CICAD. Comparative Analysis of Student Drug Use in Caribbean Countries. A Report on Student Drug Use in 12 Caribbean Countries

Transcription

1 CICAD Secretariat for Multidimensional Security Inter-American Drug Abuse Control Commission Comparative Analysis of Student Drug Use in Caribbean Countries Antigua and Barbuda, Barbados, Dominica, Grenada, Guyana, Haiti, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Trinidad and Tobago and Suriname A Report on Student Drug Use in 12 Caribbean Countries 2010

2 OAS Catalogue-in Publication Data Comparative analysis of student drug use in Caribbean Countries: Antigua and Barbuda, Barbados, Dominica, Grenada, Guyana, Haiti, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Trinidad and Tobago, and Suriname: A Report on Student drug use in 12 Caribbean Countries OEA/Ser.L/XIV.6.4 ISBN ii

3 Contents Acknowledgements viii Prologue x Chapter 1 Introduction & Background 1 Chapter 2 Methodology 4 Chapter 3 Results 8 Description of Sample 8 Alcohol 11 Cigarettes 21 Non-Medical Use of Prescription Medications (Tranquilizers and Stimulants) 28 Inhalants 30 Marijuana 39 Other Illicit Drugs (Cocaine, Crack, and Ecstasy) 53 Drugs Offered to Students 56 Availability of Drugs 57 Perception of Harmfulness 59 Cigarette Use versus Marijuana Use 63 Chapter 4 Discussion and Implications for Policy 65 Appendixes 69 Appendix A Most Indicated Risk Factors for Each Country 70 Appendix B SIDUC School Survey Methodology 72 Appendix C SIDUC School Survey Questionnaire 80 References 88 iii

4 List of Tables TABLE 1: TABLE 2: TABLE 3: TABLE 4: TABLE 5: TABLE 6: TABLE 7: TABLE 8: TABLE 9: Table 10: TABLE 11: TABLE 12: TABLE 13: TABLE 14: TABLE 15: TABLE 16: TABLE 17: TABLE 18: TABLE 19: TABLE 20: TABLE 21: TABLE 22: TABLE 23: TABLE 24: TABLE 25: TABLE 26: TABLE 27: TABLE 28: TABLE 29: TABLE 30a: TABLE 30b: TABLE 31: TABLE 32: TABLE 33: Sample Sizes and Distribution of Students by Gender Distribution of Sample by Age Group Prevalence of Alcohol Use Alcohol Prevalence by Gender Past Year Alcohol Prevalence by Age Group Past Month Alcohol Prevalence by Age Group Past Year and Past Month Alcohol Incidence Average Age of First Use of Alcohol by Gender Alcohol Use and Behavioral Problems Prevalence of Binge Drinking by Country Prevalence of Cigarette Use Cigarette Prevalence by Gender Past Year and Past Month Cigarette Prevalence by Age Group Past Year and Past Month Cigarette Incidence Average Age of First Use of Cigarettes by Gender Past Year and Past Month Prevalence of Cigarette Use by Behavioral Problems Lifetime, Past Year and Past Month Prevalence of Stimulants and Tranquilizers Prevalence of Inhalant Use Inhalants Prevalence by Gender Past Year and Past Month Inhalant Prevalence by Age Group Past Year and Past Month Inhalant Incidence Average Age of First Use of Inhalants by Gender Past Year and Past Month Prevalence of Inhalant Use by Behavioral Problems Inhalants Prevalence by Number of Repeated School Years Prevalence of Marijuana Use Marijuana Prevalence by Gender Past Year and Past Month Marijuana Prevalence by Age Group Past Year and Past Month Marijuana Incidence Average Age of First Use of Marijuana by Gender Lifetime Prevalence of Marijuana Use by Behavioral Problems Past Year and Past Month Prevalence of Marijuana Use by Behavioral Problems Marijuana Prevalence by Number of Repeated School Years Access to Marijuana Past Year Prevalence of Marijuana Use by Ease of Access iv

