Talking to teenagers regarding sexual and reproductive health: Exploration of parents/guardians’ views in Limpopo province, South Africa

Background Sexual and reproductive health are sensitive topics that may not be easily discussed among different age groups in most cultures. Most parents are uncomfortable to communicate with their children about sexual and reproductive health. The rate of teenage pregnancy and sexually transmitted infections continues to rise as parents shift the responsibility of discussing sexual health to other members of the family or teachers. Many sexual and reproductive ill-health exists among teenagers as a result of poor communication with parents or elders. The aim of the study was to explore the views of parents/guardians regarding t the discussion of sexual and reproductive health issues with teenagers. Methods The study was conducted in Capricorn and Mopani Districts of Limpopo Province where teenage pregnancy rates were reported to be very high. A qualitative explanatory approach was used. The population comprised of parents/guardians to teenagers who were pregnant or having children. Data were collected through individual face to face interview guided by one central question. Data were analysed using Tesch's method. Measures to ensure trustworthiness and ethical issues were ensured. Results Two themes emerged from the study: Views regarding discussing sexual and reproductive-related topics between parents and teenagers and Relationship of parents/guardians and their teenagers as an influence of discussions about SRH matters. Conclusion Parents/guardians still view discussing sexual and reproductive health issues with teenagers as taboo and difficult. However, discussing sexual and reproductive health issues with teenagers is seen as a beneficial practise as it might influence them positively and may decrease unwanted sexual risks such as teenage pregnancies and HIV infections.


Introduction
Teenagers' face multiple challenges during their transition to adulthood. They are exposed to mixed messages that they receive from their peers, media and the internet and sometimes parents/guardians. More than often they fail to comprehend such information, leading to risky sexual behaviours such as unprotected sex, multiple sexual partnerships, and transactional which predispose young people to sexually transmitted infections, teenage pregnancy and HIV and AIDS [1]. Parents play a critical role in the growth, development and sexual socialization of their children and should be involved in the presentation of sex education and reproductive health. During Parent-child sexual communication, parents transmit sexual values, beliefs, information and expectations to their children with the aim of influencing sexual behaviours, attitudes and decision-making of their children [2].
Sexual and Reproductive Health (SRH) matters are sensitive issues to discuss with teenagers. Socio-cultural and religious beliefs, as well as parents' educational level, are the most enhancing or inhibiting factors towards discussing such topics [3]. Furthermore, cultural beliefs and values dictate what parents should and should not say to their children about sexual health issues. In contrast, acculturation has also contributed to the sexual behaviours of adolescents. It was also indicated that acculturation is a dynamic and complex process by which individuals combine and meld their original and secondary cultures into a third, unique set of cultural values, practices, and beliefs [4]. The authors further reported that the less acculturated youths reported having sex at a lower rate, having few sexual partners and habitual condom use than their more acculturated peers.
Religion has also been cited as a factor that hinders parent-child communication, for example, the Protestant churches and Islams' believe in abstinence before marriage, maintaining of virginity and oppose sex education, and maintains that SRH programmes might encourage adolescents' preoccupation with the sex [5,6]. Religious beliefs had been contended to guide parents on what to discuss with their children, focusing on teaching their daughters about the virtues of virginity and that they should forget about sexual activities until they get married [7]. Hence this religious belief contributes to the hindrance that makes parents fail to communicate with their children about issues of sexual and reproductive health.
Parents in black African communities are uncomfortable in broaching the subject on reproductive sexual health and shifting this responsibility to the teachers at schools [3].
Furthermore, most male parents perceived talking about sexual health with children as shameful and immoral thus encouraging the children to engage in sexual intercourse [7,8]. Similarly, parents do not talk to their children about SRH topics citing that it was culturally unacceptable [9]. Parents seemed to think that SRH-related issues concerned only sexual intercourse Previous research showed that most of the communication between the parent/guardians and the teenagers focus on abstinence, menstruation, sex, HIV, contraception, unplanned pregnancy, and puberty and some of the content is not correct as parents have limited information about sexual health education [2,10]. The annual review of sex literature indicated that most of the mothers in the studies expressed relative comfort and willingness to discuss the consequences of sex, but not specific, fact-based information regarding intercourse and birth control [11]. The communication in most cases are unidirectional and takes the form of a lecture rather than dialogue and the consequences of sex were exaggerated, and what triggered the conversation was often the undesirable behaviour of the adolescents [11,12]. In addition, directive parents who tend to have a more authoritarian communication style do not invite open discussion and questions from   children, few fathers provided explicit guidance, open and honest conversations which contributed to daughters' knowledge [11].
Limpopo province is experiencing the highest number of adolescent pregnancies, sexually transmitted infections and HIV and AIDS. The South African Broadcasting Cooperation (SABC) on the 16 October 2018 reported that 36 learners aged between 10 and 19 at one of the secondary schools in the Mulenzhe area, outside Thohoyandou were pregnant and children as young as nine, are sexually active, furthermore 13 of them being HIV positive [13]. This is an indication of absent parent-child communication which predispose adolescent learners to experiment with sex at an early age. For this reason, the purpose of this study was to explore the views of parents/guardians related to talking about sexual and reproductive health issues with teenagers.
Parent-child communication on sexual reproductive health has been identified as a protective factor for adolescent sexual and reproductive health, and interactive communication strategies include making sure adolescents' voices are heard to encourage an active exchange of questions and answers, assessing current knowledge and leaving room for future discussions [14].

