Parent-adolescent communication about sexual and reproductive health and its determinants among adolescents: Baseline findings from a Randomized Controlled Trial in Tanzania

Regardless of the importance of youth in socio-economic development around the globe, adolescents aged between 10 and 19 years face problems ranging from their basic to Sexual and Reproductive Health economic needs (SRH). This study determined baseline parent-adolescent communication about SRH from a randomized controlled trial of integrated reproductive health materials in a Problem-Based Pedagogy (PBP) for shaping safe sexual behavior among adolescents in Tanzania. The study employed a baseline cross-section survey from a randomized controlled trial of integrated reproductive health materials in a problem-based learning pedagogy for shaping safe sexual behavior among 647 randomly selected adolescents in Tanzanian ordinary-level secondary schools. The response rate of the study was 100% of which 57.5% were females. Totalities of 73.3% of adolescents reported having never communicated with their parents about SRH. Parent-adolescent communication about SRH matters was found to be low and thus, recommends collaborative parent-adolescent interventions to address it accordingly. Plain language summary Do parents communicate Sexual and Reproductive Health (SRH) matters with their children? Baseline findings from a randomized controlled trial in Tanzania Purpose: This study determined baseline parent-adolescent communication about SRH from a randomized controlled trial of integrated reproductive health materials in a Problem-Based Pedagogy (PBP) for shaping safe sexual behaviour among adolescents aged between 10 and 19 years in Tanzania. Methods: The study employed a baseline cross-section survey from a randomized controlled trial of integrated reproductive health materials in a Problem-Based learning pedagogy for shaping safe sexual behavior among 647 randomly selected adolescents in Tanzanian ordinary-level secondary schools. Results: The response rate of the study was 100% of which 57.5% were females. Totalities of 73.3% of adolescents reported having never communicated with their parents about SRH. Conclusion: Parent-adolescent communication about SRH matters was found to be low and thus, recommends collaborative parent-adolescent interventions to address it accordingly. Implications: This study has addressed a very important topic to reveal an unclear understanding of the prevalence of parent-adolescent communication practices regarding SRH matters alongside associated determinants in Tanzania. The findings of this study may give a reliable and high probability estimate of the impact of PBP on enhancing parent-adolescent communication about SRH issues for safe sexual behaviour among adolescents in Tanzania. Limitations: Being a study that assessed sensitive topics and experiences of parent-adolescent communications about SRH matters among adolescents there might be some degrees of recall bias, under or over information from them, though not to a higher degree. Additionally, the methods and materials used in this study might not be sufficiently and accurately documented to allow replication studies.