5 TABLE 34: TABLE 35: TABLE 36: TABLE 37: TABLE 38: TABLE 39: TABLE 40: TABLE 41: TABLE 42: TABLE 43: Prevalence of Other Illicit Drugs by Gender Drugs Offered to Students Perception of Availability of Cocaine Perception of Availability of Ecstasy Perception of Availability of Crack Cocaine Students Perception of Harmfulness (for All Countries) Perception of Harmfulness Perception of Harmfulness of Solvents and Marijuana Perception of Harmfulness of Cocaine or Crack and Ecstasy Cigarette Use versus Marijuana Use v

6 List of Figures Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: Figure 8: Figure 9: Figure 10: Figure 11: Figure 12: Figure 13: Figure 14: Figure 15: Figure 16: Figure 17: Figure 18: Figure 19: Figure 20: Figure 21: Figure 22: Figure 23: Figure 24: Figure 25: Figure 26: Figure 27: Figure 28: Figure 29: Figure 30: Figure 31: Figure 32: Figure 33: Distribution of Sample by Gender Distribution of Sample by Age Group Past Year Prevalence of Alcohol by Gender Past Year Alcohol Prevalence by Age Group Past Year Incidence of Alcohol Use Average Age of First Use of Alcohol by Gender Past Year Prevalence of Alcohol Use by Behavioral Problems Past Year Prevalence of Cigarette Use by Age Group Average Age of First Use of Cigarettes by Gender Past Year Prevalence of Cigarette Use by Behavioral Problems Prevalence of the Use of Tranquilizers Prevalence of the Use of Stimulants Prevalence of Inhalant Use Lifetime Prevalence of Inhalants by Gender Past Month Prevalence of Inhalant Use by Gender Past Year Prevalence of Inhalant Use by Age Group Last Year Incidence of Inhalant Use Average Age of First Use of Inhalants by Gender Past Year Prevalence of Inhalant Use by Number of Behavioral Problems Lifetime Prevalence of Inhalant Use by Number of Repeated School Years Past Year Prevalence of Marijuana Use by Gender Past Year Prevalence of Marijuana Use by Age Group Past Month Prevalence of Marijuana Use by Age Group Past Year Prevalence of Marijuana Use for Students 14 Years Old and Younger Past Year Prevalence of Marijuana Use for Students 17 Years Old and Older Average Age of First Use of Marijuana by Gender Lifetime Prevalence of Marijuana Use by Behavioral Problems Lifetime Prevalence of Marijuana Use by Number of Repeated School Years Ease of Obtaining Marijuana Past Year Prevalence of Marijuana Use by Ease of Obtaining it. Easy Access versus Past Year Prevalence Lifetime and Past Year Prevalence of Cocaine Use Lifetime and Past Year Prevalence of Crack Cocaine Use vi

7 Figure 34: Figure 35: Figure 36: Figure 37: Lifetime Prevalence of Ecstasy Lifetime Prevalence of Cigarette Use vs. Marijuana Use Past Year Prevalence of Cigarette Use vs. Marijuana Use Past Month Prevalence of Cigarette Use vs. Marijuana Use vii

8 Acknowledgements A publication of this nature and the accompanying studies that underpin it would not have been possible without the necessary financial resources that are required to sustain these activities. This project was made possible by a grant from the Bureau of International Narcotics and Law Enforcement Affairs (INL) of the US Department of State. This report is the culmination of twelve separate studies in twelve countries. Each country had its own coordinator and team of interviewers with whom CICAD worked. In addition, a small group of persons were responsible for data entry in each country and for sending clean datasets to CICAD for the data processing and analysis. Before any activities took place in the individual countries permission had to be sought and received from school authorities in ministries of education and they were consulted for school enrollment data and other information so that a representative sample of students could be taken and the fieldwork logistics could be determined. In most cases all or most of this work was facilitated by local drug commissions or their equivalent. Several persons contributed to the data analysis, the drafting and review of this report and its eventual publication. As such, the persons who would have contributed in some way to this project are too numerous to mention here, but they can be assured that this report could not have been done had it not been for their support. CICAD appreciates the contributions and the support of drug commissions in Antigua and Barbuda, Barbados, Dominica, Grenada, Guyana, Haiti, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Trinidad and Tobago, and Suriname. Antigua and Barbuda: Clarence Pilgrim, Chairman, National Drug Council (NDC), Ministry of Housing, Culture & Social Transformation, Norma Jeffrey-Dorsett, Substance Abuse Prevention Officer: Substance Abuse Prevention Division, Ministry Social Transformation. Barbados: Tessa Chaderton-Shaw, Manager, and Jonathan Yearwood, Research and Information Officer, National Council on Substance Abuse (NCSA), Ministry of Home Affairs. Dominica: Jacinta Bannis, Director, and Martha Jarvis Research Officer, National Drug Prevention Unit (NDPU), Ministry of Health. viii

