiguous burden of tremendous health, social and economic consequences. The current systematic review was conducted in order to determine awareness and knowledge of Africans toward sexually transmitted infections, not only concerning HIV/AIDS, but also other STIs such as gonorrhea, syphilis, HBV, HCV and HPV. A systematic review of literature was conducted, studies were retrieved and selected after fulfilling the inclusion criteria as well as passing the assessment procedure. Related data was extracted, quantitative analysis was conducted among participants who responded to questions related to HIV, HBV, HCV, HPV or STIs knowledge, sensitivity analysis as well as subgroup analysis were also conducted. Seventy four articles addressing knowledge among 35 African countries were included and 136 questions were analyzed and synthesized. The question "does using condom reduces HIV transmission?" was answered by 1,316,873 Africans in 35 countries, 66.8% [95% Cl; 62.6, 70.9] answered yes. While the question "is sexual contact a possible route of HBV transmission?" was answered by 7,490 participants in 5 countries; 42.5% [95% Cl; 20.4, 64.7] answered yes. The differences observed among populations are highlighting the possibility for improvement by directing light toward specific populations as well as addressing specific awareness knowledge to ensure that the general as well as the related specific preventive knowledge is improved.
... nine in South Africa [24,27,29,34,37,42,46,82,84], five in each of Ghana [19,31,65,66,68] and Ethiopia [21,73,77,78,80], four in Uganda [13,55,72,75], three in Mozambique [22,26,30], two in each of Namibia [45,76]and Cameroon [59,67], one in each of Congo [25], Sudan [33], Senegal [39], Morocco [47], Gambia [50], Tanzania [53], Madagascar [71] and Egypt [74] while a Fig 2). Heterogeneity was high in all questions (I 2 more than 80%), except for the question "Is TB associated with HIV infection?" ...
... Adolescents and young people. The study participants' age were greater than 14and less than 25 years in thirteen HIV-related included studies, representing a total population of 5,908 participants; five studies were conducted in Nigeria [14,[16][17][18]63], three in Ghana [19,31,66], two in Mozambique [26,30], and one in each of Cameroon [59], Madagascar [71]and Uganda [72]. Majority of studies were toward students and adolescents (11/13) while two studies were conducted among pregnant women. ...
... Fourteen included studies assessed the awareness of 9,446 Africans in regard to HBV, three studies were conducted in each of Nigeria [61,62,64], Cameroon [20,40,58] and Ghana [12,15,28], two in Ethiopia [32,52], one in each of Kenya, Mozambique and Madagascar [26,57,71]. The oldest among the study included was conducted in 2010 while the newest was conducted in 2016 (Table 1). ...
Sexually Transmitted Infections (STIs) are ambiguous burden of tremendous health, social and economic consequences, The current systematic review was conducted in order to determine awareness and knowledge of Africans of sexually transmitted infections, not only concerning HIV/AIDS, but also other STIs such as, gonorrhea, syphilis, HBV, HCV and HPV. A systematic review of the literature was conducted, studies were retrieved and selected after they fulfilled the inclusion criteria and passed the assessment procedure. related data was extracted, quantitative analysis was conducted among participants who responded to questions related to HIV, HBV, HCV, HPV or STIs knowledge, sensitivity analysis as well as subgroup analysis were also conducted. Seventy four articles addressing knowledge among 35 African countries were included and 136 questions were analyzed and synthesized. The question Using condom will reduce HIV transmission?'' was answered by 1,799,374 Africans in 35 countries, 66.82% [95% Cl; 62.65, 70.98] answered yes. While the question ''Is sexual contact a possible route of HBV transmission?'' was answered by 7,490 participants in 5 countries; 42.58% [95% Cl; 20.45, 64.71] answered yes. The differences observed among populations are highlighting the possibility for containment and control by directing light toward specific populations or countries as well as addressing specific awareness knowledge to ensure that the general as well as the related specific preventive awareness knowledge is improved.
... A ocorrência de IST é maior entre jovens de 14 a 29 anos em comparação às demais faixas etárias, pois foi observado que o início da atividade sexual e o número elevado de parcerias sexuais resulta em maior exposição aos agentes infecciosos nessa faixa etária. A população universitária constitui um grupo que apresenta alta exposição aos agentes dessas doenças, uma vez que o número elevado de parcerias sexuais está relacionado à maior vulnerabilidade [3][4] . ...
... Estudos apontam que o ingresso em instituições de ensino superior pode contribuir para o aumento da vulnerabilidade de jovens às IST. Embora muitos estudantes universitários acreditem possuir o conhecimento necessário para a prevenção das IST, observa-se maior empenho relacionado aos cuidados para evitar gravidez indesejada, pela adesão ao anticoncepcional oral em detrimento do uso de preservativos [3][4][5] . ...
