Predictors of parent-adolescent communication in post-apartheid South Africa: a protective factor in adolescent sexual and reproductive health

Evaluating a youth-designed sexual and reproductive health mass and social media campaign in Côte d'Ivoire: triangulation of three independent evaluations

Merci Mon Héros (MMH) is a youth-designed multi-media campaign seeking to improve sexual and reproductive health and family planning (SRH/FP) outcomes among youth living in nine francophone countries. A mixed methods approach was implemented to assess the MMH campaign progress and impact in Côte d'Ivoire. Three data sources were triangulated to evaluate the campaign: social media listening (October 2019-January 2021); a quantitative cross-sectional monitoring survey (September 2020) with 412 youth (aged 16-24) and 597 adults (aged 25-49); and a qualitative study using a Most Significant Change approach (March 2021), including a total of 24 focus group discussions with youth (aged 15-24) and adults (aged 25+) exposed to the MMH campaign. Data from all three studies were analysed independently and then brought together through a triangulation workshop where the study team compared findings to achieve convergence in evaluation results. Social listening results showed topic-specific online conversations related to MMH campaign spiked significantly during the two-week period after topic-specific campaign posts (p < .05), suggesting potential campaign impact. Survey results showed both adults and youth were more likely to have spoken with someone about FP in the past five months if exposed to the campaign (p < 0.01). Qualitative findings support the campaign's effect on shifting attitudes and behavioural uptake of intergenerational communication among adults and youth. This evaluation shows evidence of MMH's strong potential for impact in encouraging communication and the need to focus efforts on strategies to strengthen supportive adults' communication competencies and redefine what it means to act in support of SRH/FP for youth.

'A difficult conversation': community stakeholders' and key informants' perceptions of the barriers to talking about sex and HIV with adolescents and young people in KwaZulu-Natal, South Africa

Adolescence and young adulthood are important periods of transition and therefore for action and intervention to ensure future sexual and reproductive health (SRH). Caregiver-adolescent communication about sex and sexuality is a protective factor for SRH, but there are often barriers to this. Adults' perspectives are limited within the literature but important as they should lead this process. This paper uses exploratory qualitative data from in-depth interviews with 40 purposively sampled community stakeholders and key informants to explore their insights into the perceived, experienced or expected challenges adults' experience when having these conversations within a high HIV prevalence, South African context. Findings suggest that respondents recognised the value of communication and were generally willing to try it. However, they identified barriers such as fear, discomfort and limited knowledge and perceived capacity to do so. They show that in high prevalence contexts adults grapple with their own personal risks, behaviours and fears that may affect their ability to have these conversations. This demonstrates the need to equip caregivers with the confidence and ability to communicate about sex and HIV, alongside managing their own complex risks and situations to overcome barriers. It is also necessary to shift the negative framing of adolescents and sex.

Exploring the culturally sensitive sexual and reproductive health information communication skill needs of parents in Ghana

BACKGROUND

Parents play a vital role in the sexual and reproductive health (SRH) of adolescents. Parents' communication with their adolescents regarding SRH is considered an important part of adolescent development, as this contributes to optimising safe SRH.

AIM

This phase of the study explored the culturally sensitive SRH information communication skill needs of parents, based on their personal and social motivation, within the Ghanaian context.

SETTING

The study was conducted at the Asante Akyem North Municipality of Ghana.

METHODS

This article describes the second phase of an explanatory, sequential, mixed-method study. Following on from the first phase systematic review, this second phase comprised a qualitative descriptive study where 10 purposively sampled parents of adolescents participated in semi-structured interviews to elicit data. Braun and Clarke's thematic data analysis process was applied. Data were saved and managed in Atlas.ti (version 23.0.7).

RESULTS

Four themes emerged on communication skills: SRH information, parent and adolescent factors, contextual factors and communication skill needs. Parent and adolescent communication on SRH takes place occasionally. Parents lack the skills to communicate with adolescents regarding SRH.