9 Grenada: Dave Alexander, Officer in Charge, Arthur Pierre, Drug Control Officer, Terrance Walters, Drug Control Officer, Drug Control Secretariat, Ministry of Education. Guyana: Angela Johnson, Permanent Secretary, and Joseph Quamina, Head of Security, Ministry of Home Affairs. Shradhanand Hariprashad, Research Officer, Ministry of Health. Haiti: Mr. René Magloire, Minister of Justice & Public Safety, France Garilus, Director, Haitian Observatory on Drugs, Commission Nationale de Lutte contre la Drogue (CONALD). Jamaica: Michael Tucker, Director, and Ellen Grizzle, Director of Information and Research, National Council on Drug Abuse (NCDA), Ministry of Health. St. Kitts and Nevis: Eileen Maclachlan Moore, Director, Paula Hazel, Executive Officer, National Council on Drug Abuse Prevention (NACDAP ), Carolyn Brownbill, Counselors (and supervisor for school survey) Ministry of National Security. St. Lucia: Elizabeth Serieux-Wilson, Coordinator, Substance abuse Advisory Council Secretariat (SAACS), Ministry of Health. St. Vincent and the Grenadines: Lanceford Weeks, Permanent Secretary, and Amrie Morris, Psychologist, Ministry of Health and the Environment. Suriname: Manodj Hindori, Chairman, National Anti Drug Council (NAR), Marie Bunwaree, Director, and Krisnadath Rambali, Policy Officer, Drug Demand Reduction Office, NAR, Ministry of Health. Trinidad & Tobago: Margaret Farray, Permanent Secretary, Ministry of Social Development, Clarence Leach, Coordinator, National Alcohol and Drug Abuse Prevention Programme (NADAPP), Elizabeth Richards, Research Officer, NADAPP, Esther Best, Senior Administrative Officer, National Drug Council (NDC), Ministry of National Security. There were a number of persons who provided invaluable statistical, technical and other support to this project. These include Daniel Sucazes (sampling), Alejandro Retamoso (data processing), and Ken-Garfield Douglas (editorial, data processing, and report writing). Within CICAD, a number of persons at the Inter-American-Observatory on Drugs (OID) each made significant contributions in all areas of this project and to this report. Dr. Francisco Cumsille, Coordinator of the OID, Luis Adrian Noble, former statistician with the OID, Marya Hynes, Specialist in Drug Research, and Pernell Clarke, Specialist in Drug Research and Coordinator of the Inter American Drug Use Data System (SIDUC) Caribbean Project. ix

10 Student Drug Use in 12 Caribbean Countries A Critical Analysis for Policy Makers Prologue In the hemispheric report 1 of the Multilateral Evaluation Mechanism (MEM) there are two statements which are difficult to refute. The first was about national drug information systems: To be able to confront a problem it is important to understand its dimensions and characteristics. The second statement was about statistics on drug consumption: Epidemiological research on the extent of drug use in national populations remain extremely limited although progress can be seen in many countries of the hemisphere These two statements taken together serve to strongly justify the work that has gone into the publishing of the information in this report which represents an important step forward in the generation of drug consumption statistics in the Caribbean. This report is the synthesis of 12 separate but similar studies that were implemented in 12 countries between 2005 and 2007, using one of the protocols of CICAD s Inter-American Drug Use Data System (SIDUC). The protocol outlines the methodology for implementing drug prevalence surveys among secondary school students. All except one of the surveys were implemented in 2005 and Guyana s survey was done early in While we have had a few published country reports of studies done in some of the countries, there are very few examples of published work that looks comparatively at drug use among groups of countries or the Caribbean region as a whole, and this type of analysis may be seen as an indication of the direction that the Inter- American Observatory on Drugs (OID) will be going in the future. James Mack Executive Secretary CICAD 1 Evaluation of Progress in Drug Control Hemispheric Report x

