Influence of Types of Sexual Reproductive Health Communication between Parents and Adolescents in Butere Sub-County

Parents are perceived to be an attractive source of information for influencing adolescents’ SRH (Sexual Reproductive Health) knowledge, attitudes, and behaviour because parents are accessible and always willing sources of information for their adolescent children. Conversations between parents and adolescents about their sexuality in particular are often difficult for both parents and adolescents in Africa. Lack of consistent SRH communication between parents and adolescents has resulted in risky sexual behaviours. In western Kenya, specifically Butere Sub County, the divergence noted in contemporary adolescent sexual behaviour can be explained within the backdrop of collapsed traditional moral codes and mechanisms that controlled and checked sexual behaviour and dereliction of responsibilities by parents while other supportive family institutions (grandparents, uncles, and aunts) have become evanescent. The study sought to determine the influence of types of sexual reproductive health communication between parents and adolescents. This was an analytic cross-sectional


INTRODUCTION
Parent-adolescents Sexual Reproductive Health communication is very imperative because they have various SRH complications such as an increase in HIV and AIDS infections, early pregnancies, and sexually transmitted infections that largely affect adolescents in western Kenya. Parents-adolescent communication is perceived to be an effective tool that can be used to shape several adolescents to adopt responsible sexual behaviour (Usonwu et al., 2021).
Usual communication techniques are speaking or writing by a person who is sending a message and also listening or reading by a person who receives information. However, there are special cases where people with disability communicate by way of sign language Toth, A. (2009). This study majored on the normal communication techniques used by parents or guardians to communicate SRH information to their adolescents like verbal communication where there is dialogue, question and answer method, and arguments, among others. Strategically, parent-child conversations on sexual health facilitate the development of risk-reduction behaviours among young people. Evidence shows that young people who report previous discussions of sexual matters with parents are seven and a half times more likely to be able to communicate with a partner about AIDS than those who have not had such communication Cederbaum (2012).
The primary objective of this study was undertaken in Butere Subcounty to find out the influence of types of sexual reproductive health communication between parents and adolescents in the sub-county. Sexual reproductive health communication among parents and adolescents happens. However, in most families, it normally happens on the same gender basis where male parents tend to communicate SRH information to their male children and mothers communicate the same to their female children. SRH communication from parents at times is in the form of cautions, intimidations, and sometimes conveyed by physical punishment. On the other hand, studies have shown that parents or guardians may limit what they discuss with their children due to a lack of opportunity, suitable knowledge, and cultural norms Amos, P. M. (2013).
Sexual reproductive health dialogue between parents and adolescents is regarded to be the most common communication technique used to convey SRH information to adolescents. Communication incidence, content, style, and tone of discussions have a direct association with barriers to effective sexual reproductive health information Motsomi et al. (2016). Suitable choice of correct communication technique can determine the degree to which parents convey sexuality matters to their adolescents.
Parents in the Western Kenya region usually engage their adolescents in face-to-face communication; the limitation comes to the extent to which this communication reaches; some parents tend to keep some information in fear that they may engage in sexual activities at a young age. For that reason, they are not given full information during such SRH discussions resulting in many adolescents turning to their peers for information about sexual reproductive health Okigbo et al., (2015). Evidencebased frameworks for assessing the influence of types of sexual reproductive health communication between parents and adolescents are needed.

Study Setting
This study was conducted in Butere Sub-County in Kakamega County of Western Kenya region, which was purposively selected for the study because of the presence of intervention to strengthen community-based health system from the community level to the County level. Butere has a well-defined community-based health information system (CBHIS) from which the development of a sampling frame for parents and adolescents was feasible and health system strengthening activities including outreaches, community dialogues, and community actions focusing on Sexual and Reproductive Health and Rights (SRHR) information and services among the young people. Furthermore, baseline information before the study indicated high cases of teenage and unplanned pregnancies, school dropouts, and early marriages as a result of a lack of sufficient parent-adolescent SRH communication in the area.

