Parent-adolescent Communication on Sexual and Reproductive Health Matters and Associated Factors among Secondary and Preparatory School Students in Robe Town, Bale zone, Southeast Ethiopia, 2017

The study conducted in Robe town, Oromia National Regional state, from April 10-25, 2017. Robe is capital town of Bale Zone located 430 Km south east of Addis Ababa. In the town there are two secondary schools and one preparatory school which are government schools. The total number of students attending in the academic year 2016-2017 in all secondary schools and preparatory school in Robe town were 4,200. From this 2031(48.36%) were males and 2169(51.64%) were females. The town has an estimated area of 8,024 hectares. According to the information obtained from the town statistics office report, the total population of the town was 80,501 with sex distribution of 40,843 were males and 39,658 were females. There is one hospital and one health center in the town.

Institution based cross sectional quantitative study supplemented with qualitative method was employed. The source populations were all secondary and preparatory students attending grade 9-12, in Robe town were the source population. And those students from grade 9-12 who were selected for this study population for this study. Students aged 19 years old or less who are unmarried and attending secondary and preparatory school at the time of the study were included. And students who were married were excluded since they may have different characteristics as compared to the unmarried.

Sample size was calculated by using a single population proportion formula with the following assumption. The proportion of parent adolescent communication in previous study done in Debremarkos town of p=36.9% ⁹, 95% CI, 5% marginal error and 10% non-response rate and the final Sample size was 394. List of frame of students was obtained from each grade’s student roster in collaboration with instructors of respective classes. Students within the age range of 13-19 years old from the existing sampling frame (students ‘roster) were drawn. Calculated sample size was proportionally allocated for each grade according to their number of students. Simple random sampling technique was used to select the study participant.

Sample size for qualitative studies purposive sampling was employed. Parents who have adolescent students of age 13-19 years were selected for FGDs. Thirty two parents, out of whom 16 females and 16 males were involved in four focus group discussions separately where the researcher obtained saturated information. FGD participants were expected to be parents of adolescent student’s age 13-19 years. The participants were selected based on the criteria to meet the objective and research question of the study. Participants of the focus group discussions were selected after communicating with kebele administrators. The four group discussion was conducted separately for males and females parents. The discussion conducted in kebele office in different time and days.

In order to have common understanding in this study the following terms and phrases are defined.

Parents in this study mean biological parents, step parents or foster parents but it does not include elder siblings

In this study the adolescent implies a segment of the people who are unmarried and whose age fall in the age range of between thirteen and nineteen.

In this particular study context parents and adolescents communication regarding SRH components is a simple discussion or talking which is interactive between parents and adolescents on the following issues: STIs/HIV/AIDS, sexual intercourse, premarital sex, condom, pubertal stage, unwanted pregnancy, contraception and menstrual cycle.

Students who discussed at least two SRH issues (STIs/ HIV/AIDS, condom, sexual intercourse, premarital sex, puberty, menstrual cycle, unwanted pregnancy and contraception) with their parents in the last 12 months ⁷.

The dependent variable was parent-adolescent communication and independent variables were demographic and Socio economic variables related to parent and adolescents such as age, sex, family size, education status of mother, occupation of father, occupation of mother, living arrangement of the student, family income, educational status of father and grade level of student. Socio-cultural factors such as general communication, parent Adolescent disclosure, parent acceptance on the importance of discussion and parent time giving for discussion. Adolescent’s SRH information school and media.

A pre-tested, self-administered questionnaire comprised of 56 items was developed for the study. The questionnaire was initially developed in English and then translated into Afan Oromo. It was translated back to English by another person to check consistency. Most of the items were adapted from existing surveys and modified based on local context. The questionnaire incorporates 14 items on socio-demographic characteristics and 42 on communication about SRH.