11 CHAPTER 1 Introduction Adolescence is a time of significant physical, intellectual, emotional and social change. As children age and grow, they pass through several developmental stages and from the age of 13 to around 20, boys as well as girls are usually trying to solidify their identities. The experiences of younger teens are quite different from those of older teens and the experiences of older teens and those of boys differ from those of girls. These distinctions are especially important as they relate to the choices teens make about smoking, drinking and using drugs 2. The development of children has several stages and from about 13 years of age, as adolescents are solidifying their identities, they are prone to experiment with minor delinquency and rebellion 3. Because of the rapid changes they are experiencing, adolescents are at the risk of developing substance abuse more quickly. Drug taking has been identified as one of the delinquent behaviors in which some adolescents engage. The use of drugs at an early age is a problem in itself, but it may also lead to or at least be associated with a set of other issues which may be detrimental to the health and well-being of young people. Several studies among the adolescent population as well as those among adults have shown clearly that there are very strong associations between persistent drug use and health related problems such as mental illness, academic difficulties, poor relationships with peers and family, and problems with the justice system which often lead to incarceration or some other sanction. Responding to these risks before they become problems can be difficult 4. Academic Problems Research suggests that there is a relationship between academic performance and adolescent substance use. Students who use alcohol or illicit drugs have been shown to be at greater risk for performing poorly in school, and vice versa 5. One Caribbean study reported that students who reported repeating two or more courses were more likely to report a higher lifetime prevalence of marijuana use 6. There have been some reports of students using drugs while on their school premises and some previous studies do corroborate this pattern 7. This level of alcohol, tobacco and drug availability should alert authorities to the obvious potential and actual negative effects that these substances may have on the school environment as a whole, and more specifically on a student s ability to perform well in the short term. Longer term effects may include gradual or 2 Douglas, K-G (1999) Patterns of Substance Use and Abuse among Post Primary Students in Jamaica. Department of Social and Preventive Medicine, U.W.I, Mona, Jamaica NIDA: Preventing Drug Abuse, A Research Based Guide for Parents Educators and Community Leaders 5 Bergen, H. A., Martin, G., Roeger, L., and Allison, S. (2005). Perceived academic performance and alcohol, tobacco, and marijuana use: Longitudinal relationships in young community adolescents. Addictive Behaviors, 30, Trinidad and Tobago National Secondary School Survey Report Unpublished. Page 58 7 NCSA: Barbados National Secondary School Survey Report

12 sudden reduction in grades, truancy, absenteeism, and reduced participation in activities related to learning. Health Related Problems Apart from the well-known physical effects of psychoactive substances on the body, there are some less direct and more medium and long term problems that are manifested through events such as vehicular accidents, suicides, homicides, and transmission of HIV/AIDS either through increased risky sex due to impaired judgment or through sharing of needles for intravenously administered substances. The available evidence however suggests that intravenous drug use is very rare in the Caribbean. There are also some mental health issues that have a strong association with substance abuse. These include depression, schizophrenia, generalized anxiety disorder, apathy, short-term memory loss and impaired learning 8. Delinquency The relationship between drugs and crime and delinquency is one of the most well studied phenomena in the drugs field. It is generally accepted that there is an association between delinquency, crime and drugs but most previous studies have stopped short of declaring that drugs cause crime. Paul Goldstein s framework 9 on the linkages between drugs and violence is very informative in this regard and he proposes three classifications: 1. Psychopharmacological: Violence due to the direct acute effects of a psychoactive drug on the user 2. Economic-compulsive: Violence committed instrumentally to generate money to purchase expensive drugs 3. Systemic: Violence associated with the marketing of illicit drugs, such as turf wars, contract disputes etc. Drug use, as well as the social context in which that use occurs, are etiological factors in a wide range of other social phenomena. Drug use is known to be causally related to a variety of physical and mental health problems, crime, poor school performance, family disruption, and the like. Previous research has also consistently found strong connections between drugs and violence. With this in mind, the SIDUC methodology addresses the problems that confront this subset of the population by providing a tool that can be used to measure their drug use history, demographic characteristics and make an attempt to identify risk and protective factors. This approach therefore seeks to achieve the following broad objectives: 8 National Institute of Mental Health, U S Department of Health and Human Services. 9 Paul Goldstein (1985) The Drug /Violence Nexus: A Tripartite Conceptual Framework. Journal of Drug Issues. Vol. 39,

