Parent-adolescent communication about Sexual and Reproductive Health Issues and Associated Factors among Mothers in Wogdie District, North Ethiopia

Background: Adolescence is a stage of rapid transition of physical, psychological and emotional development. Parent-adolescent communication has great role on the reduction of SRH problem of adolescents. However evidences shows that there is a silence between parent and adolescent because of this adolescent are affected by STIs, HIV, unsafe abortion and unwanted pregnancy. Therefore this study tried to identify factors that hinder communication in Wogdie district North East Ethiopia. Method: A community based cross-sectional study supplemented with qualitative data was conducted. Six hundred fteen mothers were selected by multi-stage sampling method for quantitative study. Interviewer administered questionnaire was used for quantitative data collection. Multiple binary logistic regression analysis was executed to assess the association between variables. Participants were selected by purposive sampling method for qualitative part. Fourteen participants were participated in in-depth interview. The qualitative data was transcribed manually using verbatim approach. Results: The magnitude of parent-adolescent communication was 198 (32.8%) with 95% CI (29.1, 36.7). Rural residence of mother [AOR=0.056, 95% CI (0.01, 0.331)], family size of >6 [AOR=0.338, 95% CI (0.13, 0.874)], maternal education status of uneducated [AOR=0.421, 95% CI (0.186, 0.951)], maternal occupational status of housewife [AOR=0.085, 95% CI (0.024, 0.298)], low wealth status [AOR=0.316, 95% CI (0.129, 0.777)], poor maternal knowledge about SRH [AOR=0.063, 95% CI (0.024, 0.164)] and negative maternal attitude towards SRH communication [AOR=0.037, 95% CI (0.008, 0.169)] were have signicant negative association with parent-adolescent communication. Cultural taboo, fear and lack of knowledge were reasons that hinder communication. sexual and reproductive


Introduction
WHO de nes adolescence as it is the transitional stage from childhood to adulthood that occurs between ages of 10 and 19. It is a period of rapid physical, psychological and emotional development. Generally this transition is natural though it can be stormy affect their health (1). The main problems of adolescent are sexual and reproductive health related issues such as HIV, unwanted pregnancy, sexual transmitted disease, unsafe abortion and early initiation of sexual intercourse (2,3). Even-though parents are in uential source of knowledge for adolescent about SRH, there is silence between parent and adolescent on the subject of SRH (4,5). Parent can help their adolescent to develop and practice reasonable sexual behavior. There are evidences that adolescent who communicate with their parents are more likely to remain sexual abstinent, post pone intercourse and use contraceptive (6,7). Without access to information about sexual and reproductive health adolescents are at high risk of contracting sexually transmitted infections (STIs) including HIV/AIDS, having unwanted pregnancies, unsafe abortions and other serious SRH problems which will negatively affect future life (8).
Adolescents frequently engage in risky sexual behaviors that adverse health outcome including unintended pregnancy, early initiation of sexual activity and sexually transmitted diseases. Globally the rates of early sexual initiation, STIs and HIV during adolescent are rising and remaining unchanged in many countries (2,9). Although Ethiopia applies national reproductive health strategy and plan to increase accessibility of SRH information for adolescent by 50% to reduce SRH problems among adolescent (10), STI (rate of reported Chlamydial among adolescent increased by1.8% during 2017-2018), HIV (60% of new infections are among adolescent), teenage pregnancy (13%) and unwanted pregnancy (49% of pregnancy of adolescent are unwanted) (2,(11)(12)(13)(14) were increased. To reduce such sexual and reproductive health problem of adolescent parent-adolescent communication is important because sexual activities begin at early age (15).
In United States and developed countries there is higher percentage (75%) of adolescent received parental SRH communication such as how to say no to sex, methods of birth control, STIs, where to get birth control, how to prevent HIV infection and how to use a condom (16,17). However, the situation is not similar in developing country including Africa. In Africa parent-adolescent communication about SRH is not practice interactively which is warning and threatening way (5,6) and lower in magnitude (18,19) Studies identi ed sex of adolescent, age of adolescent, educational status of mother, knowledge of mothers about SRH as factors for parent-adolescent communication about SRH but most studies conducted at urban areas (4,7,(20)(21)(22).
Studies conducted in Ethiopia focus on from the adolescent perspective (there are evidences which showed that when adolescent asks about communication most of them are said yes, but when the parent asks about communication the result is different this results wrongly determination of magnitude of parent-adolescent communication), conducted in urban residence and institution based (4,21,(23)(24)(25).
Mothers were participated in this study because mothers are primary source of SRH information for adolescent (26)(27)(28)(29). Therefore this study conducted among mothers, it is community based, conducted in rural setting and supplemented with qualitative data.

