Table 1 Parent-child sexuality communication studies from sub-Saharan Africa; 1990-2011

Adeyemo & Brieger, 1994

[42]

Nigeria (urban)

To examine discussions within the family of family life education topics (human development, sexual relationships, preparation for parenthood, pregnancy, contraception and STIs).

Parents from a total of 253 families were interviewed using a questionnaire. Systematic sampling of every sixth residential building and balloting was used to recruit families.

Parents reported discussing on average 3 out of the 6 family life education topics. Human growth and development was most frequently discussed, followed by pregnancy and childbirth and abortion. Half had discussed STIs, contraception was least discussed. Only 16% of parents had discussed all six topics. Parents did not feel competent to discuss the topics and thought it might encourage risk behavior. Mothers were most frequent initiators of discussions. Frequency of communication increased with higher level of education of the parents. Greater time spent at home and a positive perception of parental role in family life education was also associated with higher scores.

Adu-Mireku, 2003

[34]

Ghana (urban)

To evaluate the relationship between family communication about HIV/AIDS, sexual activity and condom use among secondary school students.

Cross-sectional study of 894 students in two randomly selected secondary schools.

It was reported that 25% of participants were sexually experienced. A large proportion (74%) reported having discussed HIV/AIDS with parents or other family members. Student-family communication about AIDS was not associated with sexual activity; however it did increase the odds of condom use at last sex. Significant gender differences in sexual activity, condom use and family communication about HIV/AIDS were also reported.

Amoran, Anadeko & Adeniyi, 2005

[47]

Nigeria (urban)

To determine parental role on adolescents' sexual initiation practice in Ibadan, Nigeria.

A random sample of 274 adolescents was selected from the community to complete a self-administered questionnaire on demographics and sexual behavior.

Early exposure to sex education by mothers was reported to encourage early sexual debut (p < 0.001). A greater proportion of adolescents (43%) who received sexuality information from peers were sexually experienced compared with 25.2% who sought information from parents and other sources (p = 0.004). Mothers communicated about sexuality more frequently than fathers (41% vs. 17%)..

Babalola, Tambashe & Vondrasek, 2005

[39]

Ivory Coast (urban)

To examine the relation between parental factors (living in same household as father, perceived parental disapproval and parent-child communication) and sexual risk-taking among young people

Cross-sectional household survey of randomly selected youth aged 15-24 years in three cities.

Living in the same household as father during childhood, perceived parental disapproval of premarital pregnancy and parent-child communication about sexual abstinence were positively associated with both primary and secondary sexual abstinence and a reduction in number of sexual partners.

Bastien et al., 2008

[37]

Tanzania (urban & rural)

To investigate changes in primary school students' exposure to AIDS information and communication from 1992-2005.

Repeated cross-sectional design. Students from 18 randomly selected primary schools in 2 regions completed a questionnaire (2026 students in 1992 and 2069 students in 2005).

Students reported higher levels of exposure to information and communication from all sources in 2005 than 1992. Students reported significantly more frequent discussion about AIDS with parents and others in the social network in 2005 in comparison to 1992, yet ranked low in both years in terms of who young people discussed AIDS with most frequently. Myths related to HIV transmission and infection was reported to persist.

Bastien et al., 2009

[38]

Tanzania (urban & rural)

To investigate whether young people in- and out-of-school differed in exposure to AIDS information and communication, the perceived credibility of the sources and preferences for SRH information.

Cross-sectional studies of 993 out-of-school youth and 1007 primary and secondary school students between ages of 13 and 18.

Communication about HIV and AIDs was reported to be influenced by a host of factors including access, agency and ambiguity. The in-school youth communicated about AIDS more frequently with all members of the social network investigated than out-of-school youth. Factors associated with frequency of communication included urban/rural residence, sex, age and SES. The in-school group ranked parents in the top 3 in terms of credibility and both groups identified parents as one of the top 3 preferred communicators of sexual and reproductive health information. However, both in- and out-of-school youth demonstrated an inability to critically evaluate modes of transmission and prevention.

Bell et al., 2008

[52]

South Africa (peri-urban)

To test the effectiveness of the CHAMP intervention (designed to target HIV risk behaviors by strengthening family relationship processes as well as peer influences) among black South Africans in KwaZulu-Natal.

Randomized controlled trial among youth (aged 9-13) and their families (245 intervention families rearing 281 children, and 233 control families rearing 298 children).

