Parent-Young People Communication on Sexual and Reproductive Health Issues and Associated Factors Among Students in Agaro Town, Ethiopia: A Cross-sectional Study

Sexual and reproductive health (SRH) is at the base of young people's living and wellbeing. A signicant number of young peoples are affected by avoidable SRH problems due to a lack of appropriate knowledge regarding SRH. Parent-young communication on SRH is critical in informing them about risk and protective behaviors which in turn decrease the likelihood of involvement in risky sexual behaviors. Therefore, the purpose of this study was to evaluate the parent-young communication on SRH issues among secondary and preparatory school students at Agaro town, Southwestern Ethiopia. Methods School based cross-sectional study was conducted from April 13 to April 20, 2019 using stratied random sampling technique. Data were collected using pretested interviewer-administered structured questionnaire entered into Epi data version 3.1; and analyzed using SPSS version 20. A variable having a p-value of <0.25 in the bivariable logistic regression model was subjected to multivariable logistic regression analysis to avoid the confounding variable’s effect. Adjusted odds ratios were calculated at the 95% condence interval and considered signicant with a p-value of <0.05.


Introduction
Globally, there are 1.8 billion young people (age10-24 years) and 90% of them live in developing countries (1,2). Young age is a critical stage of rapid biological and psychosocial changes that affect all aspects of life, and it is also an important period to lay the foundations of good health in adulthood (3). Unsafe abortion, early pregnancy, high rates of sexually transmitted infections(STIs), di culty accessing contraception, cultural factors and socio-economic are some of the challenges faced by young people (4).
Each year around the globe sixteen million late adolescent girls give birth, in which 95 percent of them occur in developing countries (5). Young people usually engage in risky sexual behaviors and highly affected by the burden of unwanted pregnancy, HIV/AIDS, STIs and other reproductive ill health due to lack of awareness about risky sexual behaviors (6-8). Globally greater than 60% of young people were living with HIV, and they also account for 58% of newly acquired HIV infections (9). Unplanned and unwanted pregnancy for unmarried young women results in dropout of school, rejection from family and community. The main cause for the above situation is the gap in promoting the sexual and reproductive health (SRH) agenda and young population health is usually ignored area in health priority (10).
One of the priorities of the Sustainable Development Goals is improving the SRH of the young population (11). To this end, Ethiopia has also developed a strategy speci cally targeting young people (12). However, the problem of SRH among young people remains a challenge (13). Moreover, lack of integration and shortage of young-friendly services are common problems in most developing countries, including our country (4).
Parent-young population communication on SRH issues is vital in reducing risky sexual behaviors and negative its consequences (14). It is fundamental process through which parents transmit sexual values, information, beliefs, and expectations to their children with the purpose of in uencing sexual behaviours, attitudes and decision-making of their children (15). Parent-young population communication is one potential source of SRH information for young people(16). Evidence revealed that 29% of premarital sex is due to inappropriate parenting (17). The Ethiopian government has established a strategic goal to encourage parental participation, but little is known about parental participation (18) and the role and current status of parent-young population discussions on SRH issues have not been well addressed yet(19).
Reasons for not discussing with parents include sociocultural norms, lack of knowledge and parental fear (20). As a result, most of the young people attempts regarding sexual matters is generally misguided by their peer group of the same sex and many teenagers do not have access to reliable information regarding their SRH needs (6,21). According to previous studies, the factors associated with the parent-young people communication about SRH were parental education, adolescent's age and living arrangements, type of parents, and parents' SRH knowledge and attitude (20,22,23).
As per author's knowledge there is inadequate evidence about the proportion of parent-young people communication in Ethiopia (24), point prevalence varies among the studies and there is no established evidence at the study area. Moreover, there are inconsistent ndings with regard to proportion and factors associated with parent and young people communication on SRH issues. For instance, according to study nding gender had a positive relationship with communication on SRH (22,25) while other studies showed no association(6).
Hence, this study was aimed at assessing the proportion and associated factors of parent young communication on SRH among secondary and preparatory school students for risk minimization and better health at the study area. This study will help to provide information regarding the proportion of parent young people communication on SRH and its determinants which helps as an input to design appropriate intervention programs. Furthermore, this study was attempted to generate evidence based information for concerned government bodies and policy makers to consider the situation and to design an appropriate intervention strategy.

Study area
The study was conducted at Agaro town, Jimma Zone, Southwest Ethiopia. It is located 45km from Jimma town and 391km from Addis Ababa. There are educational services from kindergarten to university in the town and it has two health centers and one primary hospital. There are 2 secondary and preparatory schools and 4 secondary schools in the town. According to the data obtained from school directors, the school had 2818 total regular secondary and preparatory students during the study period.

