Where and how do young People Like to Get their Sexual and Reproductive Health Information? Experiences from Students in Higher Learning Institutions in Tanzania: A Cross-sectional Study

Sexual and reproductive health (SRH) among young adults in developing countries is still a major public health concern. Early school-based sexuality education programs and sexual health information sharing between teachers, parents and young people have been considered protective against sexual health risks that young people are prone to. There is limited information on preferred choices of “where” and “how” young people like to get their SRH information. Here, we describe what young people prefer to learn with regard to sexual matters, where and who they prefer to learn from, and their experiences of parent-child sexuality communication. Methods This was a cross-sectional study, conducted from March 2019 to January 2020 among students aged 18-24 years attending Higher Learning Institutions (HLIs) within Mbeya. A self-administered questionnaire was used to collect information on SRH education, ability to discuss sexual matters with a parent/guardian, and SRH information gap during early sexual experience.

matters from uninformed sources such as their peers or social media; and their will to take preventive actions may be challenged by barriers or modifying factors towards prevention or treatment of the disease. The curriculum faces a number of limitations, such as the students' age when commencing the curriculum in relation to the reported age at sexual debut and ineffective inclusion of sensitive sexuality matters (23,24). Young people reported curriculum gaps on sexual decision-making, sexual pleasure, relationships, safer sex and condom use, and masturbation (24). Misconceptions about level of perception to sexual health risks may result from ignorance as a result of lack of comprehensive sexual education from an early age (example secondary or high school). Gender and sexuality attitudes and values are believed to start being established early in childhood and through adolescence, and eventually dictate sexual behavior and continue to affect the individual through adulthood.
Lack of proper SRH education re ects problems facing young people such as unprotected sex, unplanned pregnancies with unsafe abortions, HIV/STIs (1,2). Additional to school-based sexuality education programs and parent-child communication, other avenues for learning may include information sharing with peers, media, newspapers, Internet, and/or health personnel and facilities. In Tanzania, there is limited information on preferred choices of "where" and "how" young people like to get their SRH information. This study aimed to describe what young people prefer to learn with regard to sexual matters. Additionally, we focus on where and who they prefer to learn from, and their experiences of parent-child sexuality communication. We refer to sexual matters as sexual activities, sexual identity, sexual interests, sexual orientation, sexuality, sex and sexual relationships. Population, sample size and sampling Participants were enrolled from HLIs within Mbeya region in any year of study, if they were Tanzanians, aged 18-24 years and agreed to provide written informed consent prior to all study-related procedures. Participants were ineligible to take part if they were students attending short-term courses (< 6 months) or elective students. Proportions assessment in cross-sectional studies using random sampling was used to estimate sample size adjusted for non-response, and the minimum sample required was 494.

Sampling
Each HLI in Mbeya region was invited to participate and all the HLIs agreed to take part but Open University did not have students that were eligible because they were older than 24 years. A complete electronic list of all students registered, aged 18-24 years of age was obtained from the Academic Registrars' o ces. Probability proportional to size was used to determine the total number of students by sex from each HLI due to the different number of students from each HLI. A computerized random number was used to select students irrespective of the course they were registered for. Each selected eligible participant was noti ed via phone that he/she has been randomly selected to take part in the study and if he/she was willing to take part, he/she was then requested to report to the data collection point within their respective campuses. If the phone number was not reachable or the selected participant had no mobile phone, the class representative assisted to physically nd the selected participant and a face to face appointment was scheduled. Each selected participant was required to present a student identi cation proof before study procedures could commence.

Data collection methods, tools and study procedures
The study team used an individual self-administered questionnaire using a tablet or smart phone through a web-based software (ODK) or hard copy, which ever method the participant preferred. Pre-testing of the questionnaire was done on few HLI students from a nearby region prior to data collection; and any emerging issues from the pre-testing were factored in to revise the questionnaire in a more practical manner. The questionnaire was divided into sections, and collected information on socio-demographics (age, religion, marital status, year of study at HLI, highest academic level before current HLI, type of secondary school attended, permanent residence and source of nancial support); Sexual and Reproductive health (ability to discuss sexual matters with a parent/guardian, learning about sexual matters and Sexual and Reproductive health information gap during early sexual experience). Parent-adolescent communication and preference of source of SRH information was assessed using a set of 10 questions.