CONCLUSION

Parents in this context require skills to communicate SRH information with their adolescent children. A culturally appropriate intervention that supports SRH information communication between parents and adolescents may have value in guiding this communication process.Contribution: The findings of this study can contribute to the adaptation of a culturally sensitive SRH information communication intervention in Ghana which will promote adolescent SRH.

Family structure and function in relation to adolescent reproductive health in developing countries: A scoping review

AIM

The study purpose was to explore the relationships between family structure and function and adolescent reproductive health in the context of family systems in developing countries.

BACKGROUND

The structures and functions of family are important elements for adolescent reproductive health. However, few studies discuss their relationships with the reproductive health of adolescents.

DESIGN

This study employed a scoping review design.

DATA SOURCES

The search was conducted for literature published from 2010 until 2020 using the electronic databases PubMed, CINAHL, Scopus, and Science Direct sourcing full-text papers in English. Original research papers that focused on family structures, family functions, and adolescent reproductive health were included.

REVIEW METHODS

Data extraction and analysis were completed on all retrieved studies. Content analysis was used for data analysis.

RESULTS

Fifteen articles were included. The nature of the relationship between the family structures and functions on adolescent reproductive health were explained in the categories of (i) family process and life cycle, (ii) family norms and values, (iii) family communication patterns and processes, (iv) family roles and connectedness, and (v) family coaching and guidance.

CONCLUSION

Findings of this study suggest that the relationships between family functions and structures and adolescent reproductive health were explained in multiple constructs. Further studies are needed to examine those constructs on reproductive health in adolescent in developing countries.

Factors influencing adolescent girls and young women's uptake of community-based PrEP services following home-based HIV testing in Eastern Cape, South Africa: a qualitative study

Home-based service delivery has been used to improve access to HIV testing and antiretroviral initiation across sub-Saharan Africa, but it has yet to be leveraged to improve pre-exposure prophylaxis (PrEP) uptake. We interviewed 37 adolescent girls and young women (AGYW) in Eastern Cape, South Africa to explore why they chose to initiate PrEP or not following home-based HIV testing and referral for PrEP, and what influenced time to PrEP initiation. Participants reported that home visits provided a source of trusted information and a way to involve family members in their PrEP initiation decisions, motivating some to start PrEP. AGYW who initiated PrEP were more likely to qualitatively perceive themselves to be at high risk for HIV compared with those who never initiated PrEP. Integrating home-based HIV testing with PrEP education and referral may be a valuable way to reduce familial barriers and boost PrEP uptake among AGYW in South Africa. Trial registration: NCT03977181. Retrospectively registered on June 6, 2019.

Changing the Script: Intergenerational Communication about Sexual and Reproductive Health in Niamey, Niger

Most strategies to reduce adolescent pregnancies have been designed to educate adolescents directly about family planning (FP), while adolescents often cite peers and parents as their primary sources of sexual health information. Yet parents' lack of knowledge about sexual and reproductive health (SRH), low self-efficacy to initiate conversations, and adverse social norms act as barriers to open intergenerational communication. To better understand the normative environment influencing communication between parents and youth about FP/SRH in francophone West Africa, the USAID supported Breakthrough RESEARCH project conducted a multi-stage qualitative study in Niger. During Stage 1, the research team developed a screening tool (based on a literature review) to categorize research participants into those who practiced open intergenerational communication about FP/SRH, and those who did not. Stage 2 consisted of 40 in-depth interviews with young people (ages 15-24) and adults (≥25 years old), stratified by whether they practiced open intergenerational communication. Results showed restrictive social norms related to youth SRH and access to information and services. However, particularly among participants classified as open-communicators, there is a hierarchy of norms and normative beliefs, with abstinence as the most virtuous decision for youth, but approving communication about and access to SRH services in order to minimize harm. Participants rely on values such as the protection of youth, protection of family honor and promotion of well-being as means to act in counter-normative ways and communicate about FP/SRH. Implications for the field include demystifying and destigmatizing SRH topics, increasing adults' communication skills, and changing the "script" to a more life-affirming view of SRH.