Study period
The study was conducted from April 13 to April 20, 2019.

Study Design
A descriptive facility based cross-sectional study was conducted among secondary and preparatory school students at Agaro town.

Study population
The source population comprised of all Agaro secondary and preparatory school students during the academic year of 2019, while the study population comprised all Agaro secondary and preparatory school students who ful lled the inclusion criteria.

Eligibility criteria
Regular students were included in the study, whereas students absent from class on data collection days, sick and married students were excluded.

Sample size determination
The sample size was determined using single population proportion formula considering the following assumptions: P = 28.9% (26), signi cance level 5% and margin of error 5%.
Where n= required sample size Z = Percentiles of the standard normal distribution corresponding to 95 % con dence level assumption Accordingly it gives initial sample size of 317. Since the source population is less than 10,000, (2818), we employed population correction formula for a nite population.
Where: n = sample size N = total population (2818) nf= nal sample size By taking into consideration 10% non-response rate, the nal sample size was 286+28.6= 315.

Sampling procedure
Strati ed random sampling technique was employed to select study participants. First the sampling frame was prepared by having lists of students from grade 9 to 12 and then the sample population was proportionally assigned to each grade. Proportional allocation was done by allocating sampling proportional to the total population of each unit, using the formula: Where ni =sample size of students from each grade, n=total sample size of students, N=total population of students, and Ni = total population of students at each grade. Finally samples were selected from each class by simple random sampling technique using students' roster (Figure1).

Operational de nition
Parents: in this study mean biological parents, step parents or foster parents but does not include elder siblings (27).
Parent-young communication on SRH: Students open discussion on at least two SRH issues (STIs/ HIV/AIDS, condom, sexual intercourse, premarital sex, puberty, menstrual cycle, unwanted pregnancy and contraception) with their parents in the last 12 months initiated by the young population or both(28). Secondary school students: students who were in grade 9 and 10.
Preparatory school students: students who were in grade 11 and 12.
Regular students: students who were assigned on working day (from Monday to Friday) on regular working hour.
Young people: In this study context are peoples who are between 10-24 year olds.
Ever got SRH information = in this study context participants who had SRH information on at least two SRH issues during their life time.
Residence: In our study context place where students live for at least six months.
Ethnicity: nation of the study participant they belongs.

Data collection instrument
Data were collected using pretested, validated, self-administered structured questionnaire which was developed through reviewing different related scienti c literatures(6, 25,26,29) and it was pre-tested before collecting data to ensure data quality. The data were col lected by six diploma graduate nurses under the supervision of two supervisors and principal investigator. Data collectors were supervised by two diploma midwives.

Data quality control
Data quality was ensured through standardized data collection materials and the English version questionnaire was translated to local language (Oromic) version for appropriateness and easiness by language experts in both cases. The Oromic version was again translated back to English language to verify the content validity of the original version.
Two days of training was given for data collectors about the aim of the study, how to approach the study subjects, sampling procedure and the content of the questionnaire. The questionnaires were pre-tested on 5% of participants at the Jiren secondary and preparatory school one week ahead of actual data collection and further modi ed based on the results. Continuous follow-up and supervision were made by the two supervisors and principal investigator and collected data were reviewed and checked daily for clarity, completeness and consistency.

Data entry, processing and analysis
The collected data was compiled, reviewed, coded and entered in to Epidata version 3.1 and exported to SPSS version 20 for analysis. Data was checked and cleaned for its completeness and errors in coding and entering before analysis. Descriptive statistical analysis was used to compute frequency and a percentage of independent and dependent variables. A logistic regression model was computed to see the association of independent variables and dependent variables. Variables with ≤ 0.25 on bivariable logistic regression were considered as candidates for multivariable regression and P-values of < 0.05 were considered to be statistically signi cant in the multivariable analysis. Crude and adjusted odds ratios with their 95% con dence intervals were calculated. The Hosmer and Lemeshow goodness-of-t test were checked and gave a p value of 0.704, indicating evidence of tness of the model. The variance in ation factor was used to verify the multico-llinearity between the independent variables, and no ndings were found.

