Parent-youth communication and associated factors on HIV/AIDS related issues in rural southern Ethiopia

Abstract

Background

In 2023, an estimated 39.0 million people globally were living with HIV, with young people aged 15–24 disproportionately accounting for 40% of new adult infections concentrated in sub-Saharan Africa, highlighting significant SRH challenges and risky sexual behaviors among youth worldwide. Parental communication plays a pivotal role in fostering positive sexual and reproductive health (SRH) outcomes, including HIV/AIDS. This study, conducted among rural South Ethiopian secondary schools, aimed to measure the extent of parental communication on HIV/AIDS-related matters and identify the factors influencing it.

Methods

Using a cross-sectional, school-based design, data were gathered through a self-administered questionnaire, employing a clustering-based technique to select 577 youths from different schools. The analysis involved descriptive statistics, binary analysis, and multivariable logistic regression. Variables with a significance level of p-value ≤ 0.25 in the binary analysis were included in the logistic regression model. The adjusted odds ratio (AOR) at a 95% confidence interval (CI) was utilized to indicate independent factors.

Results

The study revealed that 39% (95% CI = 35.02% to 42.98%) of youths experienced poor communication on HIV/AIDS related issues with their parents. Youths whose mothers could only read and write were 2.7 times more likely (AOR = 2.77; 95% CI: 1.23–6.25), and those whose mothers had only attended primary school were 4.6 times more likely (AOR = 4.63; 95% CI: 1.97–10.9) to have had poor communication compared to youths whose mothers had a secondary school education or higher. Additionally, youths whose mothers were housewives (AOR = 0.34; 95% CI: 0.16–0.71), merchants (AOR = 0.22; 95% CI: 0.09–0.50), or farmers (AOR = 0.23; 95% CI: 0.10–0.53) were 66%, 78%, and 77%, respectively, less likely to experience poor communication compared to youths whose mothers were daily laborers.

Conclusion

This study underscores that a considerable proportion of youths in South Ethiopia face challenges in HIV/AIDS related communication. The findings advocate for targeted literacy interventions, particularly addressing mothers with lower educational status and those employed as daily laborers, to enhance SRH outcomes among rural adolescents. HIV/AIDS related information dissemination and co-production of literacy materials should be emphasized among rural settings.

Introduction

At the end of 2023, the global HIV prevalence was estimated at 39.0 million, within a range of 36.1 to 44.6 million. While global figures from 2019 indicate approximately 1.7 million adolescents were living with HIV (95% CI: 1.1–2.4 million), young people aged 15–24 account for a disproportionate 40% of new adult HIV infections. Notably, the vast majority of these new infections are concentrated within sub-Saharan Africa [1, 2]. Youths worldwide encounter various challenges related to sexual and reproductive health (SRH), including HIV/AIDS, largely attributable to engaging in risky sexual behavior [3]. Studies conducted in diverse countries have shown a range of SRH issues and their repercussions among adolescents. For example, Campo-Arias et al. (2010) revealed that one in three high school youths in Colombia exhibited patterns of risky sexual behavior. Another study in Thailand reported a mean age of sexual initiation at 15.6 years [4, 5].

Parental communication concerning SRH has been associated with a decreased likelihood of engaging in risky sexual behaviors and an improved understanding of risk assessment and protective measures [6]. Adolescents who openly discuss SRH matters with their parents tend to demonstrate better outcomes in avoiding risky behaviors, such as early sexual initiation, unwanted pregnancies, and other reproductive health issues [5,6,7]. Although there is a minor difference in measurement, the practice of SRH related communications in low- and middle-income countries shows variability across different locations. For example, the prevalence of good PAC in Nepal was 43% [8], in Ghana 83% [9], in Malawi 73% [10], and in Uganda it was 61% [11]. Similarly, the prevalence of communication exhibits significant variation across urban areas in Ethiopia, ranging from 26 to 83% [12,13,14,15].

Factors such as cultural taboos, parental educational status, parental occupation, residence, and feelings of embarrassment play a significant role in SRH-related communication [4, 6, 10, 13]. Despite the Ethiopian government's establishment of an adolescent and youth health strategy, reproductive health problems, including HIV/AIDS, continue to pose challenges among young people in both urban and rural areas [4]. Several studies have been conducted in various urban regions of Ethiopia [10,11,12,13,14]. However, previous studies have primarily focused on general SRH topics and urban areas, with evidence remaining scarce in rural settings, particularly on HIV-related topics [4, 8]. Communication issues related to HIV/AIDS are dynamic, with their magnitude and contributing factors varying across settings, especially in rural context where parents literacy is lower and cultural context is not permissive This study aims to address this gap by exploring the prevalence of poor parental communication on HIV/AIDS-related issues among school youth in rural southern Ethiopia.

