Parent-Adolescent Discussion on Sexual and Reproductive Health Issues and Its Associated Factors Among Parents in Sawla Town, Gofa Zone, Ethiopia


 Background: Parent-adolescent discussion on sexual and reproductive health (SRH) issues leads to increased awareness on reproductive health matters and reduces risky behaviors among adolescents and also is the base to reduce depraved reproductive health outcomes. The aim of this study was to assess parent-adolescent discussion on SRH issues and its associated factors in Sawla town, Southern Ethiopia, 2020. Methods: A community based cross sectional study was conducted among parents in Sawla town from March to April 2020. A simple random sampling technique was employed to select 697 study subjects. Data were entered in to Epi-data version 3.1 and exported to SPSS version 21 for analysis. Variables with p-value less than 0.25 in bivariate analysis were entered into multiple logistic regression models to test for association with the dependent variable at 95 % confidence level (CI). P-value less than 0.05 and 95 % CI for adjusted odds ratios (AOR) were used to declare the significance of the associations with the outcome variable.Results: Of the total participants, 168 (25.7%) respondents had reported discussion about at least two components of SRH issues in the last six months prior to the study. Multiple logistic regression model revealed that parents who attended primary education (AOR 3, 95% CI: 1.10, 7.70), secondary education (AOR 9, 95% CI: 3.87, 20.64) and diploma and above (AOR 22.33, 95% CI: 9.49, 32.56), monthly income of above 2000 Ethiopian Birr (AOR 2.40, 95% CI: 1.30, 4.55), good knowledge (AOR 2, 95% CI: 1.14, 3.50)and positive attitude (AOR 4, 95% CI: 1.57, 10) towards SRH issues were statically significant with parent to adolescent discussion.Conclusion: The occurrence of parent-adolescent SRH discussion is low in Sawla town. Educational status, average monthly income, knowledge and attitude on SRH issues were major factors affecting parent-adolescent discussion on SRH issues. Continuous capacity building on SRH issues for parents to increase the level of parental knowledge and attitude about SRH issues and sustainable advocacy should be provided about the importance of parent to adolescent discussion. Moreover, it is important to support and scale up the adult learning program to decrease the level of illiteracy.


Introduction
Adolescence is a continuum of physical, cognitive, behavioral and psychosocial change that is characterized by increasing levels of individual autonomy, a growing sense of identity and self-esteem and progressive independence from adults (1). According to World Health Organization (WHO), it is one of the most rapid and formative phases of human development. These distinctive physical, cognitive, social, emotional and sexual development demands special attention in national development policies and programs (2).
Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the ability to reproduce and the freedom to decide if, when and how often to do so (3). SRH regardless of age and sex concerns everyone for a large part of their lives. This issue starts to affect people's lives at adolescence, when they are familiar that they are starting to change from being children to adulthood (4).
Parent-adolescent discussion on SRH issues remains a challenging subject of discussion in many traditional communities as the social environment in them still constrains exchange of information on such issues (5).
The results of adolescent sexual behavior are a huge burden both for the adolescent and society. The problem is not that adolescent are sexually active but rather that they have little preparation and guidance in developing responsible sexual behavior. Developmentally, adolescents reach physical maturity before they are cognitively able to appreciate the consequences of their behavior (6).
An adolescent's primary source of information regarding sexuality is his or her peer group, all of whom are experiencing and reinforcing the same behaviors. The family, the major fraternize of other behaviors, is not as powerful a force in shaping responsible sexual behavior because of parental discomfort with sex education and sexual discussions. This is the result of a social environment in which sex is frequently portrayed but rarely linked with responsible behavior or accurate, non-judgmental information (6).
Parents most often respond with their hopes that their children will grow into adulthood without unintended pregnancy or a sexually transmitted infection (STI). They sometimes follow this with the hope that their kids will never be a victim or perpetrator of intimate partner violence or other sexual abuse (7).
The magnitude of parent-adolescent discussion about SRH issues is variable from country to country, being highest in United States of America (70.6%), Mexico (83.1%) and very low in countries like Myanmar (6.8%) and India (13%) in South and East Asia (8-11). A study conducted in Nigeria shows that 87.7% parents never discuss sexual matters with their adolescent girls (12), while another study in Alamata, Ethiopia shows that discussion was 14.7% with mothers, 3.9% with fathers, 15% with brothers or sisters, 23.4% with the same sex, 5.7% with the opposite sex and 15% discussed with health personnel (13). Adolescents are exposed to various sexual and reproductive risks such as early sexual debut, unprotected sex, early pregnancy, school dropout and STI/HIV AIDS due to lack of communication with their parents. Worldwide, HIV/AIDS is the leading causes of disease burden for young people (those aged 10-24 years) (14). Half the newly acquired HIV infections occur in young people, with most of those affected living in developing countries (14,15).
Different studies showed that parents lack of interest to discuss, feeling ashamed, culturally not acceptable, lack of communication skills, lack of awareness and belief that discussion will initiate sex as factors affecting parent-adolescent discussion on SRH matters ((16-18). Poor parental involvement in preparing adolescent people for SRH also put adolescents' victim of unwanted problems (19) The government of Ethiopia developed Adolescent and Youth Reproductive Health (AYRH) Strategy in 2006, implemented from 2007 to 2015 and revised from 2016 to 2020. The strategy encouraged adolescents and youth to utilize available health services. Besides this various challenges ranging from limitations in the scope of the strategy, lack of coordination among implementing partners, low stakeholder and parent adolescent involvement, inadequate resources, and social and cultural barriers were faced in implementing the AYRH strategy (19).
Even though discussion on SRH issues is a public health concern among adolescents, it has not received due attention in Ethiopia. The Parent-adolescent discussion and associated factors were not well studied in Ethiopia especially in Southern part. The previous studies done were school based and focused discussion on SRH issues only from adolescents' point of view. Since this study was community based and from parents' point of view, it will play major role in lling research gaps on this issue. The study also helps for advocacy, guidance and program development about parent to adolescent discussion on SRH issues since there is no program provided in community and family level for adolescents to develop good decision-making skill and responsible sexual behavior. Therefore, this study aimed to investigate the parent to adolescent discussion of SRH issues and associated factors in Sawla Town, Southern Ethiopia.