Communication on sexual and reproductive health issues
Although 92% of the respondents reported that it was important to discuss SRH issues with parents, only 61.3% had communicated with their parents on at least two SRH topics. The major topics discussed among participants were premarital sex (40%) followed puberty (37.8%) ( Table 2).  Young students, whose mothers had primary education, were 3.67 times more likely to communicate on SRH issues with their parents than those students whose mothers were illiterate (AOR=3.67; 95%CI:1.93-6.97). Similarly, young students whose mothers had secondary education were 2.86 times more likely to communicate on SRH issues with their parents than those students whose mothers were illiterate (AOR=2.86; 95%CI: 1.2,6.8).This study also revealed fathers' education [primary education (AOR=5.8 95%CI: 2.8,12.3),secondary education (AOR=3.21 95%CI:1.55,6.59)]were signi cantly associated with parent-young communication after controlling for confounders (Table 4).  (32) and 37% in Dire Dewa, Eastern Ethiopia (6). Those differences might be due to the difference in socio-demographic, cultural difference and accessing sexual reproductive health information. For example, the possible explanation of higher prevalence in our study could be due to home to home, school and mass health education and information by Jimma University health science students during community based team training program every year.
In contrast, the nding of the current study was lower than that of a study conducted in Hayik and Wolaita Sodo, Ethiopia were 83% (25) and 85 % respectively (33). The possible reason for the difference in our nding and the one from Wolaita Sodo could be due to the difference in the study population, i.e., the study from Wolaita Sodo included only female university students with large sample size who have better information. Similarly in the study conducted in Hayk, more than three-quarters of the participants lived in urban areas with adequate access to reproductive health services, and all participants were from preparatory schools. Moreover, the study from Ghana reported 82.3% (34). The difference might be related to difference in sample size used, sampling technique and culture related to openness related to SRH issues.
The major topics discussed among participants were premarital sex,puberty and STIs/HIV/AIDS, while topics like contraception was discussed less among participants. The possible justi cation might be as majority of the participants (83.5%) were Muslim followers and their religion did not encourage them to use contraception including condoms which might affect their discussion. Thus, we recommend future study supported with qualitative ndings to explore on this issue.
Regarding challenges for not discussing SRH issues shame, cultural taboos, embarrassments and parents' lack of knowledge were mentioned by the majority of participants. For instance, 76.2% of participants were not discussed regarding unwanted pregnancy due to shame and parents' lack of knowledge 46% and 24.8% respectively. This was consistent with previous studies (25,27). This might be due to the fact that sexual conversations are deemed a taboo subject in many African communities, including our country.
In agreement with earlier studies, in this study educational status of father and mother showed statistical signi cance with parent adolescent communication about SRH issues (25,35,36). This could be due to educated parents have better access to health service information, improved perceptions of SRH issue and better skill of communication.
In the same manner, the study showed that those students whose family size was less than ve were more likely to communicate compared to those whose family size was ≥ 5. This result agreed with previous study (37).This result demonstrated that those parents with small family size had better chance of discussing SRH issues with their children. Finally, the present study revealed that there were signi cant association between parent adolescent's sexual and reproductive issues and having boy/girlfriend. The possible reason for this association might be students who enter to relationship might raise about SRH issues with each other and they may discuss with their parents for more information.
Limitation of the study 1st due to cross-sectional nature of the study, it was di cult to imply cause-effect relationship. 2nd this study was done to assess parent young-people communication were based on young population perceptions, which may not re ect what parents were actually doing. 3rd, since it was based on self-reporting, it might be affected by social desirability bias because of sensitive nature and cultural barrier for open discussion and nally additional qualitative study should be done to explore more on young and parents communication.

Conclusion
This study showed about two third of young population had discussion on SRH issues with their parents on at least two SRH issues. Educational level of parents, having family size of <5 and having boy/girlfriend were signi cantly associated with communication. The main reasons for not communicated was cultural taboos, shame and parents lack of knowledge. Thus, it is necessary to educate and equip students and parents to address the identi ed problems. More research is required to identify barriers especially with regard to parents. No funding was received.

Con icts of Interest
The authors of this study declare that have no competing interests.

Ethical approval
Ethical clearance was obtained from the Institutional Review Board of the Jimma University. A formal letter of cooperation was written to the school administration Agaro District Education O ce for permission and support.

Consent to participate
After ethical approval, the objective of the study was described and oral informed consent was obtained from study participants aged ≥ 18 years and parental informed consent was obtained for those who were aged ≥ 15 years after explaining the purpose of the study. Information was recorded anonymously and con dentiality and bene cence were assured throughout the process.

Consent for publication
Not applicable

Data Availability
The data used to support the ndings of this study can be available from the corresponding author upon reasonable request.

Author contributions
Both authors made substantial contributions to conception and acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave nal approval of the version to be published and agree to be accountable for all aspects of the work.