Parent-Adolescent/Youth Sexual and Reproductive Health Communication: The Case of Secondary and Preparatory School Students in Fiche Town, Oromia Regional State, Ethiopia

Background: Adolescence/youth is a continuum of physical, cognitive, behavioral, and psychosocial development. Due to a lack of comprehensive knowledge regarding sexual and reproductive health, adolescents face a number of problems. Clear family communication of reproductive health issues often leads to increased awareness of reproductive health matters and reduces risky behaviors and its consequences in adolescent populations.


INTRODUCTION
To begin with, while adolescents are individuals aged bet-ween 10 and 19 years, youth are between 15 and 24 years. The two are together called young, people aged between 10 and 24 years. In other words, the term young covers both adolescents and the youth [1]. Because of their developmental stage, young people are exposed to problems like accidental and intentional injuries, suicide and mental disorders, and substance abuse [2]. It is said that nearly 2 billion people of the world live at a cross-road between childhood and adulthood among which 9 out of the 10 live in developing countries [3].
Studies reveal that the magnitude of ill reproductive health is increasing among young people on account of inherited traditions which discourage discussion between parents and children during early sexual initiation [4]. Worldwide, more than a million STIs are acquired every day [5]. The increased risk of sexually transmitted diseases in adolescents and youths may result in future sexual and reproductive health problems related to fertility and birth [6]. Unwanted pregnancy is also one of the major reproductive health challenges confronted by many adolescents in Ethiopia. Thirty-seven percent of pregnancies among girls aged 20-24 are unwanted because of lack of awareness concerning sexual physiology, limited use of contraceptives and inadequate access to reproductive health information and education [7]. Again, owing to lack of communication, adolescents believe that using contraceptives other than condoms cause infertility [8].
For different reasons, adolescents lack adequate access to reproductive health information, which exposes them to a number of problems [9]. Parent-adolescent/youth communication has the advantage of delaying early sexual initiation supposed to result in unwanted outcomes [10,11]. In more clear terms, when parents have sexual and reproductive health communication with their children, they shape their behavior positively [12]. Parent-adolescent communication concerning sexuality and reproductive health seems a factor in the study of family influence on sexuality. Thus, parentadolescent/youth communication concerning sexual and reproductive health matters is often considered salient and perceived to be an effective means of encouraging adolescents/youths to accept responsible sexual behaviors [13]. A study conducted in Northern Ethiopia showed that adolescents did not communicate with their parents on reproductive health issues associated with teenage pregnancy [14]. It was also shown that adolescents who had communication on SRH had less chance of participating in risky sexual behaviors [15] (Fig. 1). The status of parentadolescent/youth SRH communication is low in Ethiopia [4, 15 -22]. In spite of this, the status of this issue is not well known in the study settings in particular. Therefore, this study has been conducted to assess parent-adolescent/youth sexual and reproductive health communication in selected schools.

Study Setting and Period
The study was conducted from March 27 to 30, 2017, in one secondary and one preparatory public schools of Fiche town. The town is located in the central part of Ethiopia, 110 kilometers away from Addis Ababa, the capital city of Ethiopia. A total of 2342 students, 1173 (50.1%) were females who were attending the schools by academic year 2016/2017. There were a total of 40 sections in both schools; each section contained 60 students on average [23].

Study Design
A school-based cross-sectional study design was employed.

Source and Study Population
All regular adolescent/ young students attending secondary and preparatory schools in Fiche town were the source population, whereas randomly selected adolescent/young students who fulfilled the inclusion criteria were taken as the study population.

Inclusion and Exclusion Criteria
All regular secondary and preparatory school students aged 10 to 24 years who were willing to participate in the study were included. Students who had sight problems and sick at the time of data collection were excluded.

Sample Size Determination
The sample size was determined using a single population proportion formula, taking proportion from a study conducted on parent-student communication in Debre Markos town. The proportion of communication among adolescents is 36.9% [24], level of confidence, 95% (Zα/2) 2 = 1.96, 5%, margin of error (d= 0.05), and an additional 10% for possible nonresponse rate. Accordingly, the sample size n = [(Z/2) 2 P (1- . Adding a 10% non-response rate, the total sample size was calculated to be 394.