Research Design And Methods
For the purpose of this research, a phenomenological qualitative exploratory descriptive design was used to explore the views of parents/guardians related to the talking about sexual and reproductive health issues with teenagers. A qualitative research approach was chosen because the study was conducted in the participant's homes which is a natural setting where human behaviour and events occur. This approach allowed the researcher to interview the participant and deepen the discussions by probing and making follow-ups on certain information. Observations were made during interviews for non-verbal cues to get the holistic nature of the problem under discussions. Field-notes were taken. Parental views were explored through probing, paraphrasing, and follow-up questions. The authors sought to pursue this study given the need to understand factors influencing the rise in teenage pregnancies, teenage HIV infection rate and termination of pregnancies. The population consisted of both mothers and fathers including guardians of teenagers, who were pregnant or had babies in the current year of study. Non-probability purposive sampling method was used to select participants. Eighteen participants were selected until data saturation. Participants were identified through the school's life orientation teachers who had a list of leaners who were pregnant and those who had delivered.
Appointments were first secured with the learners, parents after they had provided assent and informed consent was sought from identified teenagers. In families where both parents were available, they were interviewed separately to ensure confidentiality and privacy.
A central question was developed in English then translated into XiTsonga for parents at Mavalana Village and Sepedi for parents in Blood River Village to ensure understanding and getting in-depth information. The research idea was introduced to the parents during the initial group meeting and more information was shared when negotiating the signing of informed consent with individuals. A date for data collection was then set as rapport had been established. Data collection was conducted from May 2018 to October 2018. In families where both parents were available, they were interviewed separately to ensure confidentiality and privacy. Interviews were conducted in the participants' comfort of their homes. The individual face-to-face interview was used to collect data. An audiotape was also used to capture information. The interviews lasted for approximately 45 to 60 minutes. Field notes were written to capture verbal and non-verbal cues. A central question was posed in the same manner to each participant as follows: "What are your views regarding discussing sexual and reproductive health issues with your teenage child?" Data were coded based on the themes and subthemes derived from the responses to the questions with the assistance of an independent coder. The recorded and documented data were compared. Data belonging to one group were assembled in one place to assist further analysis. Themes and sub-themes were formulated using Techs steps [15].
Trustworthiness was ensured through the four principles of credibility, confirmability and transferability. Credibility was ensured by a prolonged engagement which increased rapport and to clarify descriptions with participants through familiarity. Data triangulation was ensured by using different data collection methods through field notes, in-depth individual interviews, referential adequacy and co-coder. Confirmability was ensured by audit trail of voice recorder and the field notes to determine the conclusions, interpretations and recommendations if traced from their sources. Transferability was ensured through the thick description of the research methods and design.