Findings suggest greater intervention effects on caregivers than on youth. Caregiver findings show significant intervention group differences in comparison to control with regard to caregiver monitoring and control, as well as increased frequency and comfort discussing HIV/AIDS and sexuality with children, among other outcomes. With regard to youth, findings showed an increase in HIV knowledge in the intervention group compared to the control, as well as lower levels of HIV-related stigma.

Bhana et al., 2004

[49]

South Africa (urban & semi-rural)

To prevent HIV infection in youth by promoting resiliency in pre-adolescents and their families, and strengthen community protective shield through the CHAMP (Amaqhawe) programme.

Experimental design with pre and post-tests. Pilot study conducted in three areas, on urban shack settlement and two semi-rural areas. A total of 124 families, assigned to intervention or comparison group participated in the pilot phase as described in this article.

In terms of parenting communication styles, the intervention group reportedly demonstrated a shift from passive aggressive and manipulative communication styles to more assertive styles in relation to comparison group. The intervention group also showed significant improvement in their ability to engage in discussion about difficult or sensitive topics with their children in comparison to control group. Frequency of discussion also improved in the intervention group, discussion about puberty increased from 55% to 69%, whilst discussion about sex which was ranked most difficult to talk about improved from 55% to 73% post intervention.

Biddlecom, Awusabo-Asare & Bankole, 2009

[41]

Burkina Faso, Ghana, Malawi & Uganda (urban & rural)

To examine the influence of three dimensions of parenting-material support (co-residence), monitoring and communication on adolescent sexual behavior.

National surveys of 15-19 year olds in each of the countries (2948 youth in Burkina Faso, 2426 in Ghana, 2025 in Malawi and 2363 in Uganda) as part of a research project called 'Protecting the Next Generation: Understanding HIV Risk Among Youth'. Two-stage, cluster design was used.

Parental monitoring was reported to be moderate to high in all countries, with females reporting higher levels of monitoring than boys. Communication about sexuality was low across countries. Between 8% and 38% of adolescents reported discussing sex with a parent figure, with even less reporting discussing contraceptive methods. Males were less likely than females to report communication. Findings were mixed in regards to parental communication and odds of sexual activity, among Malawian males and Ugandan females only, communication was associated with increased odds of having had sex in the last year (2.2 and 1.5, respectively). Parent-child sexuality communication was positively associated with contraceptive use for Ghanaian females (3.0) and Ugandan females and males (2.9 and 1.9).

Izugbara 2008

[44]

Nigeria (rural)

To explore how and why parents in rural Nigeria discuss sexuality related

matters with their adolescent children.

In-depth interviews with 187 parents.

Parent-child discussions about sexuality are not common in rural Nigeria where it remains taboo to do so. Parents tend to portray sexuality as 'dangerous, unpleasant, and unsavory' in discussions with their children and tended to use threats and indirect speech in discussions. Parents worried that discussions would encourage early sexual experimentation.

Karim et al., 2003

[46]

Ghana (urban & rural)

To identify factors associated with

elevated risks of pregnancy and sexually transmitted infection among unmarried Ghanaian youth.

Cross-sectional survey of a nationally representative sample of 3,739 unmarried 12-24-year-olds.

Among male youth in the study, communication about avoiding sex was found to be associated with a lower probability of having had sex (OR = 0.87), while communication about contraceptive use was associated with an increased likelihood of being sexually experienced, among both sexes (OR = 1.25 & OR = 1.23 for males and females, respectively). The association between communication about sex and contraception and condom use was overall weak, except where it concerned consistent condom use with the last partner among males (OR = 1.05). It was also found that communication about contraceptives was associated with a decreased likelihood of condom use at first sex among males (OR = 0.87).

Kawai e t al., 2008

[33]

Tanzania (urban)

To examine parents' and teachers' communication about sexuality in relation to timing of sexual debut among students.

Randomized controlled trial (only data from first and second post intervention follow up reported) focused on promoting sexual and reproductive health of primary school students.

2477 virgin primary school students were followed prospectively for 6 months to investigate sexual initiation and completed the questionnaire.

27% of students reported communicating about HIV and sex with parents, but parental communication was not associated with delay of sexual debut, whereas communicating with teachers was. Those not living with their biological mother were more likely to initiate sex than those who do.

Kumi-Kyereme et al., 2007

[45]

Ghana (urban & rural)

To examine connectedness, communication and monitoring of unmarried adolescents by parents, other adults, friends and social institutions, as well as the roles these groups play in influencing adolescent sexual activity.