Sampling Technique
The study participants were selected from Abdissa Aga high school, grades 9 and 10 and Fiche preparatory school, grades 11 and 12. The calculated sample was first allocated proportionally to both schools. The share of each school was then allocated proportionally to each grade in the school. The sampling frame was also prepared from the already existing students' registration book (roster) in the respective schools' records office. The sections were selected randomly from each grade, and the share of each grade was then proportionally allocated to the randomly selected sections. The study participants from each of the selected sections were also recruited randomly.

Data Collection Tools
Data were collected using a self-administered questionnaire adapted from studies conducted on this issue previously [4,24,25]. The questionnaire contained the socio-demographic characteristics of the students and parents, knowledge and attitude of students about sexual and reproductive health issues, and factors affecting parent-student communication of Sexual and Reproductive Health (SRH) issues. The questionnaire was prepared in English and then translated into the local languages (both Afan Oromo and Amharic). The Afan Oromo and Amharic versions were then back-translated to English to check message consistency. The Afan Oromo version questionnaire was pretested on 5% of the study sample in a similar area outside the study site (at Degem secondary and preparatory school). Necessary modifications like reshuffling the order of some questions and grammar were made based on the results found prior to the actual data collection.

Data Collection Procedure
The revised questionnaires were distributed by data collectors to randomly selected students who met the inclusion criteria. The distribution was made at the same time in both schools to prevent the contamination of information. Supervisors followed the questionnaire filling activity and helped participants who faced difficulties.

Data Processing and Analysis
To ensure the quality of data, the entire filled questionnaires were checked for completeness and consistency. Then, data were entered using Epi Data Manager version 4.0.2.101 and exported to SPSS version 21 for statistical analysis. While the descriptive statistical analysis was used to compute the frequency, percentage, and mean for the dependent and independent variables, binary logistic regression analysis was applied to check the association between outcome and explanatory variables. Variables with an association in the bivariate analysis (p-value ≤ 0.25) were taken in multivariable analysis to determine the independent predictors of parentadolescent communication on sexual and reproductive health issues. In so doing, P-values below 0.05 were considered statistically significant.

Study Variables
The dependent variable was parent-student communication/discussion on SRH issues. The independent variables included socio-demographic characteristics like age of students, educational status of the parents, living arrangement of students, family size and income. Individual factors such as knowledge of students about SRH issues, their attitude about SRH issues, cultural factors, and beliefs/taboos were also regarded as independent variables.

Operational Definitions
Parent: This study refers to the bearer and/or guardian of the student. Parent-student Communication: In this particular study context is a simple discussion on issues like STIs (sexually transmitted infections), sexual intercourse, menstruation, and unintended pregnancy in the last six months. The presence of parent adolescents was considered if they had discussed at least two points from listed above. SRH Knowledgeable: students who scored points more than the mean score out of prepared knowledge questions on selected SRH topics.

Positive Attitude Toward SRH Communication:
Those respondents who had a positive stance toward SRH communication and who scored points more than the mean score out of the prepared attitude questions. Negative Attitude Toward SRH Communication: Those respondents who had a negative outlook towards SRH communication and who scored points less than the mean score out of the prepared attitude questions.

Data Quality Control
Data collectors were adolescents who completed grade twelve. In this regard, half-day training was given to data collectors on the objectives of the study, sampling procedure, and on how to check the completeness of the questionnaire. The questionnaire was also pre-tested prior to the start of the actual data collection.

Socio-Demographic Characteristics
As it was said earlier, a total of 394 self-administered questionnaires were distributed to adolescent/young students attending Fiche secondary and preparatory schools. All participants filled the questionnaire and returned it, yet not all of them were complete. In other words, of the 394 participants, 378 completed making a response rate of 95.94%. The mean age of the respondents was 17.39 (±1.51) years. More than half of the participants, 196 (51.9%) were males. Ethnic wise, the majority participants were Oromo, 366 (96.8%) and religionwise many of them were Orthodox Christians, 340 (89.9%). Most of the participants were attending grades nine, 151 (39.9%) and ten, 143 (37.8%). With regard to living arrangements, more than half of the participant students, 225 (59.5%) is living with their parents ( Table 1). The majority of the participant students' parents were living together in a marital union, 293 (77.5%). Mothers of 149 (39.4%) students could not read and write and 125 (33.1%) students' fathers attended only primary school. Farming is the main occupation on which the parents of the study participants relied on. In this regard, fathers of 207(54.8%) respondents and mothers of 122 (32.3%) of them are farmers ( Table 2).