OBJETIVO: Analisar o comportamento sexual e a ocorrência de sífilis em estudantes da área da saúde de uma universidade pública do estado do Piauí. MÉTODO: Estudo epidemiológico, transversal, realizado no período de outubro de 2017 a fevereiro de 2018, com 357 estudantes universitários da área da saúde. Os dados foram coletados por meio de questionário, com perguntas fechadas e semiabertas, e teste rápido para Sífilis. Foram realizadas análises univariadas e bivariadas por meio da distribuição de frequências e teste exato de Fisher. Os dados foram analisados com o uso do Statistical Package for the Social Sciences. RESULTADOS: Verificou-se que 135 (37,8%) estudantes afirmaram não utilizar o preservativo em todas as relações sexuais; 200 (56,0%) foram classificados com comportamento sexual de risco; a frequência do uso de bebida alcoólica apresentou associação significativa com comportamento sexual de risco (p=0,001). Foram detectados 2 (0,6%) resultados reagentes para sífilis, ambos discentes do curso de Odontologia. CONCLUSÃO: Embora a ocorrência de sífilis nos estudantes tenha sido abaixo da esperada, a utilização de álcool previamente às relações sexuais pode comprometer práticas sexuais seguras.
... Baek et al. 2012;Jaworski & Carey, 2007;AL-Malki 2014;Samkange-Zeeb et al. 2013). In particular, the transition from high school to college is an indispensable milestone that holds the potential for behavioral changes and opportunities to engage in a variety of risky sexual behaviors; this makes young people vulnerable to the health burdens of STDs (Fromme, Corbin & Kruse 2008;Reuter, McGinnis & Reuter 2018). In a study, 50% of the sexually active college students reported no condom use during sexual intercourse; this finding highlights the role of insufficient knowledge about sexually transmitted diseases (Steinmetz 2013). ...
... Due to the disease burden of STDs, young adults need to be addressed for STD prevention and education provided by public healthcare providers (Reuter et al. 2018;Von Rosen et al. 2018). ...
Background: Sexually Transmitted Diseases (STDs) are among the most prevalent infectious diseases in young people. The present study assessed the knowledge of STDs among college students.
Methods: This cross-sectional descriptive study that was conducted on 345 undergraduate students at a large public university in the United States. The students were recruited by convenience sampling method. The Sexually Transmitted Disease Knowledge Questionnaire (STD-KQ) was applied in the survey. The study participants responded to the survey anonymously through the Qualtrics online portal. Descriptive statistical analyses were conducted to examine the knowledge levels of the STDs in young adults. Independent Samples t-test and Analysis of Variance (ANOVA) were used to determine the correlation between the knowledge level and demographic data of the subjects. Moreover, SPSS was used for data analysis.
Results: In total, 345 undergraduate students aged 18-22 years participated in the present study. Among them, 196 (56.8%) were male. The samples’ Mean±SD score of STD knowledge was 15.66±5.84 (out of 27 points in total). The study participants who previously received sexual education courses achieved higher knowledge scores, compared to the others.
Conclusion: The study results revealed a lack of STD knowledge in young adults. There is a need for conducting educational programs among college students to improve their understanding of STDs etiology and prevention.
... This conclusion was reached by Kalamar et al. 75 , who evaluated young people from low-and middle- income countries and stated that risky sexual behaviour, condom use, and sexual activity are subject to social desirability bias. The changing epidemiology of oral syphilis reflects the decreasing use of barrier methods of contraception by adolescents and young adults 76 ; moreover, these individuals have a higher risk of contracting sexually transmitted infections than those in other age groups 77 . Other authors argue that a false sense of security exists, originating from the concept that STDs are curable, and that this has led individuals to have a large number of sexual partners and also to maintain sexual promiscuity, mainly with condomless anogenital and oral sex among men who have sex with men (MSM) 10,78 . ...