Results
The participants' age ranged from 43 to 60 years with 6 males and 12 females. The participants had children ranging from 4-6 and of those children about 1-3 were pregnant or having a child (See Table 1).
Insert Table 1 here Results from individual interviews yielded three themes which described the views of parents/guardians related to the discussion of sexual and reproductive health issues with teenagers (See Table 2). The themes incorporated religious beliefs affecting sexual reproductive health discussions with teenagers; communication and Discussion of sexual and reproductive health issues with teenagers; and parent-teenager relationship enhances sexual reproductive health discussions which were substantiated by direct quotations from participants. Table 2 here

Religious beliefs affecting sexual reproductive health discussions with teenagers.
Some parents, who were interviewed during the current study, disagreed with the introduction of SRH services in schools or parents being involved in discussing SRH with their children, indicating that it was against their religion, while others indicating that it was cultural taboo. In their own words the participants said: "My religion prohibits such topics; no sex before marriage. We are trying to teach our children good morals, but you want to bring things that will promote immorality." (P12, Female, 50)

Gender and cultural stereotypes influence SRH communication
Gender and culture influence sexual communication compromising sexual health and the associated with doubts of seeking or providing reproductive health information. Gender-related issues were cited by some parents as factors causing discomfort. Male parents indicated that they could not talk to their daughters about menstruation, dating or contraception. These aspects are confirmed by the following statements from the Some participants pointed out positive views that it was important to discuss SRH matters with teenagers so that they could be well informed and also understand the changes in their bodies. Some mothers said that their boys preferred to discuss SRH related matters with them rather than with their fathers. Other parents said that they were the ones who initiated these conversations during family meetings or during informal dialogues.

Parent-teenager relationship enhances sexual reproductive health discussions
Parents interviewed during the current study indicated that they had good relationships with their teenage children, which made it easier to engage in communication about SRHrelated topics with them. However, some parents did not feel comfortable to engage in SRH-related discussions with their teenage children. Some parents indicated that it was easy for them to discuss SRH matters with their teenage children. Both male and female teenagers were more comfortable discussing SRH matters with their mothers than with their fathers. In their own words, the participants said: The participants indicated that having a close relationship with their teenage children made it possible for them to be aware of dangerous situations faced by teenagers. The participants also said in some instances that teenagers could not talk about difficult situations, but having close relationships, enabled them to be open. Parents indicated that it is important to have good relationships with their teenage children as this enhanced teenagers' openness to reveal hidden issues that in actual instances they could not talk about if parents were unapproachable. The current study revealed that some parents could identify situations which affected teenagers and could give support and advice. This was found to be useful to teenagers because their challenges related to SRH were addressed. The following relevant statements from the participants support this finding: "I teach my teenage girl that she should not allow boys to touch her and that she should run away from older men who take advantage of young girls; they want to ruin their future [sic]. Actually, my girl was telling me that when they come back from school men will stop their cars and call them" (P2, Female, 55) Another participant said:

"Because we don't know what happens when they get out of the gates and go to school, what kind of friends do they meet, what is it that they tell them what we don't tell them.
So, I just keep on telling them this sexual and reproductive health issues for them to be able to protect themselves so that even if they are to engage in sexual relationships, they must protect themselves, they must start engaging knowingly, they must not only protect themselves but knowingly" (P17, Male, 57)