Self-administered anonymous questionnaires were preferred for this kind of survey to minimize social desirability bias and interviewer distortion that often limits the use of face to face interview. Four individuals, who had completed grade twelve, were selected for data collection that has experience of data collection. Data collectors were supervised by two diploma Nurses and problems faced during data collection were solved on time. The investigator was checking filled questionnaires and solution given by discussing with the supervisors and data collectors if problems arise. Finally, filled questionnaire were signed by supervisors after checking for its completeness.

For qualitative study a series of four group discussions were carried out among purposefully selected parents who have adolescent students of age 13-19 years. Participants of the focus group discussions were selected after communicating with kebele administrators. The kebele administrators was informed on the objective of the study and then assisted in selecting those parents who have adolescents age 13-19 and who were expected to be active participants in the discussion. The investigator was the moderator, and is accompanied by BSC Nurse female assistant. The assistant is note taker and recorder as well as facilitate the female parents to increase the quality of information. There were eight participants in each group. A semi-structured questionnaire guideline was used to lead the discussion. FGD study components were present using quotes and explanations.

The quality of the data was controlled by translating the questionnaire translated by an individual fluent in both English and Afan Oromo in order to identify the clarity and consistency of the questionnaire. The questionnaire was pre-tested on 5% of the sample in a similar population in Goba town. Based on the findings necessary modifications such clarity and consistency of questions and evidence based time allocation for each respondent were made accordingly. In addition, data collectors were trained for one day on the general objective of the study and on the administration of the questionnaire. Supervision was carried out throughout the data collection period by an investigator.

The focus group discussion for mothers and fathers were conducted separately to increase the quality of information that can be generated and the confidence of the respective parents. To understand their opinion fully, a tape recorder was used after they have been told the objective of the study and verbal consent obtained.

Data entering, coding and clearing were performed using Epi Data version 3.1 and the analysis was done using SPSS version 20.0. Descriptive statistics was used to describe the study population in relation to relevant variables. Binary logistic regression analysis was used to ascertain the association between explanatory and outcome variables. All variables having P value < 0.25 had significant association from binary logistic regression was entered to multiple logistic regression analysis to determine independent associated factor of adolescent parent communication on sexual and reproductive health issues by controlling the effect of possible confounder, significant statistical association was determined by using adjusted odd ratio at 95% confidence interval and P value < 0.05.

Qualitative data from FGD was transcribed by arranging the record according to forwarded questions and translated to English version. Then thematic data analysis method was used after listening audio records. Then comparison was done on the responses of different parents to identify similarities and differences. Finally, information was linked to its congruence with data obtained from quantitative findings.

Letter of permission was obtained from Madda Walabu University Goba Referral Hospital Department of Public Health. Educational bureau and school officials were also express their willingness after they were informed of the purpose of the research. Written assent was obtained from each study participants. For those study participants who were under the age of 18 years, written consent was obtained from their parents. Participants were told the objective of the study and their right to refuse completion of the questionnaires and this would not affect any support that they will get from the schools. Questionnaires were coded instead of using names as identification and hence, confidentiality was assured throughout the study. Verbal assent was obtained from the discussants of FGD to participate and for voice recording.

In this study a total of 394 students were included with response rate of 100%. The mean age of respondents’ was 16.71 with standard deviation of 1.44 years. From the study participants, 212 (53.8%) were female. Majority of the respondents were 309 (78.4%) Oromo ethnic group and 178 (45.2%) were Muslims. 286 (72.5%) were living with both parents (Table 1, Table 2).

Three hundred eight (78.2%) of the respondents mentioned that they have got sexual and reproductive health information. Among thistwo hundred eighty six (92.8%) of the respondents heard information on sexual and reproductive health issues from school which is followed by mass media 91 (29.5%) (Figure 1).

Figure 1.Students’ source of information about sexual and reproductive matters, Bale zone, Robe town June, 2017

Three hundred seventy four (94.9%) of the students had agreed on the importance of discussion on sexual and reproductive health matters with their family. It was also supported by majority of participants who involved in focus group discussion as communication between parent and adolescent on sexual and reproductive health matters since parents needs to play vital role in shaping their children behavior during adolescent age particularly regarding premarital sex and unwanted pregnancy but they have a gap of knowledge regarding sexual health.