The aim of this study was to describe 40 cases of acquired oral syphilis (AOS) and to discuss the distribution of demographic characteristics, clinical features, and differential diagnosis of the disease. A retrospective study was conducted covering a 17-year period at a single institution in southern Brazil. Moreover, a literature review was performed through a search of the PubMed database for articles on AOS published between 1955 and March 2018. Data were analyzed descriptively. The predominant group within the case series was male patients in their twenties. The vast majority of cases (92.5%) were in the secondary stage of the disease. The lips were the most commonly affected site, with greyish-white mucous patches and reddish ulcers. In the literature review, the largest number of reported cases came from North America. Male patients in the third and fourth decades of life were most affected. AOS occurred more commonly as mucous patches and ulcers on the tongue and palate. Similarities regarding the distribution by sex, age, and anatomical location were found in the present study when compared to cases reported elsewhere. Clinicians, oral pathologists, and maxillofacial surgeons should familiarize themselves with the variable spectrum of signs and symptoms of AOS in their clinical practice to improve diagnosis and management. © 2018 International Association of Oral and Maxillofacial Surgeons
Introduction:
Knowledge about HIV/AIDS is essential for facilitating safer sexual behavior change hence crucial in controlling HIV. Therefore, in the absence of a cure for the pandemic, adequate knowledge about the virus remains the backbone of prevention efforts.
Objective:
To assess the knowledge regarding HIV/AIDS among undergraduate students at a rural university in Limpopo Province, South Africa.
Methods:
A cross-sectional descriptive quantitative survey design was conducted at a rural-based university in South Africa. A self-administered questionnaire composed of 26 questions was utilized to gather data and was analyzed using SPSS version 26. Stratified random sampling was used to select 345 students. Multiple logistic regression and chi-square tests [χ2] were employed to determine the association between HIV/AIDS knowledge and demographic variables.
Results:
The overall HIV/AIDS knowledge score of students shows [74/21%] had an insufficient level of knowledge, [126/37%] had the average ability, and [145/42%] had adequate knowledge. There was no significant difference between male and female students regarding their understanding of HIV/AIDS. Student factors such as age, level of study, the field of study, and religion were not significantly associated with HIV/AIDS knowledge. However, race was significantly associated with knowledge with coloreds and mixed races, almost six times less knowledgeable than blacks.
Conclusion:
In conclusion, students had inadequate knowledge about HIV/AIDS. Misconceptions about HIV/AIDS facts, transmission routes, and prevention aspects were also prevalent among students. The present study accentuates the need for providing students with more HIV/AIDS education to close HIV knowledge gaps and misconceptions.
This article explores both the sexual desires and pleasure in the context of HIV pre-exposure prophylaxis (PrEP) use among gays, bisexuals and other men who have sex with men (GBMSM). Our main findings suggest that individuals were assuming notions of natural and unnatural sex, while these categories were linked to condomless sex, acquisitions of sexually transmission infections (STIs) and their perceptions of intimacy. Individuals also believed they could enhance pleasure and desire by acknowledging their inner subjectivity and societal positions associated with PrEP. We argue that the individuals play a positive and conflicting ethic towards sex while on PrEP.
Despite extensive multilateral programming in Madagascar, contraceptive use remains low and infection rates of sexually transmitted infections (STIs) are high. Increased understanding of how young adults – a high-risk group – participate in sex could help inform these challenges. In this study, we: (1) examined how gender and sexual orientation influence the sexual behaviors of young adults; and (2) measured respondent knowledge regarding STIs and their prevention. Using surveys of 242 young adults, we found that females (76%) were less likely to have had vaginal sex than males (91%) and did so at a lower frequency (2.34 and 5.69 times/month, respectively). Individuals self-identifying as homosexual were more likely to have engaged in anal sex (25%) than heterosexual individuals (3.8%). In addition, we found that almost 25% of respondents expressed disbelief in the existence of HIV. Although most respondents (52%) cited the use of condoms during vaginal sex, few reported having received STI-related information from healthcare practitioners. This may point to a need for additional outreach, targeting both the general public and healthcare workers. Our findings suggest that additional studies should focus on understanding the sexual activities of at-risk groups who might require unique outreach programs.
Background
Quantifying sexually transmitted infection (STI) prevalence and incidence is important for planning interventions and advocating for resources. The World Health Organization (WHO) periodically estimates global and regional prevalence and incidence of four curable STIs: chlamydia, gonorrhoea, trichomoniasis and syphilis.
Methods and Findings
WHO’s 2012 estimates were based upon literature reviews of prevalence data from 2005 through 2012 among general populations for genitourinary infection with chlamydia, gonorrhoea, and trichomoniasis, and nationally reported data on syphilis seroprevalence among antenatal care attendees. Data were standardized for laboratory test type, geography, age, and high risk subpopulations, and combined using a Bayesian meta-analytic approach. Regional incidence estimates were generated from prevalence estimates by adjusting for average duration of infection. In 2012, among women aged 15–49 years, the estimated global prevalence of chlamydia was 4.2% (95% uncertainty interval (UI): 3.7–4.7%), gonorrhoea 0.8% (0.6–1.0%), trichomoniasis 5.0% (4.0–6.4%), and syphilis 0.5% (0.4–0.6%); among men, estimated chlamydia prevalence was 2.7% (2.0–3.6%), gonorrhoea 0.6% (0.4–0.9%), trichomoniasis 0.6% (0.4–0.8%), and syphilis 0.48% (0.3–0.7%). These figures correspond to an estimated 131 million new cases of chlamydia (100–166 million), 78 million of gonorrhoea (53–110 million), 143 million of trichomoniasis (98–202 million), and 6 million of syphilis (4–8 million). Prevalence and incidence estimates varied by region and sex.