Methods And Materials
Study setting and period This study was conducted in Wogdie district from March 1 to April 1 2020. The district is located 585 km away from Addis Ababa (Capital city of Ethiopia), 345 km from Bahir Dar (Capital town of Amhara regional state) and 184 km to the West of Dessie (Capital town of South Wollo zone). There are 6 health centers, 1 primary hospital, 44 HEWs, 1 preparatory school and 4 high schools in the district. According to the national census report of 2007 the projected population of Wogdie for the year 2016 was 152,719 of whom 26.5% were adolescents. Wogdie has a total of 34 kebeles (lowest administrative units).

Study design and sampling
It was a community based cross-sectional study supplemented with qualitative data conducted among mothers who have adolescent in Wogdie district, North Ethiopia. The sample size was 615 which determined using a single population proportion formula by taking a proportion (p) of parent-adolescent communication about sexual and reproductive health in Yirgalem (59.1%) (7) at 95 % con dence level, 5 % margin of error, design effect of 1.5 and 10 % of non-response rate. The study participants were selected by using a multistage sampling technique: -at stage one nine kebeles were selected from the total 34 by using simple random sampling method. In the next stage by using simple random sampling technique a total of 615 mothers who have adolescent were selected from each sampled kebeles proportionally from 2907 mothers. To select mothers who have adolescent the existing Health Post Family Folder were used. For qualitative in-depth interview mothers and fathers who have adolescent, religious leaders and adolescents were selected purposively.

Inclusion criteria
Mothers who lived in the selected kebeles and had adolescent were included in the study

Exclusion criteria
Mothers who were seriously ill were excluded from the study.
Mothers whose adolescents were not lived with them for more than 6 months.

Data collection tool and procedure
A pre-tested interviewer administered questionnaire adapted from different literatures that explored the objectives of the study was used (13,30). According to the local culture and norm rst questionnaires was prepared in English and translated to Amharic language then back translated into English to check consistencies. Six female data collectors who had completed grade 12 educations and who had previous experience in data collection were used as data collectors. Data was collected by using interviewer administered questionnaires at the home of mothers. Data collection was taken place from March 1 to April 1 2020.
Separate in-depth interviews between selected participants were conducted. The interviews were guided with interview guide questions followed by possible probing questions to explore their experience and barriers to communicate. After some common introductory questions the principal investigator asked the participants opinions and experience about the parent-adolescent communication about SRH. Interview was conducted until the data was saturated.

Data quality control
To assure the quality of the data properly designed data collection tool was prepared. Training was given to data collectors and supervisors for two days. The training was focused on understanding the research question, data handling, ethical conduct and quality of data. On each data collection day the collected data's were reviewed by principal investigator. Questionnaire was pre-tested at Mekane-Selam district by taking 60 questionnaires to assess clarity and ow. Interview was conducted at a private place to ensure good atmosphere for interview.
In-depth-interviews were conducted in private and quiet rooms at kebele o ces, Church and Mosque where only the principal investigator and participant were present. The interviews were used discussion guide question followed by possible probing questions. Tape recorder was used in order to prevent missing of data.

Dependent variable
Parent-adolescent communication about sexual and reproductive health issues (Yes/No) Independent variables Age of the mother, Sex of adolescents, Age of adolescents, Maternal occupation status, Family size, Educational status of the mother, Wealth status, Residence, Knowledge of the mother about SRH, Attitude of mother towards SRH communication, Mass-media exposure of mother, Cultural and religious factors, Religious taboo, Cultural taboo and fear.

