A systematic review of effective parent-adolescent sexual and reproductive health information communication in lower- and middle-income countries

Background Parents play an important role in the sexual and reproductive health (SRH) of their adolescents. Parent–adolescent SRH information communication is cardinal and is expected to improve SRH outcomes of adolescents. Aim The aim of this systematic review was to search for effective SRH information communication interventions in lower- and middle-income countries (LMICs) to inform the adaptation of parent–adolescent SRH information communication intervention. Method This is the first phase of an explanatory sequential mixed method study. The systematic review was carried out by employing Joanna Briggs Institute software for reviews. Search sources included Cochrane Reviews Library, EMBASE, CINAHL, PubMed, OVID, Scopus, Web of Science and Science Direct. A systematic search strategy was formulated, making use of the key terms: adolescent, teenager, youth, parent, mother, father, caregiver, reproductive, sexual, health, information, communication and intervention. Results Five articles met the inclusion criteria for full-text screening. The interventions included addressed sociodemographic covariates; parent–adolescent general communication; parental monitoring; parent–adolescent communication about sex-related topics; parent’s sexual communication skills; parent’s self-efficacy in sexual communication; parent’s responsiveness to sexual communication; communication frequency; quality of sex‑related communication and information-motivational-behavioural skills. Conclusion Findings suggest that evidence-based SRH information communication interventions are effective in improving parent–adolescent SRH information communication to optimise safe SRH behaviour in LMICs. Contribution This systematic review identified effective SRH information communication interventions in LMICs, which can form the basis of further qualitative exploration for adaptation of a culturally sensitive intervention in Ghana.


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Introduction
Adolescence is a period of transition between childhood and adulthood, which occurs between 10 and 19 years of age (World Health Organization 2017:2).Adolescents comprise one-sixth of the world's population and are considered a great resource for all societies.However, at this stage, they engage in risky sexual practices that expose them to poor sexual and reproductive health (SRH) outcomes (Seif, Kohi & Moshiro 2019:2), especially when there are no support systems that commensurate with their needs.
Most sexually active adolescents in lower-and middle-income countries (LMICs) experience poor SRH outcomes, which include sexually transmitted infections (STIs) including HIV/AIDS, unsafe abortions, and early and unwanted pregnancies (Feroz et al. 2021:2).Also, adolescents are not well informed on SRH issues, with their major source of information being their peers (Kusheta et al. 2019:2).The information they receive from their peers may be inaccurate.
Most adolescents do not seek SRH information before they become sexually active.Their choice of sources of information may depend on the perceived knowledge of sex and confidentiality of Background: Parents play an important role in the sexual and reproductive health (SRH) of their adolescents.Parent-adolescent SRH information communication is cardinal and is expected to improve SRH outcomes of adolescents.
https://www.hsag.co.zaOpen Access the source (Muhwezi et al. 2015:2).Parents as a source of information on SRH for adolescents remain underutilised in LMICs, considering how sensitive a subject it is and the sociocultural issues that surround such discussions (Zakaria et al. 2019:2).There is a perception that the information on SRH will lead to early initiation of sex and encourage adolescents to be promiscuous (Baku, Agbemafle & Adanu 2017:10;Mekonen et al. 2018:5).
Parent-adolescent SRH information communication has gained attention currently and has been found to be one of the strategies that may improve the SRH of adolescents (Kusheta et al. 2019:1).This SRH information communication between adolescents and their parents or guardians has been described as important (Othman et al. 2020:314).Globally, there is agreement about the value of improved parentadolescent SRH information communication to advance healthy sexual behaviours among adolescents.Adolescents who can communicate with their parents on SRH matters are more likely to avoid the consequences of early initiation of sexual practices (Muhwezi et al. 2015:2).For instance, in Europe and Asia, there is evidence that interventions that trained parents and adolescents in how to communicate SRH information improved their information communication skills and enabled them to communicate SRH information comfortably (Baku et al. 2017:12;Dilorio et al. 2007Dilorio et al. :1086;;Phetla et al. 2008:504;Schuster et al. 2008:6).
The need for interventions to harness and promote parentadolescent SRH information communication has been highlighted, because of identified low levels of such forms of communication in LMICs (Bogart et al. 2013:7;Coetzee et al. 2014:315).A systematic review conducted in humanitarian and LMIC settings described and evaluated SRH interventions for young people to understand the SRH and psychosocial components of interventions that are effective for improving SRH outcomes (Desrosiers et al. 2020:1-21 (Meherali et al. 2021:363-390).It is worth observing that these two studies focused not only on adolescents but also included some groups of older people; their needs may be different.Also, the focus was not on parent-adolescent SRH information communication.This creates a gap that makes this study relevant.Findings from this review can help inform the adaptation of a culturally sensitive parent-adolescent SRH information communication intervention, to enhance parent-adolescent communication in Ghana, which is a LMIC.This is necessary because in Ghana, parents who attempt to discuss SRH issues with their adolescents as well as adolescents who also attempt to discuss issues regarding sexuality with their parents have been described as feeling uncomfortable or awkward and need to be effectively equipped to handle such sensitive issues (Baku et al. 2018:10).

Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the JBI manual guided the conduct of this systematic review.The review was prospectively registered in the PROSPERO database with registration number CRD42022297526.

Assessment of methodological quality and/or critical appraisal
Selected studies were critically appraised by F.B.A. and D.K.K. independently using the Joanna Briggs Institute standardised critical appraisal tools (Munn et al. 2020(Munn et al. :2128)).

Data extraction and synthesis
Standardised data such as authors, study aim, participants, and setting and additional information regarding the intervention components and outcomes were extracted from each study.A narrative synthesis approach was used to synthesise data because of diversity in the study outcome and the approach of interventions.Findings were therefore analysed by outcomes measured and components of interventions.

Ethical considerations
This study was approved by the health research ethics committee of a University in South Africa with reference number, S21/08/159 on 6th January, 2022 and renewal and extension was further granted on 6th January, 2023.

Results
Results of the search strategy have been summarised on the PRISMA Flow Chart (see Figure 1).The literature search through all the databases used yielded 1706 results.
After the title and abstract screening of the studies, 13 were included.Eight studies were excluded after full-text screening and five were included for the narrative synthesis. Source:

Study characteristics
The study sought to identify effective interventions to improve parent-adolescent SRH information communication.
Two studies emerged from Iran (Ahari et al. 2020

Intervention delivery
This section provides information on how the various interventions were delivered to parents and/or adolescents.

Intervention components
The intervention components are the individual parts or features that influenced the outcomes of the various interventions identified in the review.
The intervention components that were included in the study by Ziaei et  In all the identified studies, communication skills stand out in these components as the determinant of information communication, also influenced by factors such as the SRH topics discussed and attitudes towards SRH information communication.These have been developed and expanded in the themes given here.

Topics discussed in sexual and reproductive health communication
This refers to the information that was shared between parents and their adolescents.Various topics were discussed across the included studies.In Katahoire et al. (2018:91-104) Ahari et al. (2020:1-8) did not directly mention all the topics that were discussed; however, it could be deduced that the discussion centred on body changes during adolescence, abstinence and reducing sexual risks.In Ziaei et al. (2017:1-9), participants were taught how to answer girls' questions concerning matters such as pregnancy, childbirth, delivery of a baby, masturbation, methods of contraception, STIs including HIV and/or AIDS, hepatitis and protection against sexual abuse.
Certain topics were not discussed in some studies, probably because of how sensitive those topics are in relation to the prevailing cultural values of a particular setting.

Attitudes towards sex-related communication
One of the communication subthemes of the various interventions was attitudes.This refers to what personally or socially motivates parents and/or their adolescents to communicate.All the studies measured the attitudes of either parents or adolescents towards SRH information communication (Ahari et al. 2020:1-8;Bogart et al. 2013:602-608;Katahoire et al. 2018:91-104;Seif et al. 2019:1-13;Ziaei et al. 2017:1-9).
The improvement in skills led to an increased frequency of communication, which is one of the indicators of the impact of the intervention.