Conclusions
Estimates of the global prevalence and incidence of chlamydia, gonorrhoea, trichomoniasis, and syphilis in adult women and men remain high, with nearly one million new infections with curable STI each day. The estimates highlight the urgent need for the public health community to ensure that well-recognized effective interventions for STI prevention, screening, diagnosis, and treatment are made more widely available. Improved estimation methods are needed to allow use of more varied data and generation of estimates at the national level.
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Sexual health indicators for young remote-living Aboriginal women are the worst of all of Australian women. This study aimed to describe and explore young women's behaviour and knowledge in relation to sexual health, as well as to provide health professionals with cross-cultural insights to assist with health practice. A descriptive ethnographic study was conducted, which included: extended ethnographic field work in one remote community over a six-year period; community observation and participation; field notes; semi-structured interviews; group reproductive ethno-physiology drawing and language sessions; focus-group sessions; training and employment of Aboriginal research assistants; and consultation and advice from a local reference group and a Cultural Mentor. Findings reveal that young women in this remote community have a very poor biomedical understanding of sexually transmitted infections and contraception. This is further compounded by not speaking English as a first language, low literacy levels and different beliefs in relation to body functions. In their sexual relationships, young women often report experiences involving multiple casual partners, marijuana use and violence. Together, the findings contribute to a better understanding of the factors underlying sexual health inequity among young Aboriginal women in Australia.
The aim of this study was to gather knowledge regarding the conception of young people as for HIV/AIDS and the use of condoms in sexual intercourse. Survey conducted in May, 2012, at a public school in the city of João Pessoa, Paraíba, with eleven young people of both sexes. The chosen technique of investigation was a semi-structured interview. Empirical data were organized according to categorical content analysis, the following categories emerging: "AIDS: what young people think", "AIDS prevention methods" and one subcategory "Trust in the partner as a method for HIV/AIDS prevention". As observed, there is knowledge of condom use as a preventive method against HIV/AIDS; trust in the partner and faithfulness were also cited as preventive methods in both sexes. It is suggested that, when investing in national and regional proposals, not only social inequalities are to be considered but especially the local realities of different young people in different national scenarios.
This study explored community perceptions of cultural beliefs and practices that may increase sexual risk behaviour of adolescents, to understand more about meaning they hold within the culture and how they expose adolescent orphans and non-orphans to higher risks in a high HIV and teenage pregnancy prevalence context.
Using a qualitative descriptive cross-sectional design 14 focus group discussions were conducted with 78 adolescents and 68 parents/guardians purposively selected to represent their communities. Thirteen key informant interviews were also conducted with community leaders, health care and child welfare workers, and adolescents who were also selected purposively. The two methods were used to explore how cultural beliefs and practices predispose adolescent orphans and non- orphans to risky sexual behaviours. Data were analysed through line-by-line coding, grouped into families and retrieved as themes and sub-themes.
Identified cultural practices that predisposed adolescents orphans and non-orphans to risky sexual behaviours included: adolescent sleeping arrangements, funeral ceremonies, replacing a deceased married daughter with her younger sister in marriage, widow inheritance among boys, early marriage among girls, and preference for boys/sons. Cultural risks perceived to equally affect both orphans and non-orphans were sleeping arrangements, funeral ceremonies, and sister replacement. Factors associated more with orphans than non-orphans were widow inheritance among boys and a preference for boy over girl children.
Adolescent sexual risk reduction programs should be developed considering the specific cultural context, using strategies that empower communities to challenge the widely accepted cultural norms that may predispose young people in general to sexual risks while targeting those that unequally influence orphans.
Among a self‐selected group of 330 first‐year college students we assessed frequency of condom use, reasons for using condoms, and attitudes toward condoms, sexuality, and the double standard. A packet including demographic and sexual history items, along with three attitude measures, was distributed to a random sample of first‐year students. The majority (86.4%) of respondents had engaged in sexual intercourse, and 34.2% of those subjects reported two or more new sexual partners since arriving at college. Although 80.3% of those who had engaged in sexual intercourse since arriving at college reported using a condom, only 20.7% of students who had ever engaged in sexual intercourse reported using a condom every time. Logistic analyses were used to investigate the relationship between condom‐related behaviors and attitudes toward condoms, sexuality, and the double standard. These findings suggest that if condom use is to become a major element in the fight against AIDS, as well as in the prevention of other sexually transmitted diseases and unwanted pregnancies, steps must be taken to increase positive attitudes toward condoms. Recommendations for educating first‐year college students are provided.
