- SL mothers thoroughly refuse safe sex info to children, and lack skills/knowledge on adolescent SRH to communicate
Although many local mothers thought that adolescent sexual and reproductive health (SRH) information is important to adolescent girls and attempted to keep their daughters informed about related issues, they preferred abstinence-only sex education over abstinence plus comprehensive sexuality education where they thoroughly refused to provide safe sex information, and also lacked the skills and knowledge on adolescent SRH issues to communicate such matters to their children. Therefore, they required the implementation of interventions to improve their attitudes towards sexuality education of adolescent children and skills in communicating SRH matters with children.
These findings and observations were made in an article on “Mothers’ perceptions and concerns over sharing SRH information with their adolescent daughters – A qualitative study among mothers of adolescent girls aged 14-19 years in the developing world, Sri Lanka” which was authored by D. Mataraarachchi, G. Ariyadasa, C. Wijemanne, I. Gunatilake, I. Nupahewa, A. Gunasoma, P.V.S.C. Vithana (all seven attached to the Health Ministry's Family Health Bureau [FHB]), P.K.B. Mahesh (attached to the Ministry's Health Department), and T.E.A. Pathirana (attached to the Panadura Base Hospital), and published in BMC Women's Health's 23rd volume in May this year.
With the onset of puberty, intensified sexual interests result in increased sexual risk-taking among adolescents. Adolescent sexual desires are, as mentioned in S.K. Kar, A. Choudhury, and A.P. Singh's “Understanding the normal development of adolescent sexuality: A bumpy ride", influenced by increased levels of sex hormones at this age. During this time, an adolescent’s need for lovemaking and intimacy with the opposite sex increases. They tend to, as observed in M.A. Ott's "Examining the development and sexual behaviour of adolescent males”, explore different ways of lovemaking and intimacy which may put them at risk of various sexual health problems.
Poor awareness
S. Bott, S. Jejeebhoy, I. Shah, and C. Puri's “Towards adulthood: Exploring the SRH of adolescents in South Asia” indicates that the increased prevalence of premarital sex and poor awareness of SRH-related matters have led to a higher risk of sexually transmitted infections (STIs), unwanted pregnancies, abortions, and sexual violence and coercion among adolescents in the region. N.I. Thalagala, A. Lokubalasooriya, M. Danansuriya, and S. Godakandage's “National youth survey (carried out by the FHB) – 2012-2013: Health profile and risk behaviours of the Sinhalese, Buddhist unmarried youth stratum” implied that 14.7% had engaged in sexual intercourse during the previous year, out of which the majority were non-schooling youth, while disclosing poor awareness among adolescents, where only 45-55% of the adolescents knew about sexually transmitted diseases (STDs), contributing factors, and prevention.
S.B. Agampodi and T.C. Agampodi's “Adolescents’ perception of reproductive health care services in Sri Lanka” suggested that many adolescent girls (17-19 year-olds) were psychologically distressed due to SRH issues, the commonest being menstruation and masturbation, while also discovering a lack of knowledge on available sexual health services among Sri Lankan adolescents, with the lack of access to SRH knowledge being a primary reason for SRH-related matters among adolescents.
R. Ancheta, C. Hynes, and L.A. Shrier's “Reproductive health education and sexual risk among high-risk female adolescents and young adults” suggests that early SRH education is associated with reduced sexual risk behaviour. However, as observed in S. Samreen's “Comprehensive sexuality education in Asia”, similar to many other countries in the Asia Pacific region, social taboos, cultural beliefs, and stigmas have become major obstacles in providing SRH education to the Sri Lankan young generation. As a result, SRH education of Sri Lankan adolescents and youth is currently at a substandard level. Several attempts have been made at the national and district level during the past few decades to improve SRH knowledge among Sri Lankan adolescents. The introduction of SRH modules into the school curriculum, teacher training workshops on adolescent SRH, adolescent life skills programmes, and sexual awareness programmes for adolescents are some of the projects carried out at the national and district level to address the issue.
Although components of SRH have been a part of the school curriculum for nearly three decades, very little progress has been observed with SRH knowledge, attitudes, or behaviours among youth in Sri Lanka. B.C.V. Senaratne's “An assessment of reproductive health education in Sri Lankan schools” suggests that only 58% of students are satisfied with the current school-based SRH education, while finding that teachers themselves preferred the subject to be taught by an external person, probably due to their lack of self-confidence in delivering the content.
Major drawbacks
The lack of intense and continuous training of teachers and capacity building and the underuse of interactive material, and the lack of support from principals and parents have been identified as major drawbacks for a successful programme. Although sexual awareness programmes for adolescents and life skills programmes are being carried out at the Medical Officer of Health (MOH) level on an ad hoc basis, the United Nations Population Fund's “Delivering comprehensive sexuality education: Whose role is it?” observes that the consistent delivery of such programmes is not to be seen.