Data management and statistical analysis
The web-based software (ODK) was designed with smart checks for incomplete or ambiguous responses, and responses through the hard copy questionnaire were reviewed for completeness at the end of each day by the Research Assistant. Data was cleaned and analysed using statistical software Stata version 14 for Windows (Statacorp, College Station, TX 77845, USA). Data was summarised descriptively using percentages and/or proportions for categorical variables, mean and respective measure of dispersion for numerical variables. Missing data were addressed as "Not reported".

Response
A total of 632 students aged 18-24 years attending HLIs in Mbeya were sampled randomly and were eligible to participate; and of those, 504 students were enrolled. Of the 128 who didn't participate, 32 (25%) could not be reached and the remaining were not willing to participate in the study.

Characteristics of the participants
Participants' socio-demographic characteristics are shown in Table 1. The mean age of the 504 students was 21.5 years (SD 1.7), with more than half of the participants being males (56.9%), single (93.8%), and supported nancially by a parent/guardian (86.3%). Majority of the participants (78.0%) were in their rst or second year of study. Other background characteristics are shown in Table 1. There were no reports from 14 (2.8%) participants on Religion, and 1 (0.2%) on Place of residence.

Learning about Sexual and Reproductive health matters
Over seventy percent of the participants lived with both parents while growing up at the age of 12-18 years as shown in Table 2. Proportion of participants that found it di cult to discuss or did not discuss sexual matters with a parent/guardian at age 12-18 years was 61%, similar between female and male participants. Two of the common source where participants learnt about SRH matters while growing up was friends of about their similar age group (30.2%) and lessons at schools (22.7%), respectively. Female participants (47.5%) preferred discussing sexual matters with female adults while male participants (42.9%) preferred male adults. As shown in Table 2 about 70% of the participants had received a Sexual and Reproductive health Education (SRE) while in secondary school (O' Level) and 52.8% only while at University.

Sexual and Reproductive health information gap during sexual debut
Of the 504 enrolled participants, 377 (74.8%) reported to be sexually active. While recalling rst sexual experience, 35.8% of the 377 participants mentioned they were in love, 28.1% got carried away and 16.7% were just curious, Table 3.
When asked from whom they would have liked to learn more on SRH matters that they knew little about at time of sexual debut; 18.0% said they would like to learn from friends, 17% wanted to learn from Media/Books/newspapers/Internet/pornographic websites and 13% from lessons at school, Table 3. Parents ranked 4th and 5th as source of SRH at time of debut. If diagnosed with an STI, participants would rather tell a family member (48.3%) or sexual partner (53.6%) than other people. Figure 1 shows what participants would have liked to know at time of sexual debut; 26.9% said they wished they knew about sexual feelings, emotions and relationships, 13.8% on safer sex, 10.5% on how to be able to say 'No' and 10.2% on how to use a condom correctly.