Methods

Study design and setting

This study employed a cross-sectional, school-based design, utilizing a quantitative method to assess the extent of parental and youth communication and associated factors among high school youths in Bolosso Sore district, one of the most populated areas in South-Ethiopia. The total population of the district was 206,582 in 2021, with females constituting 51% of the population. In terms of education, there are 43 primary schools and 5 secondary schools offering grades 9–12. Additionally, the district is equipped with 8 health centres and 28 rural health posts to cater to the healthcare needs of the population. Agriculture is the predominant source of income in the district [16]. The data collection period spanned from September to October, 2022.

Study population and sampling procedures

We included youths from grades 9–12 from all five secondary schools in Bolosso Sore district to participate in our current study. These schools were Gurum Koysha, Woybo, Gara Godo, Hembecho, and Achura. The primary reasons for selecting these particular schools were their location and alignment with the age range of our target study population. A cluster sampling technique was used to select the study participants. First, students were clustered based on their grade level. Then, proportional allocation was made to the schools within the district and, similarly, to each grade within each school. The calculated study population comprised 583 youth students in grades 9–12 enrolled for the 2022 academic year from all five secondary schools in Bolosso Sore district. All youths present in the selected classes during the data collection period were invited to complete the questionnaire. Youths who were unwell or absent during this period were excluded from our study.

Data collection techniques

We designed a self-administered questionnaire based on data from related literature, modified to adhere to local contexts [5, 12, 15]. Opting for a self-report method was intentional, providing participants the freedom to respond without the burden of judgment [17]. The questionnaire was initially drafted in English, then translated into “Wolayitta Doonaa”, the local language, and subsequently translated back into English to ensure consistency in meaning. To preserve data quality, the “Wolayitta Doonaa” questionnaire underwent a pretest on 5% of the study population at a secondary school in Areka town. Five diploma nurses and one supervisor with a degree in public health and experience in data collection facilitated the data collection process. These data collectors received two days of training.

Study variables

The dependent variable of this study was parental communication with youth on HIV/AIDS related topics. This was tested with 3 interrelated questions using three items: about HIV/AIDS transmission, abstinence, and condom use. The independent variables can be divided into sociodemographic, psychosocial, and perception-related variables. The sociodemographic variables describe the population studied, psychosocial factors refer to both its social environment and psychological state, and the perception-related variables describe what participants think of an issue. Parental youth communication on HIV/AIDS matters was said “good” if the participant responded “yes” to at least two out of the following three items, (1. Have you ever discussed with parents regarding HIV/AIDS transmission? 2. Have you ever discussed on abstinence with parents? Have you ever discussed on condom use with parents?), otherwise labelled as “poor” communication [12, 18, 19]. Comprehensive Knowledge on HIV/AIDS was assessed using three questions for HIV prevention and five questions regarding local misconceptions on HIV prevention and transmission methods, respondents who correctly respond three HIV prevention methods and had no any misconceptions regarding its transmission will labeled as having a comprehensive knowledge while the rest labeled as having no comprehensive knowledge [20].

Data analysis

The data were exported to IBM SPSS 27 for analysis and checked for completeness before any statistical analysis. All variables were presented using descriptive statistics, such as frequencies and proportions. Percentages were rounded up or down depending on the digits behind the decimal point. Bivariate analysis was used to determine which study variables were significantly associated with the outcome variable. Cross-tabulations and chi-square tests were the statistical measuring methods used and a p-value ≤ 0.25 was the significance level, as supported by literature [9, 13, 14], and variables that were statistically significant in chi-square test were considered as candidates for the multivariable logistic regression. Adjusted odds ratios (AOR) at 95% confidence level (CI) used to indicate the significant independent associated factors by controlling the effect of possible cofounders.

Results

Sociodemographic result

The response rate was 98.9%. Out of 577 participants in the study 198 (34%) were females (Table 1). The majority were male (66%) and between 15–19 years (93%). The minimum age was 15 and the maximum 27 years. The parents of most of the study participants could not read and write, 48% and 51% for fathers and mothers respectively, followed by those who could read and write, but without having had formal education, 22% and 25%.

Table 1 Socio demographic characteristics of rural school adolescents in Bolosso Sore district of Southern Ethiopia, 2022

HIV/AIDS related comprehensive knowledge

From all study participants, 134 (23.2%) did not mention that abstinence can prevent getting HIV/AIDS, whereas 205 (35.5%) of study participants were not knowledgeable that using a condom during all sexual intercourse prevents getting HIV/AIDS. Almost half, 286 (49.6%), of the adolescent youths responded that HIV/AIDS patients could be detected by observing body build/external physical appearance. An alarming number of adolescent students, 281 (48.7%), did not know that avoiding sex with commercial sex workers helps to prevent getting HIV/AIDS (Table 2).