Introduction
Adolescents represent a large cohort that determines a huge opportunity to transform the social and economic fortunes of any nation if they are formed properly in the early years of their lives (UNFPA, 2018).Regardless of the importance of youth in socio-economic development across countries around the globe, adolescents aged between 10 and 19 years face problems ranging from their basic to sexual and reproductive health needs (WHO, 2017).Despite the decrease in HIV prevalence among adolescents and adults (15-49 years) from 5.1% in 2014 to 4.8% in 2019 in Tanzania, 5.8% of adolescents who are living with HIV in the globe, are in Tanzania (UNICEF, 2020).
Moreover, data from a report by UNICEF (2020) indicate that almost 8,600 new HIV infections occur among children between age zero and the middle adolescent stage (0 to 14 years) whereas 93,000 children of the same age range live with HIV.Likewise, out of 27,000 estimated AIDS-related deaths in the country, 5,900 deaths occur among children (0 to 14 years).On the other hand, 99,000 adolescents aged between 10 and 19 years are living with HIV of which about 57,000 of them are adolescent girls.Nevertheless, of the 77,000 new HIV infections occurring in the country, 10,000 are adolescents aged between 10 and 19 years (UNICEF, 2020).
Apart from the trend of STIs/HIV among adolescents, reports about teenage pregnancies in East African regions show that the highest percentage exists in Uganda (23.8%) and Tanzania (22.8%).Rwanda (7.3%) and Ethiopia (12.4%) have the lowest rate among other African regions.Currently, the adolescent fertility rate in Tanzania in particular has reached 128 pregnancies per 1,000 women against the target of fewer than 100 pregnancies per 1,000 women by 2020 (Millanzi, Osaki and Kibusi, 2023).The MoHCDGEC (2017) reported that 27% of adolescents in Tanzania get underage pregnancies.Yet, an estimated 8,000 (1,760 in primary schools and 6,300 in secondary schools) adolescent girls drop out of school due to teenage pregnancies (Center for Reproductive Rights, 2013).
Scholars such as Wolinsky (2016) have argued that nothing under the earth occurs from nothing.The detailed trend of STIs/HIV, teenage pregnancies, and school dropouts among adolescents presented above, for example, has been linked with the early onset of unsafe sexual behaviors (Pradhan et al., 2018).This may be the case because sexual emotions and abilities to make reasoned and informed decisions develop gradually at young ages (Busi, 2017).Emotions here include the desire for intimacy, friendship, and belonging, which at this age translate into temptations to sexual acts at an age when they have little understanding of their consequences (Mutanana & Mutara, 2015).Indeed, suggested data from Schiller (2009) on neuroscience is that changes in affective processing during adolescence may be critical to understanding unsafe behavior in this age period.
The trend of early onset of unsafe sexual behaviors alongside educational and health outcomes among adolescents has been argued by some scholars (Birchall, 2018;Do et al., 2020;Landry et al., 2017;Waktole, 2019), to be attributed to factors including peer pressure, poverty, uncontrolled social media, parenting styles, distance to schools, and or drug abuse.Moreover, the existing ways of communicating sexual and reproductive health matters among adolescents have been critiqued to fail supporting educators, parents, guardians, and or teachers on the appropriate pedagogies to assist adolescents to control sexual temptations, harassment, and peer/parental sexual pressure when they resort to using didactic methods (Celiker, 2015;Mkumbo, 2012).
Works of Mkumbo (2012), Petro Mlyakado (2013), Wanje et al. (2017), andBaku et al. (2018)'s revealed that parents and teachers for example have a positive attitude toward STIs screening and the implementation of schoolbased sexual educational syllabus among adolescents as they help orienting adolescents know themselves and individual sexual maturity.However, they claim to experience trouble when they try communicating the social and physiological parts of sexual and reproductive health matters.Topics like the human reproductive system and sexual health behavior are communicated in the classroom though with great care and respect, taking into consideration the prevailing socio-cultural sensitive issues.Haruna et al. (2018) have added that discussions about sexual health are still discussed privately due to African social and cultural taboos.Some literature argues that adult male parents at home practice SRH communications about puberty to young boys while for young girls by adult female parents or culturally acceptable relatives.Educators (considered as people who stay with learners longer than biological parents or relatives) in schools on the other side of the coin, communicate SRH materials to adolescents about the mammal reproductive system (Alabi & Oni, 2017).However, the social and psychological parts of the SRH materials are less addressed, and adolescents would need to be empowered for them to be able to make informed, reasoned, and responsible decisions over sexual behaviors (El Kazdouh et al., 2019;Millanzi, 2021;Millanzi, Kibusi, et al., 2022).
Amidst several observational studies (Kemigisha et al., 2019;Keto et al., 2020;Waktole, 2019) on the context of how teachers in schools communicate and facilitate SRH matters to adolescents, it appears suggestive that using an interdisciplinary approach to examining the prevalence and determinants of sexuality communications between parents and adolescents during early days of their lives.The focus may be to determine whether parents or adolescents initiate and practice friendly sexuality communications that may help learners to generate hypotheses and actively find the cross-disciplinary cognition they need for comprehension and manage their sexual behavior as one of the greatest sources of their health problems.
Therefore, this study aimed at determining the baseline parent-adolescent communication about SRH and its determinants among adolescents in Tanzania.Data was collected from a randomized controlled trial study of integrated reproductive health materials in a problembased pedagogy for shaping safe sexual behavior among adolescents in Tanzania.

Study Design, and Location
The study adopted a descriptive cross-sectional survey from a randomized controlled trial of integrated reproductive health materials (RHC) in a PBP among adolescents.Four districts (two districts from Dodoma and the other two districts from Lindi region of Tanzania mainland respectively) were randomly selected using simple random sampling procedures by lottery method.The study was conducted from September to November 2019.

Study Population and Sampling Procedure
This study investigated adolescents aged between 10 and 19 years in ordinary-level secondary schools on Tanzania's mainland.With an exception of form four adolescents (who were in their final national examinations) and those with severe cognitive impairments, all consented (in writing) adolescents were eligible to participate in the study, and their information was processed and analyzed.The multistage sampling technique using a simple random sampling technique by lottery method was employed to select study settings.The first stage was for the selection of 2 out of 7 zones (central and coastal) while the second stage involved the selection of 4 out of 13 districts.The third stage was performed to select 12 ordinary secondary schools on Tanzania mainland.
However, the stratified random sampling technique was used to stratify classes into classes I, II, and III.Stratification procedures were performed to discriminate the levels of classes alongside the prevalence of parentadolescent communication practices about SRH matters.The random numbers table sampling method was used to get a minimum sample of 647 adolescents.The proportionate formula ni = Pi 3 n P À Á , to establish a representative sample per school and strata/class.