Design
Mixed methods design approach was used in this research. The analytic design was used to determine relationships between types of sexual reproductive health communication between parents and adolescents and how they influence adolescents' SRH behaviour. The study aimed to utilise data collected at one point in time and hence crosssectional design was used for its appropriateness for such data collection design. A qualitative design was incorporated to seek explanations as to why some parents would choose certain types of communication techniques to communicate SRH information and how this would influence the behaviour of adolescents.
Thus, the mixed methods approach facilitated a balance between efficiency in the collection of adequate data required for the power of the test expected and analysis with data that provided context. Quantitative data quickly and efficiently captured a large amount of data from a group of respondents. Qualitative data provided contextual information and facilitated understanding and interpretation of the quantitative data.

Sample and Sampling Technique
Because the population of Butere Sub-County is more than ten thousand, the researcher therefore opted for the formula according to Mugenda and Mugenda (2003), where a researcher should take a big sample as possible because it reduces the sampling error when the target population is bigger than 10,000.
Parents of adolescents and adolescents were interviewed in these households. Parents in this context included guardians in households where parents were either dead or leave away from home. However, in all cases, a parent was a person not less than maturity age as per Kenyan Constitution 2010, from 18 years. The population of Butere Sub-County has approximately 154,100 people with 37,480 adolescents ages 10-19 years spread across 18,740 households (NBS, 2019).
Multistage sampling was used and through simple random sampling, 10 villages were selected for quantitative data collection and 1 for qualitative data collection out of an average of 12 villages in a 4 | This work is licensed under a Creative Commons Attribution 4.0 International License.
CHU. Using a sampling frame developed from the CHU household register for illegible households, starting with the first household, 10 households were systematically selected on the basis of established intervals determined using the number of required study households (10 per village) proportional to the total number of eligible households in the village. At the household level, a maximum of 4 (2 parents and 2 adolescents) and a minimum of 2 interviews were conducted.
Simple random sampling was used to identify a participating adolescent by sex in households with more than 1 adolescent of the same sex. A total of 4 FGDs per CHU were conducted, comprising of parent females, parent males, adolescent boys, and adolescent girls, each done separately to ensure maximum participation devoid of cultural challenges of sex and age differentials. Illegibility for participation in the qualitative study was based on non-participation in the quantitative study.

Analysis
Data analysis involved the application of correlations. Multilevel analysis was employed to take into account the hierarchical data structure resulting from the cluster design. The sexual behavioural practice of delayed sexual activities and safer sex practices constituted outcome variables with background (demographic and intermediate types of SRH communication types (Dialogue, question and answer and use of learning aids) as well as arguments forming key explanatory variables.
Fisher's Exact Test of significance was used to test for significant differences across the background and intervening variables under a 95% level of Confidence and Cramer's V was used to establish the strength level of the association while Kendall's tau_b correlation coefficient was used to determine relationships of interactions between types of SRH communication between parents and adolescents and outcome of sexual behaviour change. Thematic analysis technique was used to analyse data from focus group discussions.
In the interpretation of this study, limitations to be noted include a purposive selection of the rural agrarian study area of Butere and the presence of intervention for improving sexual and reproductive health rights programs that may affect the extent to which results can be generalised to similar areas.
Also, while enumerators were well trained in gaining rapport with adolescent participants, it is worth noting that some adolescents might still have found some of the questions sensitive and hence withheld some information or gave not-so-correct information affecting the quality of conclusions.
Also, data collected from questionnaires were coded in a well-designed coding framework. It was designed on the basis of a representative sample of responses to questions. The data was then analysed using descriptive statistics. Descriptive statistics enable the researcher to summarise and organise data in an effective and meaningful way.
They provide tools for describing collections of statistical observations and reducing information to an understandable form (Frankfort-Nachmias & Nachmias, 1996;Wimmer & Dominick, 2011). Frequency distributions were constructed to examine the pattern of responses. These frequencies were converted to percentages for meaningful interpretation. The data was further communicated using pie charts (Nachmias, 1996).
Qualitative data were organised according to answers to the open-ended questions in the interview guide, this was analysed thematically -the analysis of verbal or written communications in a systematic way to measure variables qualitatively.
The coding framework was developed based on the data that was collected. This was grouped according to major themes under the study and their association was identified. The data was presented in the form of narrative notes that clearly show the influence of parent-adolescent communication on sexual and reproductive health among adolescents in Butere Sub County.