Protocol: Mapping social networks, social influence and sexual health among youth in rural KwaZulu-Natal, the Sixhumene cohort study

Background: Sexual behaviour and sexually transmitted infections are strongly affected by social connections, and interventions are often adapted more readily when diffused through social networks. However, evidence on how young people acquire ideas and change behaviour through the influence of important social contacts is not well understood in high-HIV-prevalence settings, with the result that past peer-led HIV-prevention interventions have had limited success.

Methods: We therefore designed a cohort study (named Sixhumene or ‘we are connected’) to follow young people in three rural and small-town communities in uMkhanyakude district, KwaZulu-Natal, South Africa, and the people that these youth identify as important in their lives. We will interview them five times over three years, at each visit collecting information on their socioeconomic, social and sexual health lives, and testing them for HIV and herpes simplex virus 2 (HSV-2). We will use this information to understand how these young people’s sexual health decisions are formed. This will include evaluating how poor sexual health outcomes are correlated across social networks, how youth mimic the attitudes and behaviours of those around them, who is at greatest risk of acquiring HIV and HSV-2, and who might be most influential within communities and thus best able to promote protective interventions.

Discussion: The information gathered through this study will allow us to describe social connection and influence spread through these real-world social networks, and how this leads to sexual health outcomes. Sixhumene will provide vital inputs for mathematical models of communities and spreading processes, as well as inform the development of effective interventions to protect the sexual health of community members through appropriate targeting with optimised messaging requiring fewer resources.

Mental health outcomes of a pilot 2-arm randomized controlled trial of a HIV-prevention program for South African adolescent girls and young women and their female caregivers

Background

South African adolescent girls and young women (AGYW) report significant mental distress and sexual and reproductive health concerns. Mental health problems and trauma symptoms are consistently associated with sexual and reproductive health behavior. Despite their intersection, few interventions address them simultaneously or engage female caregivers (FC) as collaborators. This study presents findings from a pilot test of an empirically supported culturally adapted family-based HIV-prevention program, Informed Motivated Aware and Responsible Adolescents and Adults- South Africa (IMARA-SA), on AGYW anxiety, depression, and trauma.

Methods

Sixty 15–19-year-old AGYW (mean age = 17.1 years) and their FC from outside Cape Town were randomized to IMARA-SA or a health promotion control program. AGYW reported their anxiety using the GAD-7, depression using the PHQ-9, and trauma using the PC-PTSD-5 at baseline and follow-up (6–10 months post). Both interventions were delivered by Xhosa-speaking Black South African women in groups over 2 days for approximately 10 h. We examined intervention effects using zero-inflated negative binomial regression for anxiety, multinomial logistic regression for depression, and logistic regression for trauma.

Results

At baseline, groups did not differ in demographic characteristics but AGYW randomized to IMARA-SA had higher depression scores than controls (p = 0.04) and a greater proportion screened positive for PTSD (p = .07). Controlling for baseline mental health scores, AGYW who received IMARA-SA compared to controls had significantly fewer anxiety symptoms at follow-up (adjusted incidence rate ratio for count model = 0.54, 95% CI = 0.29–0.99, p = 0.05), were less likely to report at least one depressive symptom relative to no symptoms (relative risk ratio = 0.22, 95% CI = 0.05, 0.95, p = 0.04), and were less likely to report symptoms of PTSD relative to no symptoms, but this difference was not statistically significant.

Conclusions

Mental health is implicated in risky sexual behavior, and reducing emotional distress can mitigate exposure to poor sexual and reproductive health outcomes. This pilot study yielded promising findings for the mental health impact of IMARA-SA, justifying replication in a larger randomized trial.

Trial registration

ClinicalTrials.gov Number NCT04758390, accepted 17/02/2021.

Pathways to sexual health communication between adolescent girls and their female caregivers participating in a structured HIV prevention intervention in South Africa

RATIONALE

Interventions that promote sexual health communication between adolescents and their parents or other primary caregivers are an important tool for reducing female adolescents' behavioral risk. Understanding the mechanisms by which interventions effectively foster communication can inform future programs.