Table 2 Participants comprehensive knowledge on HIV/AIDS among rural school adolescents in Bolosso sore district of Southern Ethiopia, 2022

Magnitude of parental youth- communication on HIV/AIDS related issues

Out of the total 577 study participants, almost two-fifth, 224, (39%) (95% CI = 35.02% to 42.98%) had poor parental youth communication on issues pertaining to HIV/AIDS. Among the three questions, HIV/AIDS transmission is the least discussed topic, with only 195 (34%) participants mentioning it, followed by discussions on abstinence and condom use (Table 3).

Table 3 Communication with parents on HIV/AIDS topics among rural school youths in Bolosso Sore district of Southern Ethiopia, 2022

Factors associated with parent adolescent communication

In bivariate analysis age, father’s educational status, mother’s educational status, mother’s occupation, and level of awareness of HIV/AIDS were the only significantly associated with the dependent variable. All those variables that have shown a significant association in bivariate analysis were included in multivariable logistic regression. Among those in multivariate logistic regression, mother’s educational status, mother’s occupation, and level of HIV/AIDS awareness were significantly associated with PAC. The odds of youths having poor parental communication on HIV/AIDS related issues are 2.77 times higher for youths whose mothers can only read and write compared to youths whose mothers have a secondary school education (AOR = 2.77; 95% CI: 1.23–6.25).And youths whose mothers are housewives (AOR 0.34; 95% CI: 0.16–0.71), merchants (AOR 0.22, 95% CL: 0.09–0.50) and farmers (AOR farmer 0.23; 95% CI: 0.10–0.53) were 66%, 78%, and 77% respectively less likely to have had HIV/AIDS related communication than youths whose mothers are daily laborers. Those adolescents with poor HIV/AIDS knowledge tends to have poor parental communication (Table 4).

Table 4 Multivariable logistic regression analysis of factors associated PAC among rural school adolescents in Bolosso sore district of Southern Ethiopia, 2022

Discussion

This study aimed to evaluate the prevalence of parental youth communication on HIV/AIDS-related issues and the associated factors among secondary school youths in the Bolosso Sore district, South Ethiopia. In general, about four out of ten (39%) youths exhibited poor communication. A significant number of adolescents had poor knowledge of HIV/AIDS; for example, about half of the youths (49%) did not mention that avoiding intercourse with commercial sex workers can prevent HIV/AIDS. Factors such as maternal education and occupational status played a key role in this process. Additionally, comprehensive HIV/AIDS-related knowledge is associated with parental youth communication.

The results of this study revealed that almost four out of ten (39%) school adolescents had poor HIV/AIDS-related communication. This finding is consistent with findings from Uganda (39%) [11] and other parts of Ethiopia: 38.7% in Agaro, 40.9% in Yirgalem, and 42.4% in Mekelle town [19, 21, 22]. However, this result was lower than that found in studies from Nepal (57%) [8] and other studies in Ethiopia [14, 23]. The difference may be due to the measurement tools used, the time difference, or the settings. In contrast, the poor communication in this study is higher than in studies conducted in Ghana (17.7%) and Malawi (26%) [9, 10]. These discrepancies may be due to differences in the methods used, sample size, and socio-cultural settings. For example, in the Ghanaian study, parents and their adolescent children were interviewed, and discussion of at least one SRH-related topic was used as the cutoff [9]. These disparities in prevalence collectively demonstrate how SRH-related communication is subject to cultural and contextual variations, which is why interventions aiming to improve the SRH prospects of youths and adolescents must be tailored to the specific context.

Regarding SRH topics, about one-third (34%) of the participants didn’t discuss issues related to HIV/AIDS transmission with their parents. Questions about abstinence as a prevention method, HIV transmission through sharp materials, and mother-to-child transmission had the highest number of correct responses among all questions about HIV/AIDS. This is in line with other studies conducted elsewhere [12, 13, 19, 24]. It is reasonable to attribute this trend to the high prevalence of HIV/AIDS in LMICs and the associated life-threatening nature of the disease. However, this finding is also consistent with the prevailing pattern observed in the cultural context of sub-Saharan Africa, where discussions tend to focus on the negative aspects of SRH, along with warnings and scare tactics [25]. Sex is not discussed as a natural experience, and discussion on contraceptives is avoided to discourage sexual activity [15]. A reconstruction of the nature of communication on SRH issues in this particular context is necessary to create an open discussion environment surrounding SRH issues.