Knowledge of Students on Selected Sexual and Reproductive Health
Concerning this, 318 (84.1%) of the respondents have ever heard about sexual and reproductive health issues. In this regard, the primary sources of information according to them were school 238 (74.8%) and mass media 64 (20.1%) (Fig. 2).
Regarding STI, 370 (97.9%) of the participants reported that they had an awareness of one or more STIs. HIV was the most commonly known STI among respondents, 364 (98.3%) and followed by gonorrhea 235 (63.5%) (Fig. 3).
Of all participants, 320 (84.7%) of them have awareness about one or more contraception options available. For example, 224 (70.0%) of the respondents know about condom and 195 (60.9%) about contraceptive pills (Fig. 4).

Students' Attitudes Towards Selected Sexual and Reproductive Health Issues
The majority of the respondents 333 (88.1%) believed that premarital sex is not acceptable. Again, 196 (51.9%) participants believe that parent-adolescent/young sexual and reproductive health communication has the capacity to delay first sexual intercourse. Similarly, 192 (50.8%) agreed that unmarried couples must use condoms if they want to commit sexual intercourse. Concerning the protection of condoms against STIs and HIV, 213 (56.3%) of the respondents agree that condoms could protect against these infections ( Table 3).  Fig. (2). Source of information on sexual and reproductive health issues among students attending secondary and preparatory schools in Fiche town, Oromia, Ethiopia, June 2017 (N=318).

Socio-demographic factors
Age of the respondents' Educational status of parents Living arrangement of students Family size Family income Religion

Parent-Student Sexual and Reproductive Health Communication
The majority of the respondents, 335 (88.6%) reported that it is important to discuss sexual and reproductive health issues with parents. However, only 118 (31.2%) of the students discussed sexual and reproductive health issues with either of their parents on at least two topics of SRH issues ( Table 4).

Factors Associated with Parent-Students SRH Communication
Binary logistic regression analysis was used to see the relationship between the dependent variable (students'

Gonorrhea
Ch Contraceptive methods available discussion of SRH issues with either of their parents) and the independent variables. In the bivariate analysis, sex of the respondents, mothers' occupational and educational status, fathers' educational status, family size, students' knowledge about and attitude towards SRH issues, and perceived importance of SRH issues discussions with parents were found to have a P-value less than 0.25. The multivariable analysis made on the above variables indicate that mothers' educational status above diploma[AOR=3.52, 95%CI=1. 13-10.95 13,, and students' perceived importance of SRH issues discussion with parents[AOR=6.69, 95%CI=2.04-22.00] were independently associated with students' discussion on at least two sexual and reproductive health topics with either of their parents ( Table 5).

DISCUSSION
The current study reveals that only 118 (31.2%) respondents had ever discussed two or more topics of sexual and RH issues with either of their parents. This finding is lower than the results of a study conducted in Debre Markos secondary and preparatory school (36.9%) [24], Mekelle city (57.6%) [4], Boditi town, southern Ethiopia (40.70%) [26], Robe Town, Bale zone, Southeast Ethiopia (47%) [27], and Brong Ahafo Region Ghana (72.8%) [21]. This might be due to differences in the degree of openness between parents and their children in discussing SRH issues. Parents of the present study area might be less open in discussing SRH issues with their children compared to the aforementioned studies. The result is however, slightly higher than a study conducted in Benishangul Gumuz, Bullen woreda where 29.6% of the study participants had ever discussed more topics of sexual and SRH issues with either of their parents [17]. It is also higher than a study conducted in Dera Woreda, Northwest Ethiopia which shows only 8.8% of the participants discussed with their parents [28]. This could be due to differences in sociodemographic profile, degree of openness between parents and students for discussion, and access to reproductive health information.
It was found that 84.7% of students know at least one contraceptive method. This indicates the awareness about the contraceptive method is high. This high percentage of awareness of the contraceptive method may have resulted from the high accessibility of SRH issue-related information in and around the study settings. The contribution of school/youthbased clubs, mass media, and health extension workers might be great in this regard. The awareness of the majority of the respondents about the contraceptive method may open them access to choose from the available contraceptive methods and protect themselves from SRH-associated problems. Table 3. Attitudes toward sexual and reproductive health issues among students attending secondary and preparatory schools in Fiche town, Oromia, Ethiopia, June 2017 (N=378).