A.A.I.N. Jayasekara, P. Weerakoon, S. Beneragama, R.W.K.M.D. Rajapakshe, M.S.A. Rizwan, W.M.S.K. Wanninayake, T.A. Saranga, W.M.S.N.K. Nawaratna, and D.A.C.L. Dalugama's “A cross-sectional study on sexual practices and knowledge related to the sexual health of youth (18-24-year-olds) in the tea plantation sector; Nuwara Eliya District” indicated that many depended on unreliable sources for sexual health information, with peers being the primary source for 55%, while they considered school teachers as the least reliable source of information.
The aforementioned National Youth Health Survey indicated that the knowledge on SRH among adolescents is not up to expected standards, as more than 54.4% of females did not know that a pregnancy can happen during the first sexual intercourse and only 53.3% knew that missing a period can be a sign of pregnancy, while adolescents’ knowledge of prevention of STIs was substandard, where only 48.8% knew that the consistent use of condoms is a method to prevent human immunodeficiency virus (HIV) infection, and only 54.8% correctly understood that there is a risk of transmitting an STI even after a single sexual exposure.
Although several programmes have been planned and implemented at the school and community levels to improve SRH knowledge among Sri Lankan adolescents, these programmes are being implemented amidst lots of resistance from society. Social taboos and stigma towards providing sexual health information to adolescents are known challenges for successfully implementing these programmes in Sri Lanka. Besides, the importance of improving parent-adolescent sexual health communication to promote healthy sexual behaviours among adolescents is a current, trending topic across the world, per India, South African, and Nigerian studies.
Deficient parental involvement
M.K. Hutchinson, J.B. Jemmott III, L.S. Jemmott, P. Braverman, and G.T. Fong's “The role of mother-daughter sexual risk communication in reducing sexual risk behaviours among urban adolescent females: A prospective study” and G. Overbeek, D. van de Bongardt, and L. Baams's “Buffer or brake? The role of sexuality-specific parenting in adolescents’ sexualised media consumption and sexual development” have shown that parents can be used as a successful source of sexual health knowledge to adolescents and indicate that effective parent-adolescent sexual communication can prevent unhealthy SRH practices among adolescents and promote their health. A.A. Rogers's “Parent–adolescent sexual communication and adolescents’ sexual behaviours: A conceptual model and systematic review” showed a consistent relationship between parent-adolescent sexual communication and adolescents’ sexual attitudes and safe sex-related efficacy.
Poor awareness, negative attitudes, and perceived self-efficacy of parents are barriers to parent-adolescent communication of SRH-related matters. An Ethiopian study indicated that the lack of parental knowledge, socio-cultural norms, and concern that discussions would encourage adolescent sexual behaviours, were the reasons for poor parent-adolescent sexual communication. P.K.S. Godamunne’s “Sri Lankan parents’ attitudes towards adolescent reproductive and sexual health education needs: A qualitative study” suggested that parents are keen on providing SRH information to their adolescents and found that social taboos and embarrassment are the main barriers that prevented them communicating with their adolescents about sexual health matters.
The Ministry’s Epidemiology Unit's "Sri Lanka – Global school-based student health survey" highlighted parents’ inability to understand the different needs of an adolescent child and pointed out the lack of parental involvement in adolescent SRH matters. S.B. Agampodi, T.C. Agampodi, and U.K.D. Piyaseeli's “Adolescents’ (17-19-year-olds) perception of reproductive healthcare services in Sri Lanka” indicated that adolescents expected their parents to be more aware of adolescent SRH issues, while also revealing that negative attitudes of parents were a barrier to reach available adolescent SRH services.
Sri Lankan parents refrain from discussing sexual health topics with their children for various reasons. Not being comfortable with the topic, and the lack of knowledge and skills to communicate this topic effectively with children were some of the reasons identified. It is important to intervene early before adolescents become sexually active in order to prevent sexually risky behaviours in them. Understanding parents’ perception and concerns over communicating sexual health matters with their adolescents is essential when finding the best ways to improve SRH communication to promote healthy sexual behaviours.
A Kenyan study indicates the gender disparity in parent-adolescent sexual communication.
A local study in detail
In Mataraarachchi et al.’s study, 64 biological mothers of unmarried adolescent girls aged 14-19 years in six purposively selected MOH areas in the Kalutara District were included from November 2019 to February 2020.
The mean age of participants was 43.5 years. The majority were above 40 years (81.2%). All participants were Sinhalese and 53 (82.8%) were Buddhists, while 11 (17.2%) were Catholic or Christian. A total of 40 (34.1%) were educated above the General Certificate of Education Ordinary Level, while 21 (32.8%) were employed.
Contrary to U.N. Biswas’s “Adolescent reproductive health in South Asia: Issues and challenges” which indicated that socio-cultural norms were a leading barrier to provide sexuality education to children, many mothers in the present study believed that it is important to provide sexual health information to their offspring. This, according to Mataraarachchi et al., can be partly explained by the high literacy rate in the context of the study that made the adults realise the importance of providing sexuality education to children.