Operational de nitions
Communication between parents and adolescents on SRH issues:-In this particular study context parents-adolescent communication regarding SRH issues is a simple discussion or talking between mothers and adolescent on STIs, HIV/AIDS, safe sexual practice, abortion, sexual violence, unintended pregnancy, early marriage physical and behavioral change of adolescent and family planning (4) Mother who are communicated with their adolescent:-Mothers who were discussed at least two topics of SRH issue in the past 6 months were considered as communicated (4).
Knowledgeable about sexual and reproductive health: Those mothers who scored above the mean score from nine knowledge related SRH questions were considered as had good knowledge (4).
Attitude towards sexual and reproductive health communication: Mothers who were scored at least 75% of 10 attitude questions considered as had positive attitude.
Attending mass media: Mothers who were listen radio or watch television at least once a week in her home considered as exposed to mass-media (13).
Parent: Applies for both biological and non-biological mothers (24) Wealth quantile: Was determined by using durable household assets a total of 35 durable assets was identi ed and assigned as dummy variables. After adjusting and coding we used multivariate analysis i.e principal component analysis. Then we re-categorize in to three wealth quantiles with approximately equal number of households.

Data Processing, Analysis and Interpretation
The collected data were entered and cleaned using Epi data version 3.1 then exported to SPSS version 23 for analysis. Descriptive analysis was conducted to summarize the data and the nal result of the study was presented in the form of number, text, gures and tables. Binary logistic regression analysis was executed to see the association between variables. All explanatory variables with p<0.25 in bi-variable logistic regression were entered into multivariable logistic regression analysis and signi cant association were identi ed based on p<0.05 and odds ratio with 95% CI in multivariable binary logistic regression. The model tness was checked using Hosmer-Lemeshow Goodness of t test.
Ideas of participants were recorded, transcribed, translated and recoded. After read and read again the nding was analyzed in text form. Analysis of qualitative data was taken in each day of interviews and used verbatim analysis method.
The quantitative results and qualitative ndings were merged at results and discussion section.

Ethical consideration
Ethical clearance was obtained from the Institutional Review Board (IRB) of Bahir Dar University College of Medicine and Health sciences. Further permission was also gain from Wogdie district health and administrative o ce. The aim of the study was informed for each study participant and the study participants had a right to refuse or discontinue interviews without any restriction. The study was respected autonomy and decision of all participants. Finally written informed consent was obtained from each participant before data collection and con dentiality was assured.

Results
A total of 603 mothers completed the questionnaire with response rate of about 98.05%.