Uses nationally-representative survey data of adolescents aged 12 to 19 years in addition to focus group discussions (14-19 years) and in-depth interviews with adolescents (12-19 years).

High levels of connectedness to family were reported in addition to high levels of monitoring. Less frequent communication with family about sex-related matters compared to non-family members. Sexuality communication was reported to be more common among older respondents than younger ones. Both males and females reported more sexuality communication with mothers than fathers. There was a strong negative relationship between parental monitoring and recent sexual activity for males and females. In terms of communication, findings show that discussing with fathers has a negative association with sexual activity for males (OR = 0.46), whilst it is positive for females (OR = 1.76). Focus group discussions point to intergenerational challenges of communicating about sexuality in the home, with some young people feeling too shy to discuss sexuality with parents and fearing physical punishment for doing so. Interviews found that when communication did take place it was likely to take the form of instructions rather than dialogue.

Löfgren et al., 2009

[58]

Uganda (urban)

To explore how young people perceive and experience the role of parents in preventing the HIV among youth.

Qualitative study using semi-structured face-to-face interviews with 16 school going youth (8 males, 8 females) in 3 secondary schools between the ages of 18 and 20 years.

Young people perceived parenting styles as negatively influencing HIV prevention among youths, for instance they felt that parents tend to use fear as a tactic in discussing about sex, and also that parents lack time to engage with their children, and when they do, they use authoritarian or indulgent parenting styles. Young people described differential treatment of boys and girls by parents.

Mathew, Shugaba & Ogala, 2006

[36]

Nigeria (urban)

To assess parent-adolescent communication about HIV/AIDS and identify factors influencing communication.

Cross sectional study of 459 junior secondary school students between 10 and 14 years of age.

Only 27% and 5% of sexually active students reported communication with parents about AIDS and sex, respectively. Inadequate knowledge on part of parents was identified as a barrier to communication by respondents (64% perceived mothers as lacking knowledge, 87% thought fathers lacked knowledge). Moreover, 62% thought that their parents are too preoccupied to talk about sex, while 59% believed their parents would argue if they were to talk about sex. 30% thought their mother would think they were interested in experimenting with sex if they were to talk about it, whilst 69% believed their father would get this impression.

Mbugua, 2007

[29]

Kenya (urban)

To examine why educated mothers in Kenya have difficulty providing meaningful sex education to their daughters.

Qualitative data drawn from 2 studies conducted in 1996 and 2003 including 4 focus groups with female secondary students aged 17-19, interviews with 14 teachers and 15 mothers.

Most educated mothers reported experiencing socio-cultural and religious inhibitions which make it challenging to provide sex-education to their daughters. For instance, generational barriers to discussing sexuality were raised as an issue. Mothers also reported a reliance on the school system to provide sex education.

Musa, Akande, Salaudeen, Soladoye, 2008

[35]

Nigeria (urban)

To examine the practice of family communication on HIV/AIDS among secondary school students.

Cross-sectional survey of 420 randomly selected secondary school students.

A large proportion (80%) of students reported family communication about HIV/AIDS, while 34% of respondents reported discussion about premarital sex with a family member. Although the study specified that the member of the family most often involved in sexuality discussions was the mother (44%), compared to the father (29%). More frequent communication was reported by females, those from smaller families and among those whose parents have higher levels of education.

Namisi et al., 2009

[32]

Tanzania and South Africa (urban & rural)

To describe adolescent sexuality communication with parents/guardians, other family members and teachers about HIV/AIDS, abstinence and condoms.

Baseline data from a cluster randomized controlled trial at 3 study sites in Tanzania and South Africa and involving 80 public schools in total and 14 944 students between 11 and 17 years. The aim was to promote the sexual health of school students and prevent HIV.

Main outcome variables were frequency of communication about HIV/AIDS, abstinence and condoms.

Females preferred receiving sexuality information from their mothers, males preferred fathers. 37%, 41% and 29% reported never or hardly ever communicating about sexuality with parents, other family members and teachers. Students from Tanzania reported experiencing more silence from the various sources than in South Africa. Odds of infrequent or never communicating with parents was higher among girls than boys in Tanzania, while the reverse was true in both of the South African sites and socioeconomic status was positively associated with sexuality communication with parents.

Opara, Eke & Akane, 2010

[43]

Nigeria (urban)

To determine mothers'

perception of sexuality education in children.