Ethical Consideration
The study protocol was reviewed and received approval from the AMREF Health Africa Ethical Review Board and permission from the National Commission for Science, Technology, and Innovation (NACOSTI). Written consent was obtained from all study participants (quantitative and FGDs) after explaining the purpose of the study East African Journal of Health and Science, Volume 5, Issue 2, 2022 before data was collected. Consent for respondents below 18 years involved parents' permission for their children to participate in the study and adolescents' assent before data was collected.

Association between Behaviour and Method of Communication
Results showed no relationship of association between SRH communication type and SRH negative SRH behaviour change variables: (having multiple sexual partners, lack of use of protection during sexual intercourse, and lack of abstinence).
Three characteristics comprising abstinence, use of protection, and having not more than one sexual partner variables indicated a significant association with types of communication SRH communication. For instance, more parents of adolescents and adolescents have had a dialogue on SRH than other types of communication like question and answer and also the use of learning aids.
At 95% CI, the Fisher's Exact Test statistics is significant (communication p = 0.020, Cramer's V = 0.335; and monitoring p < 0.001, Cramer's V = 0.737 and 0.711). Out of the maximum possible value of 1, Cramer's statistics indicate a strong association for dialogue and a weak one for the use of learning aids as types used. It was observed that under communication, a higher proportion of male parents were affected to a "great extent" by embarrassment, anxiety/fear due to their own past experiences and lack of appropriate time to discuss sexual attitudes and behaviours as compared with female parents/guardians. Under behaviour change, SRH communication between adolescents and their parents showed significant associations for positive behaviour change (in abstinence and use of protection, p < 0.001, use of learning aids p = 0.024) as a type of communication.
To determine ways in which parents communicate Sexual Reproductive Health information to their adolescents, the findings in this study indicate that the majority of the adolescents (62.1%) were exposed to SRH information by their parents, while (34.5%) of the parents had not been exposed their adolescents to SRH information. This indicates that adolescents were exposed to SRH information by their parents, which is contrary to the findings by Schubotz et al. (2004) study of the sexual attitudes and lifestyles of young people (aged 14-25 years) in Northern Ireland also reported that friends (80.4%), followed by school (74.4%), were their most important source of sexuality education, with parents providing a good deal less.

Figure 1: Frequency of giving or Receiving SRH information
The from the figure above findings of this study indicate that most adolescents (34.7%) received SRH information from their parents monthly, while 27.4% received SRH information from their parents weekly and 13.7% said they never received SRH information at all from their parents in Butere Sub-County. Findings, on the other hand, indicated that 20.3% of parents give SRH information monthly and about 14.2% do it weekly, while 7.4% of the parents never give their adolescents SRH information to their adolescents at all.

Ways of Communicating SRH Information between Parents and Adolescents
The study also sought to understand the methods used by parents and adolescents to communicate SRH information. The methods included question and answer methods use of learning aid for demonstrations, arguments, dialogue, or discussions.

Interaction between Communication Types and Effects
Using Kendall's tau-b correlation coefficient, findings showed that the overall frequency of communication between adolescents and their parents was positively related to the comprehensiveness of information (r=.184, p<.05), frequency of engagement for dialogue (r=.222, p<.01), frequency of questions and answer (r=.218, p<.01) and intensity (r=.196, p<.05) of using learning aids.
The comprehensiveness of information given by parents/guardians was positively related to the frequency of engagement, frequency, and intensity of parent dialogue, with coefficients r=.341, r=.245, and r=.217, respectively, just as the frequency of engagement was strongly related to frequency and intensity of question and answer (r=.228 and r=.346, respectively, all at significant p<.01). Regarding the strength of links for correlation between communication types, dialogue as a method emerged as a major arm in the loop of positive interactions for parents and adolescents with eight (8) links of relationships, followed by a question and answer with six (6) links and use of learning aids with four (4) links.

