Parent-Adolescent Communication about Sexual and Reproductive Health and Its Association with Gender and Pre-Marital Sex Among Secondary and Preparatory School Students in Woldia Town, North East Ethiopia, 2019

Background : Adolescent today faced different health threats which are predominantly behavioral. Parent-adolescent communication about sexual matters is one of the means that encourages adolescents to adopt responsible sexual behavior. Many children in Africa is uncomfortable to have a Communication about sexual and reproductive health issues with their parents because the subject is a taboo topic in most homes. So, this study aimed to assess magnitude of communication between adolescents and parents on SRH issues and its association with gender and premarital sexual practice among school adolescents of Woldia Town. Methods : School based cross-sectional study was conducted on 368 unmarried Secondary and preparatory school adolescents (15-19 years) in Woldia Town. Simple random sampling were employed to select study participants. Self-administered questionnaire were used. Data were entered by EPI-Data version 3.0.2 and analyzed by using SPSS version 20. Result : In this study 56.3% of school adolescents had parental communication on sexual and reproductive health issues. The result of this study showed that there was a significant negative association between pre-marital sexual practice and adolescent-parent communication on SRH issues where by adolescents who had history of sexual intercourse where 64% less likely to communicate with parents (AOR: 0.36 95% CI: 0.20, 0.65). Conclusion and recommendation : This study showed that adolescent-parent communication about sexual and reproductive health issues was low in Woldia Town. Therefore, programs focusing on meeting young people sexual and

reproductive health needs in the area should focus on changing the social and cultural views of communicating sexual issues in addition to working on changing individual behaviors on contraceptive use. Background Adolescent, peoples of 15-19 years old, today faced different health threats which are predominantly behavioral. Behaviors formed in the second decade of life exposes teens to consequences of unprotected sex, unsafe abortion, sexually transmitted diseases and substance use(1). Adolescents are practicing risky sexual behaviors such as unprotected sex, multiple sexual partners, and sex at early age (2). In Ethiopia nearly 4% of women and 7% of men between the age 15 to 19 had pre-marital sexual practice though the rate of HIV testing among those groups were less than 25%(3) with high prevalence of teenage pregnancies(7.7%) (4). An estimated 2.1 million adolescents were living with Human Immunodeficiency Virus (HIV) in 2016 (5). In 2018, 510,000 young people between the ages of 10 to 24 were newly infected with HIV, of whom 190,000 were adolescents between the ages of 10 and 19 (6). Communication on sexuality issues between adolescents and significant adults results in safer sexual practices as well as closely monitoring towards adolescents daily life practice contribute significantly positive development in young generation (8). According to study findings more children are exposed to sexual images in the media as they are more private which leads them to engage in sexual behaviors at a younger age. Children who receive sex education at home are actually less likely to engage in risky sexual activity. Having open communications with children about sex and other matters is healthy and safer in the long run (9). Study results showed that the prevalence of parent-adolescent communication on sexual and reproductive health (SRH) in Ethiopia is inconsistent which ranges from 25% to 83% (10)(11)(12)(13)(14)(15). In addition to this, factors associated with Communication between parent and adolescent on SRH issues varies where by the effect of gender and premarital sexual practice differ across studies conducted in the same groups of populations. According to study finding gender had a positive relationship with communication on SRH (14,16) while other studies showed no association (10)(11)(12)(13). Premarital sexual practice was positively linked with SRH communication between parent and adolescent (10,11) while other study findings suggested that there was no association (12)(13)(14)16). So, this study aims is to assess the magnitude of communication between adolescents and parents on SRH issues and its association with gender and premarital sexual practice among school adolescents of Woldia Town.