However, an alarming number of youths (48.7%) didn't mention avoiding sex with commercial sex workers to help prevent getting HIV/AIDS. This indicates that even though HIV/AIDS transmission is a commonly discussed topic, the association with commercial sex workers is not mentioned, either due to a lack of comprehensive knowledge among parents or due to the fear of discussing commercial sex workers, which is a taboo in the community. Parents might also fear that mentioning commercial sex workers could potentially push adolescents towards experimentation [26].

The multivariate logistic regression model revealed that the mother’s educational status, occupation, and level of awareness of HIV/AIDS were significantly associated with HIV/AIDS-related communication. Youths whose mothers could only read and write, and those whose mothers had completed primary school, were about three and five times more likely, respectively, to experience poor communication compared to youths whose mothers had a secondary school education. These findings are consistent with studies conducted in various areas [17, 22, 23, 27]. A possible explanation for this is that more educated parents often have better access to health-related information, making them more knowledgeable and confident in discussing SRH issues with their adolescents [5, 15, 24]. Evidence also indicates that parents who lacked SRH information during their adolescence are more likely to pass this gap to the next generation, resulting in their children also growing up without adequate SRH information. Since the primary barriers to communication on SRH issues stem from a lack of parental capacity in various areas, targeted efforts should focus on educating and training parents to improve their SRH knowledge and communication skills [25].

Youths whose mothers were housewives, merchants, and farmers were less likely to have had poor communication than youths whose mothers were daily laborers. These findings contradict previous studies that did not identify parental occupation as a significant independent influencing factor [14, 19]. There is, however, another factor that has been found to be significant in other studies – the level of income. A positive association has been shown between a higher family income and the occurrence of communication on SRH issues [12, 14] among young people. This suggests that occupations with higher salaries, such as merchant, are more likely to facilitate communication. On the other hand, merchants and farmers tend to be self-employed and are not subject to the long working hours and demands of employers, as daily laborers are. Merchants, farmers, and housewives have space to prioritize family life, including communication with their children [25, 26]. Therefore, parental employment should be considered when designing community interventions.

Discussions on SRH matters between mothers and youths have even been found to be strongly associated with safe sexual practices among adolescents [28]. This may be because mothers are generally the preferred gender for discussing SRH issues, as they have been found to instill trust in their children, making mother-related factors important in HIV/AIDS-related communication [20, 24]. Mothers should therefore be empowered by providing them with community-based education and training on SRH issues.

In addition, the odds of having poor communication were 1.9 times higher for youths who were not considered knowledgeable about HIV/AIDS than youths who were knowledgeable (AOR = 1.90; 95% CI: 1.31–2.76). This is consistent with findings from other studies where a positive association was found between knowledge of SRH matters and parental communication [12, 24, 29]. Sievwright, K.M. et al. also found that PAC about SRH matters increased pregnancy knowledge in female respondents and the odds of using contraception [30]. A possible explanation is that adolescents who know about SRH issues are more aware of the consequences and are more likely to start talking about SRH with their parents [29, 31].

This study had several noteworthy strengths as well as a few weaknesses. The strengths encompass a high response rate, the inclusion of both sexes, the utilization of validated instruments to construct the survey, and the administration of the survey in the local language. These aspects contribute to the study’s reliability. In addition, this study emphasized HIV/AIDS-related issues, whereas previous studies focused on general SRH-related topics. The limitations, on the other hand, include the lack of generalizability of the data due to the specific study context. Furthermore, the subjective nature of self-reporting renders it susceptible to potential errors. For instance, respondents’ subjective interpretations, memory biases, and tendencies to provide socially desirable responses, considering that the study explores culturally sensitive information, can all contribute to inaccuracies in the reported information. In addition, those youths that were absent or dropped from the school were not included in this study. In addition, we observed wide confidence intervals of some estimates. Hence, future studies with larger sample size and balanced categories are advised. In addition, the casual pathways cannot be determined using such cross sectional studies.

Conclusion

This study reveals a concerning lack of parental-youth communication regarding HIV/AIDS among South-Ethiopian secondary students, highlighting the impact of cultural and socioeconomic factors, particularly maternal education and occupation, on this crucial dialogue. The findings underscore the significant role mothers play in these discussions, while also pointing to the necessity of enhancing parental knowledge and communication skills on sexual and reproductive health (SRH) issues. Community-based educational programs that empower mothers are proposed as a vital strategy for improving HIV/AIDS prevention and control, emphasizing the urgent need to address SRH communication gaps in culturally similar low-income settings. Future qualitative studies are recommended considering cultural factors influencing parent youth communication and also taking in to account school dropout students. Furthermore, since associations in this study are correlations, and future longitudinal or interventional studies are needed to explore potential causal pathways.