Data Collection Instruments and Procedures
The study collected primary data using intervieweradministered questionnaires adopted from previous studies (Dessie et al., 2015;Mbachu et al., 2020).The interviewer-administered approach was opted to minimize incomplete information and missing data.The questionnaires were anonymously filled after being translated from English into the Swahili language to facilitate understanding of the items among adolescents.Questionnaires were then shared with a statistician for review and input.A pre-tested among 65 adolescents was conducted and findings of the exploratory factor analysis revealed a Keiser-Meyer-Oklin (KMO) value of 0.691; p \ .05.
Cronbach Alpha (a) = .725;M = 2.33 6 1.027) was defined as tools that were significantly reliable for the actual field data collection as recommended by previous studies (El Hajjar, 2018;Taber, 2018).It consisted of sociodemographic profiles/data of adolescents, which were treated as independent variables including but not limited to the district, age, sex, class level, and type of family just to mention a few.Items of parent-adolescent communication were treated as the dependent variable and had ''Yes-No'' responses of which ''Yes'' had a value of 1 score meaning that adolescents communicated with their parents about SRH matters otherwise not (''No'' response = ''0'' value).
The questionnaires were administered in a separate unoccupied classroom by four trained research assistants (one per each sampled district) who were introduced to students by the school head teachers and then left in classes to give students more freedom and privacy to fill the questionnaires.Adolescents' names were not included in the questionnaires to ensure confidentiality.Adolescents' responses to the questionnaires were secured confidentially in a keyed file by the principal investigator.The responses were analytically transformed to compute a new dichotomized variable with value sums ranging from \6 (no parent-adolescent communication) to 12 (there is parent-adolescent communication).

Data Analysis
The Statistical Product for Service Solutions (SPSS), a computer software program version 23 was used for both descriptive and inferential statistical data analysis.The significance level was set at ł .05 of the 95% Confidence Interval (CI).Descriptive analysis established baseline sociodemographic characteristic profiles among adolescents while binary and multinomial logistic regression analysis determined the association between variables.

Study Respondents' Sociodemographic Characteristics Profiles
The response rate of the study was 100%.Table 1 shows that the mean age of the study respondents was 15 6 1.869 years while the most prominent age group (71.2%) ranged from 13 to 16 years.Females constituted 57.5% of the sample.Sums of 42.5% were in grade one while 52.1% of adolescents were living in nuclear families.The study assessed two types of regions including Christianity (30.1%) and Muslim (69.9%) of the study respondents.The minority of adolescents (14.5%) demonstrated a positive attitude toward parentadolescent communication about SRH matters.Their biological parents, very few (1.4%) reported never being exposed to social media, and 12.8% of the sample, abused drugs while financially protecting the 32.6% of adolescents.Other socio-demographic characteristics of the study respondents were found as shown in Table 1.

Parent-Adolescent Communication About SRH Matters Among Adolescents
As shown in Table 2, the mean parent-adolescent communication about SRH matters was (M = 1.07 6 0.318).Only 26.7% (n = 173) of adolescents communicated with their parents about SRH matters while 73.3% (n = 374) did not.The 9.1% communicated always while 17.6% sometimes.The most communicated SRH matters included STIs (11.8%) and unwanted pregnancies (11.1%) while the minority communicated about contraception use (1.5%) and sexual relationships (2.3%).Moreover, 5.4% of adolescents preferred communicating SRH matters with their fathers only, 18.2% with their mothers only, and 3.1% with both parents.

Determinants of Parent-Adolescent Communication About SRH Among Adolescents
Findings in Table 3 show that female adolescents were more times likely to communicate SRH matters with their parents than a male adolescents could do (AOR = 1.421; p \ .05;85% CI [0.988, 2.044]).Moreover, financially protected adolescents reported communicating with their parents at high odds (AOR = 1.865; p \ .05;95% CI [1.106,3.146]).Adolescents living in extended families and not abusing drugs were more times likely to communicate with their parents at the odds of (AOR = 1.406; p \ .05;95% CI [1.019, 1.941]) and (AOR = 2.350; 95% CI [1.389, 3.976]) respectively.Yet, exposure to media demonstrated a high likelihood of influencing adolescents to communicate with their parents at (AOR = 2.106; p \ .05;95% CI [1.003,3.341]).Findings of the determinants of parent-adolescent communication about SRH matters in Table 3 were determined using binary and multinomial logistic regression statistical models.Some factors such as age, region, year of study, and or sexual ideology were not significant predictors of whether adolescents initiate or get and parents initiate or provide SRH matters communication in families respectively (p ..05).