Discussion Of Findings
The findings of the study indicate that parents because of religious affiliation or adherence to cultural practices were negative towards discussing of SRH with their children. Similarly, Catholic schools and parents followed religious teachings with regard to sexual and reproductive education which emphasize abstinence [5]. In support, in the African culture, it would be considered a taboo to talk about sex with young adults or adolescents [16].
Some religious beliefs do not support the discussion of SRH issues with children, arguing that it would promote immorality. However, some parents realized that there was a need for these services to be provided in schools considering the high teenage pregnancy rate.
It has been noted that most of the participants place more emphasis on sexual intercourse and ignore other aspects related to SRH. It is therefore important to assist communities and school in attending to all aspects that form part of the SRH.
According to participants discussing issues related to SRH was viewed as being very difficult. Use of threats and indirect language was said to be some of the strategies used to initiate a discussion. In support, parents played a relatively small role in sexual socialization and education of adolescents, which could contribute to adolescents' engagement in sexual intercourse without proper guidance [17]. Others study reiterated that parents were very uncomfortable to talk about or discuss sex and sexuality issues with their children and shifting the responsibility to teachers and nurses [2,18]. Such poor communication between parents and teenagers could contribute to high rates of teenage pregnancies, STIs, HIV and AIDS infections. Parents might talk indirectly about sex with their children, something that could lead to misinterpretations and distortions of the essence of their sex education messages [19]. Furthermore, most parents felt that talking about sex with one's children was unpleasant, hence they had to wait for clues or triggers that a child was sexually active before they warned and threatened about the consequences of engaging in sex.
Factors which contributed towards making it difficult for parents to discuss SRH issues with their children were found to be ignorance, culture, gender, fear, age difference, and outsourcing of responsibility to teachers or health care professionals. Although parents could not communicate about SRH issues with their children, they showed concern about their children's safety as far as issues of sexuality were concerned. The parents reported that some of their teenage children obtained information from social media without parental guidance, which could have negative consequences. It is necessary that parents be given necessary support related to how they can engage teenagers and resources necessary to use as a reference where there is a lack of information.
The participants in the present study revealed that they realized the importance of discussing SRH issues with their teenage children. Mothers were found to be the ones that communicate more with their teenage children regarding SRH. Participants were concerned about their children's safety and about the consequences of unprotected sexual engagements. Similarly, some parents did educate their adolescents about sex, STIs and HIV [3]. Parents also encouraged their adolescent children to have one sex partner and always to use protection when engaging in sexual activities. Communication about SRH had sometimes been initiated by parents [20].
Parent-child SRH communication had been found to be mainly delivered by mothers and rarely by fathers [21]. Most young people are more relaxed talking to their mothers than talking to their fathers, but some adolescents do not trust their parents and censored what they could tell their parents for fear of punishment [22]. It has however been noted that the absence of the fathers in the discussions could have a negative effect on the outcome of such discussions. Involvement of both parents in the discussions could have a positive outcome as teenagers could realise the importance of the subject by the involvement of both parents.
The findings show that some parents had good relationships with their teenage children which facilitated two-way communication, but mothers seemed to communicate more often with their teenage children than fathers. Researchers also supported the findings that parent-child communication about SRH happened in most families and the communication was mainly on the same-sex basis, mother-daughter and rarely father-son or father-daughter [22]. On the contrary, a study revealed that both Australian fathers and mothers encouraged their children to protect themselves and others when engaging in sexual activities [23]. Of noteworthy, mother-child closeness is related to the later onset of sexual intercourse for daughters, but not for sons [24]. These findings appear to be contrary to a study that indicated that there was minimal if any, dialogue about sexual health between teenagers and their parents [25]. Thus, it is important to promote, encourage and maintain parent-child relationship s well as the dialogues related to sexual and reproductive health.
A positive relationship between parents and their teenage children was said to open a good communication channel between parents and teenagers. Similar findings to those of the current study demonstrated that the most consistent finding of numerous studies was that parent-child connectedness (support, closeness, and warmth) was related to lower adolescent pregnancy risk attributed to delayed and reduced frequency of sexual intercourse [25].
It has been identified as a close relationship between parents and teenagers open a door for parents to realise difficulties that face teenagers which they themselves could not have faced. This allows them to walk with them in this path and understand the world of the teenagers to can intervene appropriately. Contrary to these findings, other authors found that families rarely discussed contraception and condoms with their teenagers [23].
This study, however, did not indicate if this absence of communication was related to a strained relationship.

Limitations And Strengths
The study was conducted in Capricorn and Mopani districts of Limpopo Province and therefore, the results cannot be generalized to other districts without conducting similar studies elsewhere. The strength of the study was individual interviews which were used to obtain in-depth information.

Conclusion
The study highlighted that parents have trouble discussing sexual and reproductive health issues with their teenage children. Therefore, workshops to educate parents are recommended. The study focused on views of parents related to discussing sexual and reproductive health issues with teenagers. The findings yielded positive and negative responses as some parents were comfortable, while others displayed some discomfort.
Parents should be empowered to be able to communicate sexual and reproductive issues in a frank and assertive manner. Breaking cultural, religious and gender stereotypes and strengthen their knowledge regarding sexual health issues.

Declarations
Education, Limpopo Province. Permission was also be sought from the participating Health Facilities where Health Care workers would be interviewed. Fundamental ethical principles were adhered to throughout the study. The participants' rights were explained. Informed written consent was sought from the participants prior to commencement. Participation in the study was voluntary and confidentiality and data safety were maintained.

Consent for publication
Not applicable.