OBJECTIVE

An initial evaluation of Let's Talk, a structured, family-centered HIV prevention intervention for vulnerable adolescents in South Africa, found an increase in caregiver-adolescent sexual communication. This analysis expands upon initial findings to explore the role of parental knowledge, the quality of the parent-adolescent relationship, and the mental health of both parties on caregiver-adolescent sexual health communication.

METHOD

Using mixed methods data collected in 2015 and 2016, structural equation modeling of differenced pre- and postintervention survey data from 64 female Let's Talk participants ages 13-17 and their caregivers was used to explore the pathway to increased frequency of caregiver-adolescent sexual health communication. Focus group discussions (FGDs) were held with intervention participants (n = 25) and facilitators (n = 6).

RESULTS

The path analysis indicates that caregivers' mental health indirectly affected caregiver-adolescent relationship quality, and adolescents' mental health exerted a direct effect. Relationship quality, in turn, directly affected the level of parental sexual communication reported by the adolescent. FGDs suggested that cultural norms inhibit frank discussions between caregivers and adolescents about sexual health, but that thoughtfully designed interventions such as Let's Talk can mitigate this barrier. Qualitative findings also echoed quantitative findings about the role of caregiver-adolescent relationship quality and mental health on communication frequency and highlighted the importance of enhancing participants' technical knowledge and particularly their skills related to expression, listening, and anger management to help enable sensitive conversations.

CONCLUSIONS

Findings overall suggest that a holistic intervention approach emphasizing caregiver-adolescent relationship development and designed to support the mental health of both parties may hold significant promise for enhancing sexual health communication.

Obstacles to intergenerational communication in caregivers' narratives regarding young people's sexual and reproductive health and lifestyle in rural South Africa

BACKGROUND

Statistics from South Africa show the world's highest HIV prevalence with an estimated seven million people living with the virus. Several studies have pointed to communication about sexuality between parents/caregivers and children as a protective factor. However, communication between generations has been described as problematic, especially due to discomfort in discussing sexual matters. The aim of this study was to explore how caregivers in a poor, rural part of South Africa talked about young people in general, their sexuality, and their lifestyle practices. A particular interest was directed towards central discourses in the caregivers' narratives and how these discourses were of importance for the caregivers to function as conversation partners for young people.

METHODS

In this qualitative study convenience sampling was used to select and invite participants. Information was collected from nine one-on-one interviews conducted with caregivers from rural areas within South Africa. The interview guide included nine main questions and optional probing questions. Each interview took place in an uninterrupted setting of choice associated with the caregivers' home environment. The interviews were transcribed and analyzed using discourse analysis.

RESULTS

Interview narratives were characterized by three central discourses - demoralized youths in a changing society, prevailing risks and modernity and a generation gap. The youths were discursively constructed as a problematic group relating to specific prevailing risks such as early pregnancies, modern technologies, STI/HIV and contraceptives. The interview narratives illustrated that caregivers tried to impose their views of a respectable lifestyle in young people. At the same time caregivers expressed a morality of despair mirroring a generation gap which counteracted their ability to communicate with their children and grandchildren.

CONCLUSIONS

The findings add to the body of earlier research illustrating that rural South African caregivers and their children/grandchildren hold different moral standards. The interview material reflected a 'clash' between generations relating to their differing perceptions of a desirable lifestyle. To overcome the generational gap, we recommend further research about how a well-founded national and community collaboration linked to school-based programs can support family participation in order to empower adults in their communication with young people.

Understanding the role played by parents, culture and the school curriculum in socializing young women on sexual health issues in rural South African communities