This is evident from the response, “We are supposed to tell our adolescents everything that has to do so with reproductive health. But I do not feel that we know all information they need,” (a 38-year-old female discussant).

However, 186(47.2%) of students had ever discussed on at least two sexual and reproductive health topics with their parents. Large number of the study participants 228(57.9%) had reported as they have discussed on condom from which 223(56.6%) of them undertaken the discussion with their friends/peers. Majority of them 89% discussed some times.

The majority of the students discussed on different sexual and reproductive health matters with their peers/friends followed by with sisters. From the total female participants, majority of them has seen their first menses at the age of fourteen years which account for 17.8% followed by fifteen years of age (15.7%). About 20(9.4%) of study participants had discussion before they have seen their first menses. Nearly 65% of them had a discussion with their sisters about menses before they have seen it followed by with peers (45%) (Table 3).

One hundred nine (27.7%) of the students haddiscussed about contraceptive (Table 3). On the other hand 285 (72.3%) did not discuss contraceptive with their parents were shameful and parent’s lack of communication skill 254 (64.5%) and 237 (60.2%) respectively (Table 4). However, these respondents had discussed with their mothers 64 (16.2%) and 61 (15.5%) with friends (Table 3). Majority, 80.7% discussed sometimes. Lack of knowledge regarding sexual and reproductive health matters as well as social norms attached to dealing with such kind of issues were mentioned by majority of focus group discussion participants as a reason for not discussing sexuality with children.

One hundred thirty one (33.2%) of the students haddiscussed about STI/HIV/AIDs. From those had a discussion, 109 (27.7%) and 47 (11.9%) discussed with their peers and sisters respectively (Table 3). Majority, 77.9% discussed sometimes. On the other hand 263 (66.8%) did not discussed with their parents due to shame and parent’s lack of communication skills which account 233 (59.1%) and 227 (57.6%) respectively (Table 4). From qualitative data, nearly half of the focus group discussants mentioned as they do not discuss about STI/HIV/AIDs due to lack of knowledge regarding sexual and reproductive health issues.

One hundred three (26.1%) of the students discussed about sexual intercourse (Table 3). Majority, 72.8% discussed sometimes. On the other hand 291 (73.9%) did not discuss sexual intercourse with their parents were shameful and parent’s lack of communication skills 261 (66.2%) and 252 (64.0%) respectively (Table 4). However, these respondents had discussed with their peers 81 (20.6%) and 42 (10.7%) with sisters (Table 4).

From focus group discussion, a female participant said that, “it less likely to discuss about sexuality in the house and in the community as well which basically related with cultural unacceptability and religious matters”^{a 35 years old female participant}.

One hundred nineteen (30.2%) of the students had discussed about unwanted pregnancy (Table 3). Majority, 75.6 % discussed sometimes. On the other hand 275 (69.8%) did not discuss unwanted pregnancy with their parents were shameful and parent’s lack of communication skill 245 (62.2%) and 222 (56.3%) respectively (Table 4). However, these respondents had discussed with their peers 96 (24.4%) and 62 (15.7%) with sisters (Table 3).

One hundred thirteen (28.7%) of the students had discussed about premarital sex (Table 3). Majority, 61.1% discussed sometimes. On the other hand 281 (71.3%) did not discuss premarital sex with their parents were shameful and parent’s lack of communication skill 250 (63.5%) and 239 (60.7%) respectively (Table 4). However, these respondents had discussed with their peers 91 (23.1%) and 42 (10.7%) with sisters (Table 3).

One 50 years old male parent said “keep their virginity until marriage almost all of the discussants agreed on a virgin girl in our community is respected ” (50 years old male FGD participant).