13 To determine the lifetime, past year and past month prevalence of consumption of licit and illicit drugs To estimate the past year and past month incidence To determine age of initiation To determine risk and protective factors and the perception of harm To assess the relationship between drug use and risk factors To determine the level of offers, availability and access to drugs 3

14 CHAPTER 2 Methodology The SIDUC survey of secondary school students utilizes a standardized methodology that was created by CICAD and developed through consensus by survey experts and practitioners in the hemisphere. The main objective of the uniformity of the approach is to allow the direct comparison of cross-sectional data from surveys that were implemented in different countries and at different times. As a result, the sampling procedures, data collection, the questionnaire, and data management methods are all the same (or comparably similar) in each of the countries included in this comparative study. Population The population targeted for this survey includes students in secondary level (or high) schools in forms 2, 4 and 6 (this is similar to grades 8, 10 and 12 in the USA school system). Generally, it would be expected that the corresponding ages would be 13, 15 and 17, but this rule can be adapted to suit the realities of the particular country. For instance, countries with very low levels of students at the 6 th form level would have included students at the 5 th form level. Sampling The sample frame for this survey contains all students enrolled in 2 nd, 4 th and 6 th forms in all secondary schools in a particular geographic location such as a city, urban locale, rural locale, or the entire nation. The data presented in this report represents national level data for the sample frame for all of the participating countries and the classes included meant that students who are 13, 15, and 17 years of age were included in the sample frame. The last age group however was modified to 16 years of age because in the Caribbean, most of the school systems normally see a dramatic drop in the number of students in the classes corresponding to the 6 th form. This does not mean that there are not students above 16 in the sample, but the overall numbers are significantly smaller. In addition, the delineation between age groups by grade is not always reflected in the reality of the classrooms. A final adjustment was made in the database, and analyses were performed on age categories of 14 years old or less, years old, and 17 years and older. The information used to define the sample frames were taken from complete lists of student enrollment for the grades required in all schools in the country. The information includes the actual or average number of students in each of the class rooms in the relevant grades. The final sampling unit is the classroom and a number of these classes are randomly selected. All of the students in the selected classrooms are included in the final sample. Class samples are therefore nationally representative and the information collected on the sample frame allows the results of the surveys to be expanded to the general student population in the selected grades by using an expansion factor. 4

15 Data Collection Data is collected from the sample of students by applying a pre-coded, self-administered questionnaire that has a core standard section to ensure the comparability discussed earlier. Survey leaders in individual countries are free to add modules to explore issues of interest to them. To ensure the quality as well as the anonymity of responses, SIDUC recommends that data collection occurs in surroundings familiar to the students which in all cases was their classrooms and with minimal or no involvement of teachers in the administration of the questionnaire. This type of fieldwork requires a well-trained team of persons for implementation, particularly since, this group of persons serve as the main point of contact with the student. The team usually consists of a project leader, supervisors, and facilitators each with a clearly articulated set of responsibilities. The questionnaire consists of a standard set of questions that are arranged as follows: Basic socio-demographic information Beliefs about future academic performance Discipline and academic problems Opinion on harms associated with the consumption of drugs Prevalence of substance use and patterns of consumption Incidence of substance use Frequency of use Data Entry and Analysis The data from these studies was transcribed using a customized Microsoft Excel spreadsheet that was formatted to allow double entry for cleaning and verification. This data is then imported into SPSS 10 for processing using univariate and bi-variate analysis. Because of differences in the age and gender distribution from country to country a statistical adjustment was made using a direct standardization method so that the prevalence, incidence and other estimates can be directly compared and are not affected by these two variables. Definitions of Terms Throughout this report certain terms have been used to describe the prevalence of substance use. These definitions are: Never - those who have never used the substance Lifetime prevalence is the percentage of students who have used the substance at least once anytime in the past. Last year or past year prevalence is the percentage of students who had used the substance at least once during the one year period prior to the administration of the survey. 10 Statistical Package for the Social Sciences 5