Study Area
The study was conducted in Sawla Town, located in Southern nations and nationalities and People Regional State (SNNPR), Ethiopia. It is 310km far from Hawassa, capital city of South Regional State in Ethiopia and 549 km away from Addis Ababa, the capital city of Ethiopia. Sawla has total population of 46,957, of which 51% are females. According to Ethiopian Health and Demographic Survey (EDHS) 2019, around 25.4% (11,927) adolescents were expected to live in the town. The town has 10 kebeles (smallest administrative unit) with 9,582 households; of these 3,903 households have adolescents. Sawla has one General Hospital, one public health center, two government clinics, nine private primary clinics, two private medium clinics, two pharmacies and seven drug stores which provide maternal and other health services to the population. Only one health center provides the adolescent and youth friendly services (20).

Study design and period
A community based cross-sectional study was conducted from March to April, 2020

Study participants
The source population was all parents living in Sawla town who had children between 10 and 19 years (adolescent) of age. Parents who were unable to communicate or severely ill at the time of data collection were excluded from the study.

Sample size Determination and Sampling Procedure
Sample size was calculated using double population proportion estimation formula in EPI-INFO version 7 based on key variables taken from previous studies. The assumptions are 95% con dence interval, 80% power of test and ratio of exposed to unexposed =1:1. The calculated sample size was 634. After adding a non-response rate of 10%, the nal sample size became 697.
A simple random sampling method was employed to select the households. The number of households included in each kebele, the smallest administrative unit, is determined in proportion to the total number of households in each kebele. A computer generated random numbers were used to randomly select households from the lists of households who have adolescents ( gure 1).

Data collection and measurement
Data was collected using pretested structured questionnaire, adapted from EDHS 2016 and other published literature (21,22). The questionnaire consists of questions about socio-demographic factors, knowledge about SRH issues, attitude towards SRH issues and discussion between Parents and Adolescents concerning SRH issues. Parent-adolescent discussion on SRH issues was considered if they Discussed at least two SRH issues (physical and psychological changes during puberty, sexual intercourse, condom, STI/HIV/AIDS, unwanted pregnancy, contraception) with adolescents in the last 6 months (21,23). Parents were considered as Knowledgeable on SRH if they Scored above the mean of sexual and reproductive health knowledge related questions (21,24). Positive attitude about sexual and reproductive health issues was taken if they scored above the mean of SRH attitude related questions (21).
Face to face interviews were conducted by six experienced health professionals, supervised by public health o cer from the town health o ce. Data collectors and supervisor were trained for two days through practical exercises.