Two hundred twenty eight (57.9%) of the students had discussed about condom (Table 3). Majority, 89 % discussed sometimes. On the other hand 166 (42.1%) did not discuss with their parents were shameful and culturally unacceptable 136 (34.5%) and 126 (32.0%) respectively (Table 4). However, these respondents had discussed with their peers 223 (56.6%) and 41 (10.4%) with sisters (Table 4).None of parents discussed about condom use.

One mother said that “discussing about condom is opening the way or initiating our children to have sex” (32 years old female FGD participant).

One hundred twelve (28.4%) of the students had discussed about puberty (Table 3). Majority, 67.9 % discussed sometimes. On the other hand 282 (71.6%) did not discuss with their parents were shameful and parent’s lack of communication skill 241 (61.2%) and 223 (56.6%) respectively (Table 4). However, these respondents had discussed with their peers 85 (21.6%) and 60 (15.2%) with sisters (Table 3).

One hundred fifteen (29.2%) of the students had discussed about menstrual cycle (Table 3). Majority, 53% discussed sometimes. On the other hand 97 (24.6%) did not discuss with their parents were shameful and parent’s lack of communication skill 97 (24.6%) and 96(24.4%) respectively (Table 4). However, these respondents had discussed with their peers 74 (18.8%) and 52 (13.2%) with sisters (Table 4).

In this case one female participants of focus group discussion mention “I frequently discuss with my child regarding menses with the purpose of developing her confidence since the issue is naturally occurs on human being” ^{34 years female FGD participants}. But majority of participants did not discussed on menses as a result of discomfort and shame of dealing with children.

With regard to adolescents major reasons for not discussing sexual and reproductive matters with their family, about 261 (66.2%) of students reported as shameful hindered them for discussing about sexual intercourse followed by parent’s lack of communication skill which account for 252 (64.0%). In general, being ashamed, parent’s lack of communication skill and lack of parents’ knowledge about sexual and reproductive health issues were the major reasons mentioned by the students for not discussing about sexual and reproductive health matters with their parents. The reason not discussing RH issues is bound by several socio cultural norms and expectations: “In our culture discussing about sexual issues is very rare. Let alone discussing with your child, wife-husband discussion on this issue is not experienced. Everybody is shy about it. These culture, taboo and traditions are passing from generation to generation. We were brought up like this and are doing it today,” (45-year-old female parent).

Bivariate logistic regression analysis was performed to assess association between each independent variable and outcome variable. Results of bivariate analysis showed that grade level, sex of student, mother occupation, mother education status, father education status, living arrangement and family size become significantly associated with parent adolescent communication.

Multivariate analysis was performed to identify factors independently associated with parent adolescent communication. In the multivariate analysis those variables with a p value <0.25 in the bivariate analysis were included and backward stepwise model was used. In the multivariate analysis, and the Hosmer- Lemeshow test indicates a p > 0.05 which signifies that the overall model fit is good. From 11 variable entered in to the multivariate analysis four of the variable including sex of student being female, being student grade 11, student from father education status diploma and above and students living with relative/friend or living alone were significantly associated with parent adolescent communication after controlling for confounders (Table 5).

Accordingly, students whose father education diploma and above were 3.35 times more likely to have parent adolescent communication than students whose father were illiterate (AOR, 3.35 95% CI (1.73, 6.47)). It was also found that, grade 11th students were 4.88 times more likely discussed on sexual and reproductive health matters with their parent compared with grade 9th students (AOR: 4.88 95%CI: (1.76, 13.54)).

In this study, female study participants were nearly 2 times more likely to discussed about sexual and reproductive health matters with their parents when compared with their counterparts (AOR: 2.02 95%CI: (1.25, 3.26)). Again the odd of parent adolescent communication Study participants whose living arrangement were with relatives were less likely discussed on sexual and reproductive matters when compared with those students living with both parents ((AOR: 0.32 95%CI: (0.12, 0.80)).

However, factors that were statistically significantly in the bivariate analysis like mother education, mother occupation and family size were not showed statistically significant association in the multivariate analysis after controlling for confounders