Methods
Study Settings and period: The study was conducted in Woldia Secondary and preparatory school, Woldia town, Amhara region, Ethiopia. Woldia is found 521km from Addis Ababa on the high way from Addis Ababa to Mekelle. The total population of Woldia town was 46,139 with sex distribution of 50.2% females and 13,027 found in the age group of 15-24 (17). In Woldia Town there was one preparatory (Woldia) and two High Schools (Woldia and Millennium). Accordingly there were a total of 3434 High School and 1557 preparatory school students in the town (18).The study was conducted from April 25-30/2019. Sampling techniques and procedure: Simple random sampling procedure was used to select representative sample of students in the selected schools by using the roster of students as sampling frame. From the two high schools having students of grade 9 and 10 Woldia High School was randomly selected by lottery method but the preparatory school was purposively included. Based on the number of students, proportional allocation was allotted to ensure representation for the secondary and Preparatory school. All regular students who were single, not blind or not having known visual impairment were included to the study.
Study Design and Sample size determination: School based cross sectional study was conducted. The sample size was determined by using single population proportion formula with confidence interval at 95 %, 5% desired precision, 5% nonresponse rate and proportion of adolescent who had communication on sexual and reproductive health issues with their parents (35%) (13). A total of 368 (198 secondary and 170 preparatory school) students were required for the study.
Data collection methods and instruments: Data was collected through structured self-administered questionnaires with close ended questions. The questionnaire used in this study were derived from previously published articles (10)(11)16). A pre-test questionnaire on 5% of the sample size in Sirinka Secondary and Preparatory school was tried to know the length, content, question wording and language understandability of the question before two weeks of the actual data collection time. The data collected by pre-test were not included for the analysis.
The questionnaire were designed in English and translated to Amharic language for data collection. Data were collected through the use of five fourth year University students who were the data facilitators after having a one day training about the objectives of the study.

Study Variables
Dependent (outcome variable): Parent-adolescent communication on SRH issues Exposure variable: Premarital sex and Gender Covariates: Students age, Religion, Parent educational status, parents occupation, Ethnicity, Family size, family monthly income, residence,, grade level of the student, Family income, having sexual relationship, family size, monthly pocket money received from family.
Data processing and analysis: Data cleaning and entry was performed by using EpiData version 3.0.1 and was analyzed by using SPSS computer software package version 20. Bivariable logistic regression and multivariable logistic regression analysis was done to show the association between dependent and independent variables. Those variables with p value < 0.2 in Bivariable logistic regression was entered in to multivariable logistic regression analysis to control confounding variables and those exposure variables with a p value ≤ 0.05 in multivariable logistic regression analysis was considered statistically significant.
Ethical Consideration: To conduct the study permission was obtained from Woldia University College of Health Sciences after ethical review and approval of the contents of the proposal, and a formal letter was written to study sites ensuring the approval of the proposal. After having permission from School Directors, information was collected, after having verbal consent from each study participants. There was no information that identify participants in particular. Participation for the study was fully voluntary and they were informed that they had the right to declare to participate or not in the study, were not forced to answer any question that they did not want to answer.

Operational definition/ definition of terms
Parents: -Biological parents (father, mother), grandparents, elder sister/brothers and any othercaretakers without being paid as an employee Adolescent:--are Unmarried peoples who are between 15 to 19 years old.
Communication: -refers to the exchange and sharing of knowledge, ideas, and other information concerning SRH issues among adolescents and their parents.
Communication on SRH:-Students who discussed at least two SRH issues (Contraceptive, STIs/HIV/AIDS, Unwanted pregnancy, pre-marital sex) with their parents in their life time.

Results
A total of 368 contacts were made, whereby 9 declined to participate, making the total number of respondents to be 359 (97.6%). Of the 9 who declined to participate, 4 were because of not answering communication questions, 5 were because of unreturned questionnaire and 1 were because of returned questionnaire without any responses. The mean age of participants were 17.08(SD±1.33) years old (median age 17 years) and 82.3% were Orthodox Christianity followers. Among the total sample 54.04% were High School Students (Grade 9 and 10) and 53.2% were female. (See Table 01).
Adolescent Parent communication on SRH issues: Majority of the adolescents, 297(82.7%) believed that discussing SRH issues with parents are important, thought, the level of communication with at least two SRH issues in this study was 56.3%. Nearly 61% of males, 67% of those 18 years and above, 74% of grade 12 students and 77% of students having sexual experience were communicated with their parents on SRH issues (See Table 02). About 44%, 52.6%, 44.3% and 45.7% of the study participants discuss about contraceptive, STIs including HIV/AIDS, unwanted pregnancy and pre-marital sex with their parents respectively (See Figure   01).    Availability of data and Materials: The data set used and analyzed for the study are available from the corresponding author on reasonable request. The Investigators are responsible for all information's provided to the journal.

Competing interest: No competing interest
Funding: Woldia University covered all the costs incurred by the study. PAC-STROBE_checklist(cross-sectional).doc