Background: the decline in South Africa’s HIV infection rates especially among young women is encouraging. However, studies show that the 15–24-year-old cohort remains vulnerable. As they still report early sexual debut, being involved in sexual partnerships with older men as well as having unprotected sex. These risky sexual behaviors may be linked to factors such as the parent–child sexual health communication and the timing of the first talk. The quality of sexual health information received in school may also be important for enhancing healthier sexual behaviors. Aims and Objectives: to investigate the what, when and how sexual health communication occurs in rural South African families and to determine whether such communication patterns have changed over time. We also wanted to get an in-depth understanding of the roles played by culture, sexual health education and peers in the socialization of young women on sexual matters. Methods: a purposive sample of (n = 55) women who were 18–35 years old was selected and interviewed in focus group discussions (FGDs). Results: the FGD findings show that parent–child communication on sexual matters in rural communities is limited to messages that warn against pregnancy. It is also laden with cultural idioms that are not well explained. The school sexual health curriculum also fails to adequately equip adolescents to make informed decisions regarding sexual matters. All this seems to leave room for reception of misguided information from peers. Conclusions: findings highlight a need for designing interventions that can create awareness for parents on the current developmental needs and sexual behavior of adolescents. For adolescents programs would need to focus on providing skills on personal responsibility, and how to change behavior to enhance sexual health.

Development and Testing of the Family Structure and Family Functions Scale for Parents Providing Adolescent Reproductive Health Based on the Friedman Family Assessment Model

Background and Purpose:

To describe the development and testing of a psychometric of Family Structure and Functions (FSF) that measures parents’ ability to provide adolescent reproductive health (ARH).

Methods:

A cross-sectional study of Indonesian parents (n = 525). Multifactors FSF-ARH were examined using construct validity (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]) and content validity (Content Validity Index [CVI]). Internal consistency was explored using Cronbach’s α coefficient.

Results:

EFA revealed nine factors with 26 items accounting for 61.64% of explained variance and CFA validity testing fit for the construct validity of FSF-ARH. The CVI indicated adequate content validity (0.80–0.10) and acceptable internal consistency (0.70).

Conclusions:

FSF-ARH contains valid, reliable, and robust measures although some subscales performed moderate reliability, establishing the purpose for further research.

Acceptability and stakeholders perspectives on feasibility of using trained psychologists and health workers to deliver school-based sexual and reproductive health services to adolescents in urban Accra, Ghana

BACKGROUND

Adolescent sexual and reproductive health is recognized as a key developmental issue of international concern. However, adolescents' access to sexual and reproductive health (SRH) information and services is largely inadequate in sub-Saharan Africa. With increasing enrollment in schools, this could be an avenue to reach adolescents with SRH information and services. This study was therefore conducted to assess the acceptability and stakeholders' perspectives on the feasibility of using health workers and trained psychologists to provide school-based SRH services in Ghana.

METHODS

Fourteen (14) focus group discussions (N = 136) were conducted; 8 among adolescents aged 12-17 years (4 boys, 4 girls groups), 4 among parents (2 males, 2 females groups) and two among mixed teacher groups. We also conducted 18 in-depth interviews with teachers, managers of schools, health workers, clinical psychologists, as well as adolescent SRH program managers in the Ghana Health Service, Ghana Education Service, UNICEF, UNESCO and National Population Council, Ghana. We audio-recorded all interviews and took field notes. Interviews were transcribed and transcripts imported into NVivo 11 for analysis using grounded theory approach to qualitative data analysis.

RESULTS

Many respondents reported that it was challenging for parents and/or teachers to provide adolescents with SRH information. For this reason, they agreed that it was a good idea to have health workers and psychologists provide SRH information and services to adolescents in school. Although, there was general agreement about providing SRH services in school, many of the respondents disagreed with distribution of condoms in schools as they believed that availing condoms would encourage adolescents to experiment with sex. While majority of respondents thought it was acceptable to use psychologists and health workers to provide school-based sexual and reproductive health to adolescents, some teachers and education managers thought the implementation of such a program would oppose practical challenges. Key among the challenges were how to pay for the services that health workers and trained psychologists will render, and the availability of psychologists to cater for all schools.

CONCLUSION

Stakeholders believe it is feasible and acceptable to use trained psychologists and health workers to deliver school-based SRH information and services in the Ghanaian school context. However, provisions must be made to cater for financial and other logistical considerations in the implementation of school-based SRH programs.