At the same time, mothers had their own fears about providing sexual health information to adolescent girls, believing that it might aggravate the child’s curiosity to explore more, thereby putting her at more risk of sex during adolescence. B. Zaman, R. Shampa, and M. Rahman’s “Mothers’ knowledge about the reproductive health needs of their adolescent girls (South Asia)” reported that parents were concerned about experimentation and possible early sexual exposure due to sexual education.
The majority of mothers in the present study believed that the provision of sexual health information to adolescents should be done within limits. They preferred abstinence-only sexuality education over abstinence-plus or comprehensive sexuality education.
A Fijian study (among parents of adolescents aged 15-18 years) identified that parents limited their discussions to advising children about not engaging in sex. Y. Kee-Jiar and L. Shih-Hui’s “A systematic review of parental attitude and preferences towards implementation of sexuality education” indicated that parents from countries like Bangladesh and Malaysia preferred sexual education to be in line with religious teachings, values, and cultural context. Nonetheless, a United States (US) study indicated a failure of abstinence-only education in preventing teenage pregnancy in Western cultures.
Mothers in the present study found it easier to discuss sexual matters with children when they had prior sexuality education in school. J. Jones, A. Mitchell, and J. Walsh’s “Talking sexual health: A parents’ guide” indicates that when children participate in school-based sexual health education programmes, sexual communication between the parent/s and the adolescent increases.
Issues related to menstruation, preventing sexual violence, chastity, and sexual abstinence were the commonly discussed topics between the mother and daughter.
Mothers in the present study setting regarded their teenagers as small children and did not want to admit that they get sexual desires. Per K.L. Pariera’s “Barriers and prompts to parent-child sexual communication”, in the US, many mothers considered their adolescent children as “too young” to engage in sexual activities, and this was identified as a major barrier for a sexual discussion between mothers and daughters.
According to the present study, many mothers who had been discussing SRH matters with children, have been doing so, while watching or listening to incidences of sex-related matters. A Bangladeshi study found that mothers who had good media use such as newspapers and television (TV) were having a high level of SRH communication with their daughters. The finding reflects the importance of information, education, and communication (IEC) material to explain SRH topics to children, which mothers are not comfortable with.
Discussion
Godamunne's study (among 71 parents in Kurunegala) indicated that parents were reluctant to discuss SRH matters with children mainly due to shyness, embarrassment, and the lack of knowledge. Moreover, Pariera reported that the lack of self efficacy and perceived value in sex-related communication are factors determining the mother-daughter sex-related communication.
Parents’ interest in developing a sexually healthy adolescent can be well used to plan public health programmes to improve SRH awareness among children and adolescents. The unconditional love towards the child, trustworthiness, and the ability to offer developmentally appropriate, individualised information consistently makes the parent a reliable and tailored source of sexual health information to children. Moreover, the ability to adapt the messages to suit religious, cultural, and family values would make this approach more acceptable in society, where there is much resistance against providing sexuality education to children.
Even though many mothers had recognised the importance of mother-daughter sexuality related communication and had taken the first steps already, there were exceptions in society who had not realised the need to provide sexual health information to adolescents. The findings indicate the need to carry out public health programmes targeted at parents to improve their knowledge and attitudes towards sexuality education of children. Furthermore, out of the mothers who had been doing something to address the issue, the majority were ignorant about what, when, and how to communicate sexual matters with children. The finding indicates the need to develop parents’ capacity in sharing SRH information with children.
The present study identified the main areas that need to be focused on during future public health interventions targeting parents and adolescents to promote adolescent SRH as the need to make a positive change in parents’ attitudes towards sexuality education of adolescents, improving parents’ knowledge on SRH needs of adolescent children, the need to develop communication skills of parents, and the need to develop adolescents’ capacity to identify correct sources of sexual health information and to seek help when faced with SRH issues.
School and community-based interventions have to be targeted to cover the above objectives. Advocacy programmes targeting the education staff – including school principals – to get the active involvement of parents during school sexuality education sessions is also a requirement.
Recommendations
Mataraarachchi et al. recommended the following:
Policymakers need to consider parents as a primary source of sexual health information for adolescent girls; the implementation of parental awareness and skill-building sessions in parallel to school-based sexual health education programmes; the use of print, local, and mass media messages to create awareness among mothers on adolescent SRH matters and mothers’ role in supporting adolescent SRH issues; since mothers used material such as newspaper articles, movies, TV shows, and textbooks to explain SRH matters to children, the development of video clips and other information, education, and communication material, which can be used by parents and teachers when giving SRH education to children; since mothers wanted to give abstinence-only sex education to their adolescent children, where they thoroughly refused to provide safe sex information to adolescents, future interventions should focus on improving mothers’ attitudes towards sexuality education of adolescent children; and since mothers perceived that school-based sexuality education is not up to the level of expectation, and perceived the reluctance of school staff to provide SRH information to children, interventions should target school principals and other relevant staff on improving their knowledge and attitudes towards sexuality education and skill-building sessions for teachers.
Future research, per Mataraarachchi et al., should be conducted to examine fathers’ concerns over sharing sexual health information with adolescent children, including sons.