Questions Category Frequency Percent
Premarital sex has no problem on students Agree 42    Regarding STIs knowledge, the study shows that 98.3% of the participants have awareness about HIV which is in line with a study conducted in Ghana [21]. HIV is one of the most highly spoken and targeted health issues in the modern era, and the widespread of information to the public about it might make the majority of the participants in the current study get aware of it.
Findings from the current study also identified mothers' educational status is among factors that predict parentadolescent/youth sexual and reproductive health communication. More specifically, students whose mothers have completed primary school were 3.34 times more likely to discuss SRH issues and students whose mothers completed secondary school were 5.54 more likely to discuss about the same issues with either of their parents compared to students whose mothers are illiterate. Here, one has to note that this finding mirrors with some studies that have been done previously. For example, a study conducted in Boditi (town in southern Ethiopia) reveals similar outcome in that students from educated family background discuss more openly than their illiterate family counterparts about SRH matters [26]. Therefore, from this finding, it is possible to deduce that education is a key tool in increasing the awareness of mothers about SRH matters and their openness for discussion concerning issues that are connected with their children. In short, the bare bones of the argument concerning education seems to lay on the statement that the more awareness of mothers about SRH issues, the more open they become and the more freedom they give to their children to discuss SRH issues.
The same is true with fathers. It was found that fathers' educational status is one factor that positively determines parent-student SRH issue discussions. That is, students whose fathers received a diploma and above were 3.84 times more likely to discuss SRH issues with either of their parents compared to students whose fathers could not read and write. A study in Haiyk Town (North East Ethiopia) also shows that educational status of parents influences parent-adolescent/ youth SRH communication positively [29].
Students who did not accept the importance of discussion about sexual and reproductive health issues with either of the parents were 6.69 times less likely to discuss SRH issues than their counterparts. This result is similar to the study conducted at Debre Markos secondary and preparatory school [24] and in Boditi town, southern Ethiopia [26].
Knowledge of students concerning SRH was strongly associated with parent-student sexual and reproductive health issues discussions. Respondents who knew well about SRH issues were4.8 times more likely to discuss SRH issues with either of their parents when compared to those who had low knowledge. This is similar to the study conducted in Dire Dawa Ethiopia [25] and in Harar, Eastern Ethiopia [30]. Increased discussion with increased knowledge may help students to protect themselves and their friends from bad sexual practice and its consequences.
Students' attitudes towards SRH issues were also strongly associated with parent-student sexual and reproductive health communication. That is, students who had a negative attitude towards SRH issues were less likely to discuss when compared to students who had positive attitude. And this mirrors with a study conducted in Uganda [31] and Harar, Eastern Ethiopia [30].

LIMITATION OF THE STUDY
Students' self-reported data might not provide complete information about the communication they have with their parents because their communication was not observed. There were no data received from the parents' side regarding the details of the communication they had with their children.

CONCLUSION AND RECOMMENDATION
Students in the study settings knew various components of SRH issues. Students who were more knowledgeable about SRH issues and had a positive attitude toward these issues were open to discussion with their parents. In this regard, students from literate parents discuss more about SRH matters compared to students from illiterate ones. All in all, school administration in collaboration with other stakeholders should establish an adolescent friendly reproductive health centers and should increase awareness by delivering various SRH issues related services at the center.

AUTHORS' CONTRIBUTIONS
MF involved conceiving the idea, study design, data analysis, and interpretation, and managing the overall progress of the study. TN involved in study design, data analysis, and writing up of the manuscript. HA and TA contributed to study design, data analysis, and revising the manuscript. The final manuscript was read and approved by all authors.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
Ethical approval and clearance were received from the Research and Ethics Committee (REC) of the School of Allied Health Sciences, Addis Ababa University, Ethiopia (study protocol No. 139/2017). The letter of permission was written to the Regional Education Bureau and to the zonal school office and finally to each school to conduct the study.

HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION
The purpose of the study was explained to the respondents, and consent was obtained.