Discussion
Findings of this study revealed that adolescents and their parents in families miss opportunities to initiate friendly communications about SRH matters respectively.Although many adolescents preferred to communicate with their mothers than they would do with their fathers and or both parents, issues about the use of contraception and sexual relationships were less communicated than teenage pregnancies and STIs.Being female adolescents, having an employed mother in the family, parental financial protection, exposure to media, and drug abuse were significantly associated with parent-adolescent communications about SRH matters.
In line with the work of Muhwezi et al. (2015) in urban and rural Uganda, revealed that parentadolescent communication on SRH was perceived to be foundational for adolescents' health.However, its implementation was noted to be very rare among parents.Infrequent parent-adolescent communication on sexual and reproductive health issues would limit the accessibility of protective sexual information and its services to adolescents.This, make adolescents unaware of sexual and reproductive matters and being exposed to unsafe sexual activities.In the same veil, Dessie et al. (2015) argued that missing close parental connectedness as it commonly occurs among employed parents might lead to poor parent-adolescent communications on issues around SRH.
Tallying with that adolescents may find themselves being connected by relatives, strange people, and friends where they find easier ways of communicating SRH matters with them than they can do with their biological parents.The sociocultural norms of Tanzania may favor the situation because parents feel uncomfortable initiating and leading communication and educating their children about SRH.The trend of low parent-adolescent communication is linked with their parents' perceptions that early initiation of communication about SRH among children might catalyze them to try it once or even twice in their life (Busi, 2017;Mpondo et al., 2018;Muhwezi et al., 2015).
Busi (2017) maintained that parents are afraid to communicate with their children because they hold beliefs that early communication about SRH catalyzes adolescents' sexual emotions prematurely).Parents link premature sexual emotions with adolescents' intentions to try practicing sexual intercourse for just pleasure, material gain (prostitution), and or hesitate to share their sexual concerns with their parents.However, the connectedness levels between adolescents and other relatives become easy and practical to the level they are not afraid to educate, guide, monitor, and control adolescents on issues about SRH.Their attempt to communicate with them makes it possible for the cohort of adolescents to be responsible for their health (Mpondo et al., 2018;Muhwezi et al., 2015).
Although adolescents' sexual freedom and activity patterns of communicating with parents about SRH matters were low, they differed markedly according to sex, religious backgrounds, parental financial protection, exposure to media, and drug abuse.There seems a need for promoting continuous parent-adolescent communication about SRH matters through comprehensive sexuality education among adolescents and family life education among parents to help shape adolescents' sexual behavior for their future investment and the economic prosperity of the country The findings above may imply that adolescents lack comprehensive age-appropriate information about SRH and its associated health services and thus, the trend may be linked to the increased incidences and prevalence of early onset of unsafe sexual behavior among adolescents.Early-onset of sexual behavior among adolescents appears to be associated with resurgences of unintended teenage pregnancies, new STIs/HIV infections, and or school dropouts that in turn compromise healthy adulthoods and their contribution to productivity at individual, family, and national at large.
The low practice of parent-adolescent SRH communication observed in this study may be addressed better by using interdisciplinary and well-structured collaborative sexuality educational interventions that employ real-life critical incidents, scenarios, health-related problems, and experiences (Millanzi, 2021;Millanzi, Osaki, et al., 2022).
It is time for program, curriculum, and project developers to consider developing educational interventions that target parents and adolescents for significant behavioral outcomes on SRH communication practice to promote a healthy and productive cohort of adolescents around the globe.

Conclusion
Despite the growing scope of expanding the availability and accessibility of sexual and reproductive health information alongside health services among adolescents, parent-adolescent communication practices about SRH matters appear to be low.Based on a vast number of media, friends, and or relatives who disseminate incomplete and inappropriate sexual and reproductive health information, adolescents need to be developed in a parental-guided and supportive environment for appreciative and timely sexuality decisions.Early parentadolescent bonding and communication about SRH matters may hold the potential of developing adolescents toward healthy and productive adulthood.Sexuality communication between parents and adolescents may help delay early sexual relationships, early sexual debuts, and thus, unplanned teenage pregnancies, sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS).Parents and legally acceptable relatives need to play a key role in initiating SRH communication with their children using real-life critical incidents, experiences, and or problems that might not make them feel shy before, during, and after conversations.Thus, effective support particularly through sexual education interventions and comprehensive family life education should be given priority among adolescents and parents to promote their sexual health.

Strengths of the Study
This study has addressed a very important topic to reveal an unclear understanding of the prevalence of parentadolescent communication practices regarding SRH matters alongside associated determinants in Tanzania.The findings of this study may give a reliable and high probability estimate of the impact of PBP on enhancing parent-adolescent communication about SRH issues for safe sexual behavior among adolescents in Tanzania.

Limitations of the Study
Being a study that assessed sensitive topics and experiences of parent-adolescent communications about SRH matters among adolescents there might be some degrees of recall bias, under or over information from them, though not to a higher degree.Additionally, the methods and materials used in this study might not be sufficiently and accurately documented to allow replication studies.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Table 3 .
Determinants of Parent-Adolescent Communication About SRH Matters Among Adolescents.