Data quality and management
Questionnaire was prepared in English language, translated to local language (Goffatho) and back translated to English by an expert for consistency. Questionnaire was pre-tested on 5% of the calculated sample size among parents from Galma Town which is not included in the actual study to ensure clarity of the questionnaire and then the necessary modi cations and correction was made to standardize and ensure its validity. Adjustments in the sequence and wording were made based on the results of the pretest. Questionnaire was checked for completeness on a daily basis. Incorrectly lled or missed questionnaire were sent back to respective data collector for correction. Principal investigator would recheck the completed questionnaires.

Data processing and analysis
The collected data was coded and entered in to Epi-Data Version 3.1 (25) and analyzed using SPSS Version 21 software (26). Descriptive analysis such as proportions, measure of central tendency and dispersion were computed for relevant variables. Model tness was tested using Hosmer and Lemeshow test (>0.05).All variables with p-value less than 0.25 in bivariate analysis were entered into multiple logistic regression model to test for association with the dependent variable at 95% con dence level (CI). P-value less than 0.05 and 95% CI for adjusted odds ratios (AOR) were used to declare the signi cance of the associations with the outcome variable.

Socio -demographic characteristics of respondents
The response rate was 94% (653 of 697 parents participated). The mean age of respondents was 42 years (standard deviation (SD) 6.60). Most of the respondents (521, 79.80%) were Christians. and ethnically Gofa (518, 79.3%). One hundred fty-three (23.4%) of the respondents had no formal education while majority, (227, 34.8%) were civil servants. One hundred forty-ve (22.2%) had monthly income of 1000-2000 Ethiopian Birr. Majority of the respondents were married (581, 89%) and were either father (320, 49%), mother (322, 49.3%) or guardian (11, 1.7%) (Table1).   knowledge and attitude about SRH issues were found to be signi cantly associated with discussion on SRH issues (Table 4). Parents who had good SRH knowledge were two-fold more likely to discuss SRH issues with their adolescents (AOR 2, 95% CI: 1.14, 3.50) than their counterparts. The odds of discussing SRH issues with their adolescents were 4 times higher among parents who had positive attitude than their counterparts (AOR 4, 95% CI: 1.57, 10) ( Table 5).  (27) which shows that the discussion rarely occurs despite accepting its importance. The results of this study are relatively higher than studies from Zeway, Ethiopia (20%) (28) and Lesotho (20%) (29). This difference could have been due to the time gap as improvement in accessing SRH information may have occurred. This result is also lower than the ndings in Mekele (57.6%) and Alamata (68.2%). The difference might be due to difference in measurement tools as study in Mekele considered discussion on one topic enough as compared to this study where at least two topics were used as cutoff. Similarly, different results from the study in Alamata may be due to the fact that, they considered discussions between sisters, brothers and health personals as parental discussion (13,30). When compared to results from studies in other continents the results were much lower. For example Mexico reported 83.1% parents have spoken to their children about SRH issues (11). A study from New York, Alabama reported about the proportion to be 70.6% (9). This might be due to difference in educational level of parents, knowledge, skill of communication and accessing sexual and reproductive health information which is better in Mexico and New York, Alabama compared to Ethiopia.
In this study discussion about puberty was 8.3%, which is similar to previous study done in Ziway (10.6%) (28). However, this result was much lower than in the result reported from Yirgalem, southern Ethiopia (39.7%). This difference may be a result of difference in measuring tool as they considered one topic enough to constitute parental discussion. In addition time period was not restricted, which may have resulted in increased proportion (31). The discussion about sexual intercourse (23.9%) was similar to study done in Debremarkos (27.6%) but much lower than the studies done in Yirgalem (33.5%), Bullen woreda of Benishangul Gumuuz (42.2%) and Harar (50.02%). This may be due to different in measurement criteria. In Bullen, discussion with teachers, friends, sisters and brothers was considered as being part of having parental discussion (21,23,31,32).
Only 7% participants in this study reported discussion on contraception. This is lower than reported by other studies done in different parts of Ethiopia, including in Debremarkos (25.9%), Harar (26.39%), Yirgalem (36.1%) and Bullen woreda of Benishangul Gumuuz (41.3%). The difference may similar to as reported above, being difference in measurement criteria (21,23,31,32). Only 3.7% of the participants from this study discussed condom use and the result is far lower than other studies done in Ethiopia (21,31,32).
One fth (21.1%) participants of this study discussed about STI and HIV/AIDS. This is lower than the study in Bullen woreda of Benishangul Gumuuz, Ethiopia (78.6%). This may be due to difference in study population and that they considered discussions between teachers, friends, sisters and brothers as parental discussion (32). Eighteen percent of the respondents discussed about unintended pregnancy which is similar to the study from Ziway (20.7%) but much lower than other studies in Debremarkos (28.5%), Yirgalem (36.1%), Harar (42.59%) and in Bullen Benishangul Gumuuz (54.1%) This may be due to difference in measurement tools and study population (21,23,28,31,32).
Parents also indicated various reasons why they do not discuss sexual and reproductive health issues with their adolescents. Among the major reasons, cultural norms (54.2%) was mentioned which is in line with the study done in Ziway (54%) but greater than other studies done in Yirgalem, Harar and Bullen woreda of Benishangul Gumuuz (21,23,28,31,32).This shows existence of extensive cultural taboos throughout the country. Fear of discussion (41.5%) was also mentioned as one of the major reasons this is in line with many other researches (18, 23,31,33). This may be due to the taboo nature of discussion about SRH issues in many Ethiopian settings.
Thirty-six percent of the respondents do not discuss due to lack of communication skills. This result is consistent with many studies done in different parts of Ethiopia and from abroad (18, 23,31,33,34) indicating a gap in communication skills among parents. Belief that discussion would initiate sex (34%) was also mentioned as a reason, which is similar to the study done in Debremarkos (33.1%) and Harar (33.8%) where parents perceive that discussing sexual matters with their adolescents might encourage the children to engage in premarital sex (21,23). Some of the participants also mentioned lack of knowledge (20.8%) as a reason for no discussion. This result is similar to the study done in Wollega and Benishangul Gumuuz (32,33). This may be due to parents' perspective that the adolescents know more than them.  (23). Parents who had good SRH knowledge had a two fold increase in the odds of discussing SRH issues with their adolescents (AOR 2, 95% CI: 1.14, 3.5) than their counterparts. This result was consistent with previous ndings (23,33,34,36). This may be due to respondents who had good knowledge were eager to discuss and their knowledge may initiate discussion and they may have interest to share their knowledge. The odds of discussion on SRH issues were 4 times higher among parents who had positive attitude than their counterparts (AOR 4, 95% CI: 1.57, 10).This result was also consistent with previous ndings (23,33,34,36). This may be due to their perceived importance of discussion for their adolescents.
Limitation of the study The study was based on self-reporting and responses might be affected by social desirability bias because of the sensitive nature and cultural barriers for reporting. Since the study design was cross sectional, cause and effect relationship could not be established.