Discussion
Findings from the study among 18-24 year old students attending HLIs in Mbeya-Tanzania showed that three-fth of the participants found it di cult to discuss or did not discuss sexual matters with a parent/guardian while growing up at age 12-18years; and majority learnt about SRH matters from friends of about their similar age group and lessons at schools. Young people also report on gender-biased preference on sexual matters discussions among family members, such that female and male participants preferred discussions with female adults and male adults, respectively. About seven in ten students received a SRE while in secondary school (speci cally O' Level) and just over a half of the participants (52.8%) while at University. Recalling their rst sexual experience, participants felt they needed to know more about sexual feelings, emotions and relationships (26.9%), safer sex (13.8%), how to be able to say 'No' (10.5%) and how to use a condom correctly (10.2%). Students reported they would prefer to learn SRH issues rst from friends, media and schools.
In this study, 6 out of 10 participants found it di cult or did not discuss sexual matters at all with their parents while growing up. Additionally, parents were not mentioned in the topmost common sources where participants learnt about sexual matters while growing up from age 12. Contrast to our ndings, in a study on the use of reproductive health information among university undergraduates in Nigeria, more than half of the respondents mentioned parents, relatives, and health workers as their main source of health information (25). Similar to our ndings, other studies in South Africa and Tanzania have also reported on the lack of or insu cient communication on sexual matters between parents/guardians and their children (19,20,23). Such observations may be due to cultural differences in African settings, such that other cultures and traditions do not entertain parents educating their children about SRH matters. Comparable to SRH lessons at school, parent-child communication can actively promote desirable preventive behaviors against sexual health threats among young people. As with other developmental and behavioural aspects that parents/guardians can advocate among their young ones, sexual behaviour and attitudes towards sexual health can also be learnt and in uenced at the household/family level. Programs advocating parent-child communication and SRH among adolescents/young adults need to factor in enhancing parents' communication skills regarding sexuality matters, self-e cacy as well as appropriate SRH knowledge.
Many times young people start discovering and learning primarily about sexual issues from their peers and/or sexual partners, as reported in our ndings. In the process of growing up, there is a exible shift of emotional bonds from parents/guardians to peers to sexual partners (26). Times when these emotional bonds peak are also likely to be convenient learning times on sexual matters; and parents often have the initial and most crucial stage and are at an added advantage. It is important to understand that adolescents and young adults go through a "transition phase" whereby the family can not quite de ne them as children or yet adults (26), and this is a period when the habitual position of the parents/guardians may get overridden slowly by peers/friends of a similar age. In situation where parents/guardians do communicate about sexual matters, then talks or conversations have been known to either be threatening, authoritative, subjective to an already existing incidence (27,28), triggered through examples of acquaintances who suffered STIs/HIV or messages from radio/TV programs (19). Unfavourable methods of parent-child communication about sexual matters are confusing and rarely successful in modifying behaviour of adolescents/young adults who are highly experimental and "fragile". In a qualitative exploration of sexual health by Kajula et al., parents were likely to use fear to discourage unpleasant sexual behaviours among their children and children noted that sexual health conversations with parents were unclear and just full of warnings and dangers of HIV/STIs (19).
Parents/guardians may face challenges when it comes to speaking to young adults on sexual matters as they may lack su cient knowledge (28) or some may believe that sharing SRH information will encourage sexual practices among their children (29). Evening or weekend radio/TV programs could usefully be used to set off such family talks as in most urban and some rural African settings, parents/guardians after work would sit with their children to unwind while watching news or comedy shows. In African settings during the old times, the community would have a scheduled time for adolescents/young adults to meet with community or family elders (respectable distinguished males or females) who would take them through information on sexual matters and the culture of being able to postpone sexual encounters until when deemed appropriate. In recent years times have changed and due to urbanization, many of such cultures have disintegrated (30) and the family structure is left to operate on its own. It is therefore important, now than ever, for parents/guardians of adolescents/young adults to be able to speak up friendly, calmly, clearly and fearlessly about sexuality and sexual matters with their children.
Adolescent/young adults prefer to talk to their parents/guardians as evident from our ndings and those reported elsewhere (19,20,27), but important to note that there is a gender-biased preference on such (20,28,31). Additional to their peers, female children would prefer to speak to their mothers, while male ones with their fathers. It is valuable to understand why parents/guardians cannot speak with their adolescents/young adults, and vice versa. Parents/guardians need to recognize and accept that it is also their responsibility to protect their children against sexual health risks which they are prone to, and that this is not a responsibility referred to teachers or health care workers or their children's peers. Adolescents/young adults may experiment on risky sexual behaviours and not seriously perceive the health threat, either because of having poor sexual health information (2,32) and/or limited access to SRH care (2,5,33) and be at risk for STIs and/or HIV.