Effectiveness of interventions
Effectiveness refers to the degree to which the interventions were successful in maximising parent-adolescent SRH information communication.
The five studies identified reported improvement in outcomes related to SRH information communication.All the studies were randomised control trials, except for Seif et al. (2019:1-13), which used a quasi-experimental approach.Bogart et al. (2013:602-608) tested whether 'Let's Talk', a worksite-based parenting programme, improves parentchild communication about HIV and sexual health, as well as parent condom use, self-efficacy and behaviour.Regarding the communication on sexual health and HIV, results after the intervention delivery showed that there was a statistically significant difference (p = 0.005) in the pre-to-post increases in the intervention means compared with the control means.
The number of new topics discussed as baseline was greater among intervention parents (M = 5.9, standard deviation [SD] = 4.7) than among the parents in the control group (M = 2.8, s.d.= 3.6; p < 0.001).Seif et al. (2019:1-13) assessed the effect of an intervention aiming to improve caretaker-adolescent communication on SRH matters, through improving information, motivation and behavioural skills related to SRH communication.It was found that SRH communication in the experimental group was significantly greater than the control group in statistical terms F(1,827) = 16.74;(p ≤ 0.01) albeit with a small effect size (d = 0.3), which shows that there is a nonoverlap of 21.3% in the two distributions.At 6 months, the results showed a statistically significant difference between the experimental and control groups, which favoured the former F(1,827) = 17.9; (p < 0.001) albeit, also with a small effect size (d = 0.3).At 1 year follow-up, the results still demonstrated a statistically significant difference that favoured the experimental group, with a small effect size (d = 0.4).The marginal increment in Cohen's d may highlight that the longer the participants receive and practice the intervention, the more they are influenced by it.This may translate to improved outcomes.Ziaei et al. (2017:1-9) determined the effect of group counselling based on communication skills of mothers, through their sex dialogue with their daughters.It was found that there was a statistically significant difference in the mean score of mother-daughter dialogue on sex one week after the intervention, between the intervention (34.48 ± 8.74) and control (40.44 ± 9.49) groups (p = 0.001), and 1 month after the intervention, between the intervention (30.41 ± 10.07) and control (42.47 ± 9.62) groups (p < 0.001).Katahoire et al. (2018:91-104) examined the effect of a schoolbased intervention aimed at improving aspects of parent or caregiver-adolescent communication on sexuality.Regarding the quality of sex-related communication, in terms of openness and parental competence, the results showed that there were significant effects among parents or caregivers as well as among the students.
The effect sizes were 0.36 (t = 5.162; p < 0.001) (parents or caregivers) and 0.26 (t = 5.279; p < 0.001) (students).The study assessed the attitudes towards SRH communication and found that there was a significant difference between the two groups on positive attitudes with effect sizes equal to −0.31 (t = 4.424; p < 0.001) for parents or caregivers and 0.20 (t = 2.772; p = 0.006) for students.In the intervention group, the reduction in negative attitudes towards sex-related communication was significantly greater than in the control group, with effect sizes equal to −0.17 (t = 2.349; p = 0.019) parents or caregivers and −0.19 (t = 2.662; p = 0.008) for students.
Ahari et al. (2020:1-8) evaluated the effectiveness of a sexuality education programme for parents of male adolescents to promote parent-adolescent sexual communication.It was noticed that the mean scores of parent-adolescent communications about sex-related topics, parent's sexual communication skills, parent's self-efficacy for sexual communication and responsiveness to sexual communication increased in at least one of the stages (from the baseline to first and second follow-up) in the intervention group, and that all were statistically significant between the two groups.
The researchers conducted a Bonferroni test for pairwise comparisons of the three stages (from the baseline to the first and second follow-up).They found that the mean differences in parent-adolescent communication about sex-related topics and parent self-efficacy for sexual communication proved that parents in the intervention group had greater improvement throughout all three stages (from the baseline to first and second follow-up p < 0.001; from the first to second follow-up p < 0.05).With regard to parents' SRH communication skills and their responsiveness, those in the intervention group showed higher mean score changes at the first and second follow-ups than the baseline (p < 0.001 for each) but this did not remain statistically significant from the first follow-up to the second (p = 0.90 and p = 0.31, in the order mentioned).
https://www.hsag.co.zaOpen Access The effectiveness of these interventions could have been influenced by factors such as the components of the interventions and how the interventions were delivered.

Summary of findings
In summary, the study sought to identify effective interventions to improve parent-adolescent SRH information communication that optimise safe and healthy SRH behaviour in LMICs.The findings highlight that the identified interventions were effective in improving communication.This behavioural change was influenced by the improvement in SRH communication skills, which was evidenced by the improved quality and self-efficacy regarding SRH communication.Sexual and reproductive health communication skill was influenced by the SRH information communicated and participants' motivation to communicate, expressed as attitudes in most of the studies.This has been presented as a conceptual framework to understand how behavioural change was influenced by the indicated factors (Figure 2).
Regarding the information communicated to recipients of the various interventions, it was also observed that most of the topics were similar, with a few exceptional topics such as alcohol and drug use, sex exchange for gifts, dating and masturbation.It was also significant that Bogart et al. (2013:602-608), Katahoire et al. (2018:91-104) and Ziaei et al. (2017:1-9) reported on studies that included both parents and adolescents.Interventions that educate both parents and adolescents are beneficial; communication should not only be initiated by parents but also by adolescents.
Communication will be sustained when both parties have the skill to do so also knowing that, in the end, it will optimise safe and healthy sexual behaviour among adolescents.

