The gogos in the study provided care and parenting to the children they looked after and expressed a common desire to keep them safe and healthy, even in cases where the gogos were not biological grandmothers of the children in their care. Despite acknowledging the need to speak to the children in their care about sex, sexuality and HIV and AIDS, the experiences of gogos in doing so were extremely limited and fraught with challenges and fears. The difficulties were exacerbated by contextual and structural barriers such as culture, gender and generational issues, as well as personal challenges which included past experiences of SRH conversations and lack of skills and knowledge around SRH. As a result of these difficulties most of the gogos had never spoken about sex, sexuality and HIV and AIDS to the children in their care.
Regarding the broader cultural context, SRH communication in Africa is difficult, as many communities regard conversations around puberty, sex and sexuality as taboo (5). All the gogos spoke about the complicated and difficult conversations about SRH that they had both with their own parents and while at school. Hence, traditional values and cultural norms were seen by the gogos as barriers to open conversations about sex, particularly as many gogos had very limited experiences of these types of conversations while growing up. When or if these conversations did occur, they were impacted by normative beliefs and culture and often contained misinformation. Gender and generation issues also appeared to impact perceptions of how to communicate about SRH, and these combined factors translated into challenges and barriers to SRH communications between primary caregivers and third generation children.
According to research on parent–child SRH communications, the genders of the parent and the child appear to play a dominant role for both parties as to the manner in which SRH discussions occurred, as women tended to speak to girls and men tended to speak to boys (5, 8). The gogos in this study did not express preferences related to which gender child they spoke to, but they did comment on the fact that it was the social norm for men to speak to boys and for women to speak to girls, and that they found it more difficult to speak to boys.
A number the participants commented on the fact that they were gogos and not mothers of these grandchildren. Generational differences present their own specific challenges to grandparents who may not feel prepared to deal with these conversations (15). The gogos experienced aspects of intergenerational conflict as mentioned by Nyasani et al.(2009), with problems with child discipline and disharmony in the intergenerational relationship between themselves and the grandchildren they were caring for (13). This added to the problems and barriers around SRH communication between gogos and their grandchildren. Gogos experienced perceived dismissal from grandchildren, feared losing respect in the eyes of their grandchildren and being laughed at by their grandchildren when attempting to initiate SRH communication.
According to a study by Armistead et al. (2014), parental involvement in sexual communication is generally a new notion for South African families (23). In addition to the cultural and social obstacles discussed previously, the gogos’ explanation for the lack of SRH communication was that their parents feared that discussion and knowledge of sexual topics would lead to children engaging in sexual activities. In addition, the conversations about sex that the gogos had had with their own parents had often been negative and punitive. Many of the participants found themselves as parents having the same types of negative conversations about SRH with their own children and again when speaking to grandchildren about sex, sexuality and HIV and AIDS. Many gogos commented that how they did not know how to talk about HIV and AIDS as they had had no experiences of talking about HIV and AIDS when they were growing up.
The fear that speaking to children about sexual behaviour would promote sexual activity is common theme in sub-Saharan Africa (5). The gogos in this study explained that their parents had also had this fear and it was at least partly responsible for the lack of perceived efficacy on the part of the gogos in addressing SRH with their own children, as they had had limited opportunities to experience these types of discussions during their own upbringings and while raising their own children. However, it is not necessarily a barrier to SRH conversations in and of itself and the gogos did not experience this fear when it came to speaking to their grandchildren as the gogos had experienced firsthand that not talking about sex did not result in children not having sex. A study by Cornelius et al. (2008) found that African American grandmothers did not fear that talking about sex would promote sexual behaviour in their grandchildren, and that these grandmothers embraced the idea of talking to their grandchildren about sex (18). African American grandmothers, in fact, wanted to talk about sex and were able to have open SRH communication with their grandchildren in contrast to the views and experiences of parents (17). The results of our study reflects the finding of Cornelius et al. (2015) as fear of promoting sexual activity was not mentioned by the gogos as a barrier to having conversations about sexuality with their grandchildren or children in their care although it had been a fear for their parents and when they were raising their own children. The gogos in this study showed that there has been a shift away from this belief based on their lived experiences that not talking sex, sexuality and HIV does not prevent sexual behaviour or HIV infection. The gogos in this study, like the African American grandmothers in the study by Cornelius et al. (2015), wanted to be able to talk about SRH but both groups felt they lacked the skills to do this.