Frequency of SRH Communication
The findings in this study revealed that the most common method of communicating SRH information by parents to their adolescents is SRH dialogue which is also discussion (22.0% for parents and 27.6% for adolescents), Question and answer method (10.8% for parents and 16.5% for adolescents), Use of learning aid for demonstration (3.75 for parents and 12.7% for adolescents), and finally Arguments (2.5% for Parents and 3.3% for adolescents).
This depicts that sexual reproductive health-related issues are discussed using various methods including dialogue or discussion on SRH matters, question and answer methods, use of learning aids for demonstration as well as arguments. Dialogue and discussion were the favourites and this can be explained by the fact that it allows both the parents and adolescents to express their views.
The key informants were also asked for their opinion on how different methodologies of parentadolescent communication on sexual and reproductive behaviour are associated with different types of sexual behaviour among adolescents. The following was the view of a parent: -

Influence of Parent-Adolescent Communication on Sexual Reproductive
The majority (53.2%) of the adolescents agreed that SRH conversation between them and their parents influences their sexual reproductive behaviour, while 9.3% disagree with this. In addition, most (30.2%) of the adolescent parents agreed that conversations between them and adolescents influence their adolescents' sexual reproductive health behaviour, while 7.3% disagreed.
For that reason, the conversation between adolescents and their parent influence their sexual behaviour. This is in agreement with the study according to Whitaker et al. (2000) observed that serious parent-adolescent discussions about sex and condoms can be important for adolescents in communicating with sexual partners about sexual risk and condom use and in preventing adolescents from conforming to more permissive peer norms about sexual risk-taking.
In qualitative data, key informant interviews were investigated on whether SRH content in parentadolescent communication stimulates riskier sexual reproductive health behaviour among adolescents living in Rural Butere. The following was the view of one of the parents interviewed in Shiatsala village:

R:
To a certain level because very few parents discuss sexual content in detail with their children, adolescents do not get such content from their parents. But with this era of the internet and mobile devices that support browsing on the internet, children are exposed to graphic content on sex which could contribute to risky sexual behaviours amongst them. In addition, adolescents do not come out openly during communication on what types of sex content they have discovered, and so parents may assume that their children are too young and unexposed to some content. In such cases, the discussions on content are not really discussed during parent-adolescent communication.

R:
Parent-adolescent communication contributes to the healthy sexual behaviour of adolescents in most cases. When adolescents are warned against engaging in sexual behaviours or for those who cannot, advice on safe ways to engage in sexual behaviours plays a key role in ensuring they uphold healthy sexual behaviours. Parents advocate for the use of protection or being with a single partner at a time. Some parents even go to the extent of undertaking HIV and AIDs tests regularly on children they suspect are engaging in sexual behaviours.

Challenges of parents-adolescent communication on Sexual Reproductive Health
Study findings have indicated that communication problems pose the greatest challenge in the communication of SRH between adolescents and parents (85%), another challenge faced by the respondents was an embarrassment (84%), gender issues; 82% of female adolescents found it uneasy to discuss SRH issues with the parents of the opposite gender and vice versa, lack of appropriate time to discuss SRH (79%), age or development issues (76%), anxiety (72%), and finally lack of knowledge (45%). This illustrates clearly that challenges in regard to parent-adolescent SRH communication exist in Butere, and the major one to be investigated is communication techniques to be used by parents and adolescents to communicate SRH issues between themselves at the household level.
When adolescents were asked the challenges they face while communicating SRH information to their parents, one respondent said that: -

R:
There are various challenges of parentadolescent communication in influencing sexual and reproductive behaviour. To begin with, most parents and adolescents are not open to discussing sexual topics. This is mainly because of the age gap and the consideration that adolescents are not aware of matters of sex. Some adolescents might be afraid of being punished or victimised for seeking sexual and reproductive information.

Discussion
The findings in this study revealed that the most common method of communicating SRH information by parents to their adolescents is a dialogue which is also discussion at 22% for parents and 28% for adolescents, question and answer method at 11% for parents and 17% for adolescents, use of learning aid for 48 demonstrations at 3% for parents and 13% for adolescents, and final arguments at 3% for parents and 3.3% for adolescents. This depicts that sexual reproductive health-related issues are discussed using various methods including dialogue or discussion, question and answer methods, use of learning aids for demonstration as well as arguments. Dialogue and discussion were the favourites and this can be explained by the fact that it allows both the parents and adolescents to express their views.