The aim of this study was to examine HIV sexual risk behaviours and perception of HIV risk among 1 095 students from the United States of America (US), Turkey and South Africa. Randomly selected students who were enrolled in general education courses completed a structured questionnaire. Results revealed statistically significant differences in specific HIV-related sexual behaviours among students from the three countries and among male and female students in each country. A higher percentage of US and South African students engage in HIV risky sexual behaviours compared with their Turkish counterparts, and a higher percentage of female students in the US and South Africa engage in HIV sexual risk behaviours compared with their male colleagues. A higher proportion of Turkish male students engaged in sexual risk behaviours compared with their female counterparts. The perception of HIV risk was low among US and Turkish students, and high among South African students. There was no agreement between engaging in risky sexual behaviour and self-perception of HIV risk among South African female students, while agreement was poor for US male and female students, Turkish male and female students, and South African male students. The observed optimistic bias needs to be considered in the design and implementation of HIV prevention programmes for these populations.
Objectives:
Peripartal transmission of human immunodeficiency virus (HIV) and Treponema pallidum, the causative agent of syphilis, leads to severe consequences for newborns. Preventive measures require awareness of the maternal infection. Although HIV and syphilis testing in Madagascar could be theoretically carried out within the framework of the national pregnancy follow-up scheme, the required test kits are rarely available at peripheral health centres. In this study, we screened blood samples of pregnant Madagascan women for HIV and syphilis seroprevalence to estimate the demand for systemic screening in pregnancy.
Methods:
Retrospective anonymous serological analysis for HIV and syphilis was performed in plasma samples from 1232 pregnant women that were taken between May and July 2010 in Ambositra, Ifanadiana, Manakara, Mananjary, Moramanga and Tsiroanomandidy (Madagascar) during pregnancy follow-up. Screening was based on Treponema pallidum haemagglutination tests for syphilis and rapid tests for HIV, with confirmation of positive screening results on line assays.
Results:
Out of 1232 pregnant women, none were seropositive for HIV and 37 (3%) were seropositive for Treponema pallidum.
Conclusions:
Our findings are in line with previous studies that describe considerable syphilis prevalence in the rural Madagascan population. The results suggest a need for screening to prevent peripartal Treponema pallidum transmission, while HIV is still rare. If they are known, Treponema pallidum infections can be easily, safely and inexpensively treated even in pregnancy to reduce the risk of transmission.
The current sexually transmitted disease (STD) epidemic in adolescents has led to concern about the potential for spread of the human immunodeficiency virus (HIV). In 1988, a total of 5514 students in first-year community college and university classrooms across Canada were surveyed to assess STD/HIV-related knowledge, attitudes, and risk behavior. The students' mean age was 19.7 years; the male-to-female ratio was 1:1.4. Students knew more about HIV/acquired immunodeficiency syndrome than other STDs. Of the 74.3% of the men and 68.9% of the women who were coitally active, 14.3% of the men and 18.6% of the women had participated in anal intercourse and 5.5% reported a previous STD. Only 24.8% of the men and 15.6% of the women always used a condom during sexual intercourse. Among the 21.3% of the men and 8.6% of the women with 10 or more partners, regular condom use was reported in only 21% and 7.5%, respectively. In this subgroup, anal intercourse was practiced by 26.9% of the men and 34.8% of the women, and previous STD was reported by 10.6% and 24.2%, respectively. Factors associated with not using a condom included number of sexual partners, embarrassment about condom purchase, difficulty discussing condom use with a partner, use of oral contraceptives, insufficient knowledge of HIV/STDs, and the belief that condoms interfere with sexual pleasure. These factors are potentially amenable to change. Effective, behaviorally focused educational programs are needed to improve condom use and reduce STD/HIV risk.(JAMA. 1990;263:3155-3159)
This article investigates some issues related to gender and education based on a qualitative, empirical study of women in higher education in the Toliara region of Madagascar. The focus is on how women’s participation in higher education has created changes in gender relations, and how these women have succeeded in achieving higher education. In spite of the interviewed women’s more influential social position and individual freedom, we found that the traditional gender expectations and economic expectations from the extended family are still present. Indeed, it appears that with rising social position and individual freedom, the pressure and demands from their extended families increase.