Convenience sample

of women attending a Christian women's convention. 158 women filled in a structured questionnaire.

The majority (77%) believed that the home was the best place for sexuality education to take place with 70% believing that it is the responsibility of both parents whereas 38% thought it was the sole responsibility of the mother. In terms of content of sexuality education, discussion centered on descriptions of

body parts and reproductive organs. Regarding timing of discussions of sexuality, 41% believed it should take place between the ages of 6-10 years while 32% thought it should take place between 11- 15 years. 65%) reported having discussed sexuality topics with their children, but only 12% had discussions as frequently as three times per month.

Phetla et al., 2008

[48]

South Africa (rural)

To prevent HIV and IPV by actively challenging barriers to engaging with young people about sexuality and promoting communication between adults and young people

Community cluster randomized controlled trial. Data collected at baseline and 2 years later in 4 intervention and 4 control villages.

Women from poorest half of households eligible to participate, organized into 'loan centers' and 'solidarity groups'.

-trained facilitators conducted interactive education and empowerment activities to raise awareness and discussion of gender inequality, IPV, sexual health and role of culture in shaping norms (program called Sisters for Life)

-Four centers (120 women) were monitored to assess effects, meetings were observed and data collected using flip charts, standardized forms to record process and content of discussions. Focus groups conducted with 8 loan groups both after the intervention and one year later. Among young people, 24 interactive workshops and 6 follow-up interviews to examine perceptions of intervention and household and community effects.

Both qualitative and quantitative findings indicate the intervention improved participants' motivation and skills to engage with young people about sexuality. Interviews indicated women felt greater confidence to talk to children, used clearer messages instead of vague ones, and a range of communicative strategies. Quantitative data showed a significant increase in proportion of women at follow-up reporting having talked about sexual issues with children compared to the control group (80% vs. 49%, adjusted risk ratio 1.59 (1.31-1.93).

Young people confirmed that mothers and relatives altered their communication style and content after exposure to the intervention.

Poulsen et al., 2010

[40]

United States and Kenya (rural)

To identify and compare factors associated with parent-child communication about HIV/AIDS in US and Kenya using baseline data from HIV prevention intervention called Parents Matter! In the US and Families Matter! In Kenya.

A total of 403 parent-child dyads completed the survey at baseline, but article focuses on baseline data from parents. Main outcome was whether or not parent-child communication about HIV/AIDS had occurred and to identify variables associated with communication.

Participants were adults who are primary caregiver to a child aged 10-12 years at baseline and lived with the child for past 3 years.

40% of parents in Kenya had never talked to their child about HIV/AIDS, with 38% of parents thought that talking about sexuality encourages sex, and 61% believing their child was too young to learn about sex. Communication was associated with parental perceptions of child readiness to learn about sexuality, if they had received information to educate their child about sex and if they had greater sexual communication responsiveness (skill, comfort & confidence).

Vandenhoudt et al., 2010

[53]

United States and Kenya (rural)

To assess community acceptability and impact of Families Matter! Intervention on parenting practices and effective parent-child communication.

Data collected from 403 parent-child dyads at baseline and 321 parents-child dyads at 1 year post intervention. Only follow-up data reported.

High attendance from parents at all intervention sessions and reported being satisfied with the intervention, finding it helpful and a confidence booster. The majority also reported having shared intervention information with persons other than their child, indicating high levels of dissemination. Significant improvement in parental attitudes concerning sexuality education, with parents reporting greater use of positive reinforcement and monitoring. Improvements in sexual risk reduction communication, with increase from 17% to 38% baseline to follow-up of children reporting ever having asked their parent a question about sexuality, similar change among parents reported (14% to 50% at follow-up).

Wamoyi et al., 2010

[55]

Tanzania (rural)

To explore parent-child communication about sexuality in families, including the content, timing and reasons for communication with children aged 14-24 years.

Ethnographic design. Eight weeks of participant observation, 17 focus group discussions and 46 in-depth interviews were conducted with young people aged 14-24 years and parents of those in this age group.

Parent-child communication about sexuality was common in families and mainly on same sex basis. It typically consisted of warnings, threats and physical discipline and was triggered by seeing or hearing something a parent perceived as a negative experience (such as a death attributable to HIV and unmarried young person's pregnancy). A lack of trust in what they could say to their parents was reported by young people for fear of punishment. Parents were constrained in their communication due to lack of knowledge and restrictive gender and cultural norms.