This is not to say that personal beliefs and experiences can be totally discounted as a barrier to SRH discussions, as many parents are from a generation where discussing sexuality topics was linked to embarrassment (5, 8) and, although grandparents in these cases are perhaps receptive to discussing sex and sexuality with their grandchildren, they experience different levels of comfort with these conversations (18). These findings were supported by our study as gogos expressed discomfort and a lack of confidence and ability to acknowledge, confront or discuss the difficult and uncomfortable topic and issues of adolescent sexual behavior, although this could potentially be mitigated by providing support for the gogos, enabling them to conduct the discussions more effectively.
In fact, despite increasing evidence of programmes that target grandmothers (as opposed to mothers) to support SRH communication having positive outcomes (20, 21), only one gogo in our study had received any prior HIV training. Cornelius et al. (2015), likewise found that African American grandmothers were unprepared for discussing topics regarding sexuality and sexual health with their grandchildren or the children in their care and required assistance when communicating with their grandchildren about SRH in order to do this more effectively (17). In South Africa, a study conducted by Mangxola (2007) demonstrated that grandparents in the Eastern Cape were unsuccessful in communicating SRH matters to youth and concluded that grandparents should be supported in communicating sexual matters to their grandchildren(25). A similar need was identified through our research, with the participants acknowledging the value of these conversations in reducing HIV infection and unintended pregnancy and our findings clearly demonstrate the need to engage with gogos to increase effective SRH communications. All the participants expressed the wish to be able to have these SRH conversations more effectively with increased knowledge about SRH.
This study supports the view that it has become imperative to examine the changes in family composition in sexuality education in South Africa (23, 26, 27, 28). A number of studies in South Africa have commented on the importance of the extended family and caregivers other than parents (23, 24, 26, 27, 28). In addition, this study supported findings in other research (17, 22) for the need for healthcare providers and programmes to recognise that there are differences in SRH communication and conversations between parents and grandparents.
Research conducted by Aubel (2005) showed that the concern that grandmothers might be biased and unable to adapt to modern practices and new ideas was incorrect and that this should not be a reason that interventions do not make use of older people as drivers in community and family-based interventions (29). Aubel (2005) reports that grandmothers are in fact open and receptive to change and new ideas and can in fact be very powerful resources in promoting health changes (29). Like Aubel (2005), our findings challenged the stereotype of grandmothers as being conservative and resistant to change as all the gogos expressed a desire to be able to have informed and effective SRH conversations with the grandchildren they were looking after or raising.
The findings need to be considered in the light of the following limitations related to the collection of data and the role of the researcher. The lead researcher (JS) was female, white, middle class, and had prior links to Ratang Bana. However, these attributes of the lead researcher did not impact on the data collection as the primary interviewer was a black African woman of a similar age group to the gogos. Nevertheless, it is possible that her interpretation of the findings and the coding of data could have been affected by the fact that the researcher was aware of the difficulties experienced by the participants; she was sympathetic to parenting issues as a mother of adolescent children herself, and had established relationships with some of the participants prior to the commencement of the research. In addition, the participants all came from the same centre, Ratang Bana which could have influenced which details were shared. However, this was mitigated by having an interviewer who did not have any prior connection with the organisation. Furthermore, although the participants were typical of gogos in Alexandra, they were all accessing support at a local NGO which could have influenced their experiences and how they engaged in the interviews.