Discussion
The aim of this review was to identify effective interventions to improve parent-adolescent SRH information communication that optimise safe and healthy SRH behaviour in LMICs.
Considering the differing nature of these SRH issues, it may be difficult to draw stronger conclusions regarding the overall effects of the interventions.Additionally, the small effect numbers reported across some studies may highlight a need for cautious interpretation of the review findings.These caveats notwithstanding, the review findings suggest that interventions focused on information communication may be able to improve parent-adolescent SRH information communication.
Most of the studies involved both parents and adolescents in the communication process, and both parents and adolescents were trained.This is effective in promoting communication that can be started by any of the parties.An adolescent may have a need that must be communicated and that cannot wait for the parent to initiate the communication, and vice versa.
Involving both parents and adolescents has proven to be effective in the studies identified in this systematic review and other studies (Widman et al. 2016:55).Parent-based studies identified in this systematic review were also effective in optimising communication between them and their adolescents.This also concurs with a study by Santa Maria et al. (2015:39).When parents are well-trained, they can recognise the needs of their adolescents and communicate effectively.This makes them more assertive in supporting their adolescents.Besides, increasing knowledge can improve their self-efficacy in breaking out of the societal code of secrecy surrounding issues of sexuality.Most of the identified studies used a variety of methods to deliver interventions, such as lectures, role-play and discussions.This correlates with the fact that most intervention studies in this area make use of such delivery methods (Aninanya et al. 2015:3;Mathews et al. 2016Mathews et al. :1830)).What remains unknown, however, is the impact of each individual mode of delivery on outcomes, considering the sensitive nature of sexuality issues.It was also found in the review that interventions were delivered by teachers, nurses and experts in adolescent health.Generally, intervention studies involving adolescents make use of experts in adolescent health and those who directly care for adolescents.Similar findings were observed in other studies (Ross et al. 2007(Ross et al. :1947)).(Bastien, Kajula & Muhwezi 2011:12-13;Forehand et al. 2007Forehand et al. :1125Forehand et al. -1127)).

Personal moƟvaƟon and Social moƟvaƟon
A variety of SRH topics were discussed in each of the interventions identified in this review.This helps the parents, and their adolescents, to get information on the topics and how to discuss such topics with each other.
The study also shows that the various interventions improved self-efficacy and quality of communication.This was shown in the openness and comfort associated with talking about issues of sexuality.This finding is not different from other study findings.In evaluating a parent-based programme in a similar study, it was noticed that there was parental comfort in communication (Klein et al. 2005:S97).It also corroborates the study by Barr, Johnson Moore and Howard (2012:259-260), which was a pilot project to increase parents' comfort in communicating with their children about SRH.
The frequency of communication on SRH was another finding of the review.Generally, interventions on sexuality communication increase the rate at which parents and their adolescents communicate on SRH matters (Forehand et al. 2007(Forehand et al. :1127;;McKay et al. 2004:88).This showed a positive attitude towards communication on SRH matters.
The identified interventions that trained parents and/or adolescents were effective in improving parent-adolescent SRH information communication.These interventions can be adapted by countries within the LMICs and be made culturally appropriate for the context.An SRH information communication intervention that is relevant in context may improve SRH outcomes.Therefore, the findings in the study could inform policymaking and further research that can lead to the adaptation of these interventions within a specific culture.

Limitations
Only studies reported in English were considered; other studies in other languages were therefore excluded.The focus only on quantitative studies could not bring conceptual depth and rich information regarding the feasibility and acceptability of the various interventions.The study was restricted also to interventions in LMICs.The search was limited to randomised controlled trials (with the exception of quasi-experimental studies).The researchers limited the age of adolescents to 13 to 16, which may have excluded some effective SRH interventions for younger or older adolescent populations.

FIGURE 2 :
FIGURE 2: Conceptual framework of sexual and reproductive health information communication skills as deduced from the study.
review offers a comprehensive summary of effective parent-adolescent SRH information communication interventions in LMICs.It highlights the components of the identified interventions, thematic analysis of the intervention delivery characteristics, frequency, quality, attitudes towards communication on SRH and communication skills.The findings of the systematic review provide information that can guide the adaptation of a culturally sensitive parentadolescent information communication intervention in the context of Ghana, which is a LMIC and can also inform stakeholders' decisions to further invest in the adaptation of interventions.This can broaden the understanding of healthcare providers and policymakers about what works most effectively in improving SRH outcomes.

TABLE 1 :
Characteristics of included studies -Quasi-experimental study form.

TABLE 2 :
Characteristics of included studies -Randomised controlled trial form.
The discussion will address those who received the interventions, the frequency of sessions, the length and duration of the interventions, and the methods used to deliver the interventions.It also addresses those who delivered the interventions and the settings where the interventions were delivered.
Regarding the methods of delivery, most interventions used more than one delivery method, including lectures, role plays, group discussions, posters and games.Apart from these delivery methods, in the study byKatahoire et al.  (2018:91-104)andBogart et al. (2013:602-608), take-home assignments were given.
In their review, they found that participants in the intervention group of the studies were 68% more likely than those in the control group to report increased SRH communication, and 75% more likely to report increased comfort.Most interventions in parent-adolescent SRH communication have proven to be effective both in LMICs and advanced countries