Conversation between Adolescents and Their Parents Influence Their Sexual Behaviour.
This is also in line with the findings of Ashcraft et al. (2017), which found that parents are an influential source of information about sexuality to their adolescents and have the ability to shape their principles and manners and that should communicate comprehensive, medically correct information to their adolescents as well as include discussions about positive aspects of sexuality, such as pleasure, satisfaction and intimacy into these conversations.
Parents as well were of the opinion that parentadolescent SRH communication positively influences adolescents' sexual and reproductive health behaviour in Butere, especially in abstinence and use of protection in case of sexual activeness.
These findings support those of Joffe and Franca-Koh (2001), whose UK research called into question the result between greater sexual communication on the part of parents and later age of initiation of sexual activity. They explored the link between remembered non-verbal sexual communication at home and current sexual behaviour among young British adolescents.
The researchers found that higher levels of parental non-verbal sexual communication were linked to earlier onset of sexual activity, fewer sexual partners, and lower feelings of sexual guilt. Greater openness about nudity in the home, in particular, was linked to earlier onset of sexual activity. In addition, while greater expression of affection between parents was associated with having fewer sexual partners, this had no relationship to contraceptive usage.
Additionally, using data from the National Survey of Sexual Attitudes and Lifestyles, Wellings et al. (1999) found that the most important factor influencing the chances of becoming a teenage mother was the quality of communication about sexual matters in the community.
The study findings have also indicated that communication problems pose the greatest challenge in the communication of SRH between adolescents and parents at 85%, embarrassment at 84%, gender issues; that is, female adolescents found it uneasy to discuss SRH issues with their parents of the opposite gender and vice versa, lack of appropriate time to discuss SRH 79%, age or development issues 76%, anxiety 72%, and finally lack of knowledge at 45%. This illustrates clearly that challenges in regard to parent-adolescent SRH communication exist in Butere and the major one to be looked into is communication techniques to be used by parents and adolescents to communicate SRH issues between themselves at the household level. A study by Rosenthal and Feldman (1999) affirms that the provision of sexual and reproductive information by parents involves not simply the dissemination of information on the part of parents but also requires friendliness on the part of the listener. Similarly, Jerman and Constantine (2010) found that the majority of parents in California reported having difficulty in talking with their children about specific topics related to sexuality and sex.

CONCLUSION
This study has come to the conclusion that parents and adolescents in Butere Sub-County engage in Sexual reproductive health communication at their homes. This communication takes different forms depending on which one these parents and adolescents are comfortable with. Communication techniques being used by parents are diverse.
Parents and guardians are key players in influencing adolescents' sexual and reproductive health behaviour change. Nevertheless, there still exist various challenges in regard to the types of sexual reproductive health communication between parents and their adolescents. Health managers, as well as policymakers need to pay attention to details of sexual reproductive communication types and interactions that take place along the communication process for effective designs and policies. Through examination of these interactions from types of communication and adolescents' sexual reproductive behaviour change, we have highlighted key interactional interface points for consideration in the design, implementation and monitoring of a parent-adolescent sexual behaviour change communication process.

Recommendations
Adolescent-parent communication on SRH should be that which is appropriate and acceptable to both parents and adolescents to enhance the observed positive effects on sexual behaviours amongst adolescents.
Parents and adolescents should be willing to engage each other through discussion of SRH issues, teaching and learning sex education, adolescents should be stimulated to use any available time that they have to get sex-related information from their parents.
The community should appreciate the worth of parent-adolescent sexuality communication and identifying interventions to enhance communication on sexuality should be considered to overcome economic challenges to ASRH communication in the area.
Parents and adolescents should be encouraged to talk about sexual reproductive health issues more openly. Adolescents should be provided with ASRH information to enable them to overcome the many challenges like early pregnancies and HIV and AIDS infections in this area. This is also based on the findings of this study which found that many adolescents prefer face-to-face conversation with their parents in regard to ASRH.
ACKNOWLEDGEMENT I wish to extend my sincere gratitude to Prof. Rosebella, Dr. Wafula and to the entire lecturers of the School of Public Health, Department of Community Health of the Great Lakes University of Kisumu for their remarkable support. I am indebted to the SIMAVI SRHR project for its support and encouragement towards this work. I am grateful to the parents and adolescents of the entire Butere Subcounty for their time and valuable responses during data collection, also the Research Assistants who took part in data collection. I also wish to extend my gratitude to all my classmates for their moral support, encouragement and everyone who might have contributed in one way or the other towards the successful completion of this work. May God bless you all.