Rethinking HIV-prevention for school-going young people based on current behaviour patterns

The aim of the research was to gain increased knowledge regarding the sexual risk behaviour of school-going young people in South Africa after two decades of HIV-education in schools, to contribute to the development of improved HIV prevention strategies. In collaboration with the Department of Education, a sample of 5305 learners (between 10 and 18 years in Grades 5-12) from high-risk communities were identified. They completed a survey that assessed self-reported sexual risk behaviour and variables that potentially underlie sexual risk, such as attitudes towards preventive behaviour, perceived social norms and self-efficacy (based on the theory of planned behaviour [TPB]) and social factors like caregiver relationships and gender norms (based on the social ecological theory). Lifetime sex was reported by 49.4% of boys and 30.5% of girls in Grades 8-12, while 56% of the sexually active young people reported consistent condom use. Accurate knowledge about HIV transmission was low (37.8%). Regression analysis showed that risk behaviour was more prominent among older male youths, who perceived social norms as encouraging sexual activity, who use alcohol excessively, and who have negative attitudes towards abstinence. Perceived traditional community gender norms and negative relationships with caregivers were also associated with sexual risk behaviour. This research showed that the TPB can be used in planning HIV prevention interventions for young people. It also revealed that HIV-prevention strategies should focus beyond educating the individual, to address community factors such as improving caregiver relationships, the culture of substance abuse, peer group norms and inequality in community gender norms. These community processes influence young people's behaviour and need to be addressed to allow the youth to make healthy behavioural choices.

Tobacco and alcohol use among adolescents in South Africa: shared and unshared risks

OBJECTIVE

Tobacco and alcohol use by adolescents are major public health concerns in South Africa. However, the extent to which key psychosocial risk factors for tobacco use and alcohol use by adolescents in South Africa are shared or unshared is unclear. This study sought to examine the shared and unshared risk factors for tobacco and alcohol use among adolescents in Johannesburg.

METHOD

Participants comprised 736 males and females aged 12-17 years who were recruited via a household survey conducted during 2004. The participants were interviewed using a questionnaire comprising measures of personal, family (parental bonding and family legal drug use) and contextual (school and neighbourhood) factors. Separate multiple logistic regression analyses were conducted to predict lifetime alcohol use and lifetime tobacco use from variables within each domain (personal, family and contextual), controlling for demographic factors.

RESULTS

Personal, family (parental bonding) and contextual factors (school factors) were primarily shared risk factors for tobacco and alcohol use, while family legal drug use and neighbourhood factors were largely unshared.

CONCLUSIONS

Interventions addressing personal, parenting and schooling factors are likely to have an impact on preventing both tobacco and alcohol use, whereas interventions focused on ameliorating family drug use and neighbourhood factors may need to be more substance-specific.

Psychosocial correlates of alcohol and other substance use among low-income adolescents in peri-urban Johannesburg, South Africa: A focus on gender differences

Alcohol and other drug use is prevalent among peri-urban, South African adolescents. We identified correlates of alcohol and other drug use by gender among adolescents (age = 16-18 years; N = 822) in peri-urban Johannesburg. Interviewer-administered surveys assessed sexual activity, alcohol and other drug use, and relevant psychosocial factors. In separate logistic regression models of alcohol and other drug use stratified by gender, violence exposure and sexual activity were associated with alcohol use for both males and females. For females only, depressive symptoms were associated with drug use. For males only, being older and sexually active were associated with drug use. Substance use interventions for South African adolescents should consider psychological health, sexual health, and tailoring by gender.

Psychosocial correlates of alcohol and other substance use among low-income adolescents in peri-urban Johannesburg, South Africa: A focus on gender differences

Alcohol and other drug use is prevalent among peri-urban, South African adolescents. We identified correlates of alcohol and other drug use by gender among adolescents (age = 16-18 years; N = 822) in peri-urban Johannesburg. Interviewer-administered surveys assessed sexual activity, alcohol and other drug use, and relevant psychosocial factors. In separate logistic regression models of alcohol and other drug use stratified by gender, violence exposure and sexual activity were associated with alcohol use for both males and females. For females only, depressive symptoms were associated with drug use. For males only, being older and sexually active were associated with drug use. Substance use interventions for South African adolescents should consider psychological health, sexual health, and tailoring by gender.