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Out of the total mothers 443 (73.5%) were lived in rural residence. Five hundred thirty three (88.4%) of mothers were married. The mean age of the mothers was 42.01 ± 7.16 SD years and with the range of 27-58 years. Out of the total mothers 343 (56.1%) of mothers were educated. Three hundred two (50.1%) of mothers were Orthodox by religion and 7 (1.1%) of mothers were Protestant religion followers. Four hundred twenty two (70.3%) of mothers were housewife and 69 (11.4%) of mothers were government employed. Three hundred twelve (51.7%) of mothers were had family size of 1-3 members.  A 54 years old Sheik explained that:-"QUARAN is very complete book in the world. If parents read it (QUARAN) they (parent) know about SRH and educate everything including sexual and reproductive health but people do not read."   (21,24,31,32), But this nding higher than studies conducted in Awabel (25.3%) and Mizan (28.9%) this might due to time variation and socio demographic difference like in Awabel the magnitude of urban population was 23.9% which is lower than the study area and in Mizan about 57.3% of populations were unable to read and write which is higher than the study area (33,34). This nding is lower than stuies conducted in Yirgalem (59.1%), Debre-markos (36.9%), Dire-dawa (37%), Hawassa (61%), South Africa (57%), Ghana (72.8%) and Mynamar (62%) this might due to study area difference (these studies conducted at institution but this study was community based), lower illiteracy rate (Debre-markos 20.5%, Yirgalem 7.4%, and Dire-dawa 20.5% and Myanmar 6.3%) and more urbanized (Mekelle 84.9%, Hawassa 73.2%) (4,5,7,20,23,35,36).
In this study rural residence had signi cance negative association with parent-adolescent communication. This nding is concurrent with studies conducted in Awabel, Wollega and Bangladesh (31,34,37). The possible justi cation might be mothers who lived in urban residence were more accessible for SRH information, media exposure and more knowledgeable as compared with rural mothers.
In this study uneducated mothers had signi cance negative association with parent-adolescent communication as compared with educated mothers. This nding concurrent with studies conducted in Debre-markos, Woldia, Debre-tabor and Myanmar (4,21,22,36). The possible justi cation might be educated mothers have good knowledge and positive attitude about SRH communication.
In this study mothers who had negative attitude towards SRH communication were less communicated as compared with those mothers who had positive attitude towards SRH communication. This is supported with study conducted in Bangladesh (37). This might due to those mothers who have positive attitude were have a positive tendency to communicate.
In this study house-wife mothers were less communicated as compared with government employed mothers. The possible justi cation might be housewife mothers were less educated than government employed so-that housewife would have poor knowledge about SRH. This is supported with qualitative data from 37 years old housewife mother said that:-"I am uneducated and nothing knows about SRH and also most of the time I stay at y home so I didn't gets any information about SRH from my peers." In this study mothers who had family size of 4-6 and >6 were less communicated as compared with mothers who had family size of 1-3. This nding is supported with studies conducted in Bangladesh (37).
This may be due to as family size is increase; parents are less concerned to communication on SRH issues. This also supported with qualitative data from 51 years old mother explained that "I have eight family members and I can't communicate with each my adolescent. May be if I have one or two, I might communicate." In this study mothers who had low wealth status were less communicated as compared with mothers who had high wealth status. This nding is agreed with study conducted in Myanmar (36). This might due to most low wealth status mothers were uneducated so-that those mothers were not accessible to SRH information and had poor knowledge as compared with high wealth status mothers.
In this study poor knowledgeable mothers about SRH were less communicated as compared with mothers who had good knowledge about SRH. This nding is agreed with studies conducted in Woldia, Hadiya, Myanmar and Bangladesh (21,24,36,37). This also supported with qualitative data from 48 years old male parent who live in rural residence explained that "we (he and his wife) have no enough knowledge about SRH rather they (adolescent) could gain SRH information from school and peers." Other qualitative data from 37 years old mother who live in urban residence explained that "I had no good knowledge about SRH and I prefer my husband to communicate with them (adolescent)." A qualitative nding of this study explored that Lack of knowledge, fear, cultural taboos of communicating SRH with makes adolescent rude and religious taboos of communicating about SRH predispose adolescent to make sin were the major reasons that hinder parent-adolescent communication. This is supported with studies conducted in Yirgalem, Uganda, South Africa and Zanzibar (5)(6)(7)38).

Conclusion
In this study parent-adolescent communication on sexual and reproductive health issues was found to be low as compared with Ethiopia national reproductive health strategy and plan which is 50%. Rural residence, maternal educational status of uneducated, maternal occupation of housewife, low wealth status, family size of 4-6 and >6, poor maternal knowledge about SRH and negative attitude towards SRH communication had signi cant negative association with parent-adolescent communication. HIV and STI were the most communicated topics. Lack of knowledge about SRH, fear, cultural taboos of communicating SRH with adolescents makes adolescent rude and religious taboos of communicating about SRH predispose adolescent to make sin were the major reasons that hinder parent-adolescent communication.

Recommendations
Amhara regional education o ce Please incorporate sexual and reproductive health issues course in the curriculum.

Wogdie district health o ce
Please give great attention to those parents who have family size of more than three to improve their attention towards SRH communication with adolescent.

For health professionals and community leaders
Home to home and community health education of mothers is recommended to create good knowledge and positive attitude about sexual and reproductive health.

For researchers
Since husband has in uence on adolescent sexual and reproductive health so-that future husband participation is recommended. Topics of communication about sexual and reproductive health issues among mothers who have adolescent in wogdie district, 2020 (Multiple response is possible)