Conclusion
Different evidences suggest that parent to adolescent discussion on reproductive health issues is the basis for safe and healthy transition to adulthood. However, in this study even if parents had good knowledge and positive attitude, the proportion of discussion about sexual and reproductive health is low. This is bounded by different cultural taboos, fear of discussion and lacks of communication skill and belief that talking about sex will initiates sex. Parents who attended primary education had better chance of discussing on SRH issues with adolescents. Those with higher monthly income had discussed on SRH with adolescents. Similarly, those with good knowledge and positive attitude also had discussed about SRH with their adolescents than their counterparts. We recommend provision of continuous capacity building on SRH issues for parents to increase the level of parental knowledge and attitude about SRH issues and sustainable advocacy should be provided about the importance of parent to adolescent discussion. Moreover, it is important to support and scale up the adult learning program to decrease the level of illiteracy. Finally, research is needed to fully understand the issues relevant to social meanings and beliefs that were major reason for low discussion between parent and adolescent.

Authors' contributions
Nigatu Teferi conceived the research idea, conducted the data collection, data analysis and data interpretation, and wrote and reviewed the paper. NetsanetAbera and TadeleYohannes approved the proposal, participated in data analysis and revised subsequent draft of the paper. All authors read and approved the nal paper.
Consent for Publication Figure 1 Schematic representation of the sampling procedure of parent-adolescent discussion and associated factors on SRH issues among parents in Sawla town, Southern Ethiopia, 2020 Distribution of parent-adolescent discussion on SRH issues in Sawla town, Southern Ethiopia 2020 (n=653)