16 Last month or past month prevalence is the percentage of students who had used the substance at least once during the one month period prior to the administration of the survey (also referred to as current prevalence). Behavioral Problems at School For the purpose of this study, problems at school are identified using two main indicators the number of occasions that students are disciplined for behavioral problems and the number of years repeated during the course of their studies. When asked about the number of times they were disciplined, responses categories were never, few times and frequently. The options given for number of years repeated during the course of studies were none or one or more times. Definitions of Substances The drug categories used in this report are identical to the categories used in the questionnaire and follow the descriptions and examples provided to students in the questionnaire within each country of administration. Empirical Association Empirical association between demographic variables and drug use do not imply causal relationships. The tables presented are particularly useful for the purposes of identifying demographic sub-groups with relatively high or low rates of drug use regardless of the underlying causes of drug use. Given the size of the national samples and the rigorous sampling methods employed, differences of more than a few percentage points can quite confidently be considered significant and of concern. Limitations This comparative report is based on a combination of datasets from different studies in 12 countries. Not all of the studies occurred at the same time, so strictly speaking the data spans a period of about 2 years between the oldest and the most recent study. The effect of natural changes over time is therefore a factor that can affect the comparability of the results in this report. There is not enough time series data from the participating countries to determine an adjustment factor to compensate for this. The samples of students taken in each country had different age and gender distributions. A direct method was used to standardize the data based on these two variables. Self report surveys rely on the truthfulness of respondents, their memory of things that have occurred in the past, and their level of comprehension of the questions in the questionnaire. Each 6

17 one or all of these things can contribute to inaccuracies in the data. The questionnaire was designed in such a way as to detect intentional dishonesty by respondents among other things. Data transcription is another potential source of error. The data entry that was done for all of the surveys in the countries analyzed here was done using double data entry into a standard data entry template using Microsoft Excel. The spreadsheet also included built in verification macros and data validation settings to minimize data entry errors. 7

18 CHAPTER 3 Results Description of Sample The samples of students taken in the individual countries yielded an overall total of 38, 534 students, all of which are included in this comparative analysis. Weighting resulted in an effective population size of 170,580 nationally represented students across the region. The largest individual sample was taken in Haiti (10,638 students) while the smallest was taken in St. Vincent and the Grenadines (1,018). For the most part all other country sample sizes was close to or above recommended students based on the standardized methodology. TABLE 1: Sample Sizes and Distribution of Students by Gender. Country Sample Size Weighted Population Percentage Distribution of Sample by Gender Males Females Antigua and Barbuda 2,057 2, Barbados 2,220 11, Dominica 2,369 2, Grenada 3,088 3, Guyana 2,461 19, Haiti 10,638 10, Jamaica 4,536 61, St. Kitts and Nevis 2,100 2, St. Lucia 2,072 2, St. Vincent and the Grenadines 1,018 4, Suriname 2,066 11, Trinidad and Tobago 3,909 39, Total 38, , The figures in table 1 show the sample sizes and effective weighted population in each of the twelve countries along with the gender distribution of the sample. It is evident that the gender distribution varies from country to country, and because of this, a statistical adjustment was made to correct this problem to facilitate the calculation of prevalence and other estimates and increase the comparability of the results. The largest variations were reflected in the data from Guyana and St Vincent and the Grenadines where more than six of every ten respondents were females. The distribution is shown below in figure 1. 8

19 Figure 1 Distribution of Sample by Gender 70 Males Females Antigua & Barbuda Barbados Dominica Grenada Guyana Haiti Jamaica St. Kitts and Nevis St. Lucia St. Vincent & the Grenadines Suriname Trinidad & Tobago Total Table 2 and figure 2 show the distribution of the sample by age category. The age categories are used in this way to make the SIDUC survey results comparable with those from other regions such as those in Europe. It is clear that the age distribution is very uneven from country to country and from age group to age group. The overall distribution showed that just over third were 14 years or less (39%) or years (37%) with about a quarter (24%) being 17 years and older. Notable differences were seen in Haiti and Suriname where more than four of every ten students were 17 year and over. TABLE 2: Distribution of Sample by Age Group. Country Distribution of Sample by Age Group 14 or less or more Antigua and Barbuda Barbados Dominica Grenada Guyana Haiti Jamaica St. Kitts and Nevis St. Lucia St. Vincent and the Grenadines Suriname Trinidad and Tobago Average

20 Figure 2 As was mentioned before, due to the differences in gender and age distribution among the countries, the direct method was used to standardize the indicators shown in this report. 10