From our ndings, three-quarter of the participants report to have received a SRE while in school and majority during O' Level secondary education; and of those who were already sexually active, looking back at their rst sexual experience, majority thought they should have waited. Further, participants felt they needed to know more about sexual feelings, emotions and relationships, safer sex, how to be able to say 'No' and how to use a condom correctly; such information may indicate that during such an encounter probably even a condom or other protective means to STIs/HIV and/or pregnancy were not used. The SRE curriculum that was introduced in Tanzania in primary schools during early 2000's in response to the control of HIV epidemic has been important for adolescents in primary and secondary schools, but the challenge is the inability of some of the teachers to deliver the message and topics clearly (34). Mkumbo (2012) showed majority of urban and rural teachers are in favour of teaching SRE (12), but Cardoso and Mwolo noted ineffective inclusion of sensitive sexuality matters in the school curricula (34). Such curriculums lack enough resources and the students do not appreciated much the school as a tutor for sexual health matters. Introduction of SRE earlier on in life carry considerable bene ts of delayed sexual intercourse, addressing misconceptions, preventing risky sexual behaviours and eventually STIs and/or HIV (2,35).
School-based sexual health education has been found effective in relation to STI-related outcomes and is highly recommended worldwide (36,37). On the contrary, evaluations of curricula in sub-Saharan Africa have been inconclusive on their impact towards risky sexual behaviours and reducing STIs incidence among young adults (36,38). In a study done in Dar-es-salaam-Tanzania among adolescents on timing of sexual initiation, a larger proportion (35.6%) of students reported communicating about HIV and sex with teachers and only 26.9% with parents (39). Delayed sexual initiation was signi cant among students who communicated with teachers, and authors acknowledged teachers' effective role in exploring HIV and sexual matters with young people. Subsequent to parents, teachers through SRE given in schools, play a vital role in shaping sexual behaviour among young people that is preventive against STIs and/or HIV (14,36,40).
In this study, peers, lessons at schools and media were identi ed as key sources of SRH information and overall sex education. Additionally, we report ndings that young adults who claim to have received the SRE, and have already experienced sexual encounters needed to know more about sexual feelings, emotions, relationships, safer sex practices and ability to turn down a sexual encounter. It is crucial to understand whether the SRE curricula indeed cover the "sexual" aspect. Could it be that the "sexual" aspect is missing from the SRE? Could it be that teachers are still not comfortable to teach such sensitive issues considering our culture that may label such topics as taboo? Nearly a decade after Mkumbo's work on teachers' attitudes towards and comfort about teaching school-based SRE in urban and rural Tanzania (12), it is probable that, even though they would have liked to teach, they experience di cult and discomfort in teaching most of the key sexuality education topics. It is important to teach and send across clear messages to adolescents from a young age and throughout secondary and higher learning on sensitive sexual matters, also to build capacity of their teachers with the correct and up-to-date knowledge as well as the con dence to teach. As peers are the typical source of information on sexual matters, it is unclear how well-informed they are and how reliable is the information shared. Sexual practices and behaviors being largely in uenced by peers is directly related to the circle of information one is in. It is therefore important to invest on availability of comprehensive SRH information among adolescents and young adults within schools and their surrounding communities so as to make the information they share credible.
Nearly half of the participants reported receiving SRE while at University. In Tanzania, implementation of health education and awareness campaigns in HLIs are compromised either due to lack of policies and staff commitment or nancial prospects (41). Funding for such activities is mainly from external sources and often sexual health education programs are not streamlined (41). This has an effect on the quality of the health services or educational packages, and students nd them repetitive and lacking creativity. At HLIs, there have been reports on a dearth of SRH initiatives and if present, there are concerns on their quality. Health education campaigns being labeled and perceived as "boring", "repetitive" or "normal"; and senior staff members lack commitment to SRH matters (41). Students in HLIs are generally young adults within the de ned STI/HIV high-risk group of 15-24 year olds, probably at their peak years of sexual activity, sexuality curiosities and experimentation; and many are "free" of immediate parental supervision. Studies have shown that while majority of students believe that they are at low or no risk to STIs/HIV, they were actually found to be at high risk after assessing their sexual behavior practices (6). Regional and district health management teams could be engaged to assist HLIs with regard to health promotion and targeted health awareness campaigns to minimize students' sexual health risks.

Study Limitations
Our study ndings may have been biased from recalling past experiences, especially those of a sexual nature which were unpleasant. Also, this crosssectional study did not assess other family factors which may have an in uence towards parent-child communication. The level of SRE among participants was not uniform as some had received SRE starting from Primary school level.

Conclusion
Young people have a gender-biased preference when it comes to learning about SRH matters from their parents; however, such conversations seldom occur.
Sexual behavior among adolescents/young people is in uenced largely by familial, structural and environmental factors; and therefore, talks on sexual matters need to actively begin at the family level. Community health Information, Education and Communication (IEC) should incorporate the agenda on the urgency of building skills of parents on parent-child communication on sexual matters so as to empower them to con dently initiate and convey appropriate and su cient sexual health information. Further, comprehensive SRH education and skills building is needed in the current school SRH curriculum in order need to meet the demand and needs of students' and teachers'.

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