Adolescent–parent communication about sexual and reproductive health among junior high school students in five areas with the highest prevalence of HIV in Indonesia: A qualitative study

Abstract

Objective

To explore female adolescents’ perceptions of their communication with their mothers on the topics of sexuality and reproductive health.

Method

A qualitative methodology was used for this study. Data were obtained via focus-group discussions involving 78 female junior high school students, aged 11–15 years. The data were analyzed using content analysis. This study was conducted in Papua, Bali, Jakarta, Riau, and Pontianak.

Result

Several themes: (1) knowledge of sexuality and reproductive health, (2) mothers as primary sources of information about reproductive health, (3) factors facilitating communication between adolescents girls and their mothers with mothers, and (4) problems faced by adolescent girls when discussing SRH.

Conclusion

Although mothers and daughters communicate freely about many topics; however, discussions of SRH occur infrequently. Parent-based approaches could be effective strategies, especially in terms of improving communication with daughters.

Introduction

The sexual and reproductive health of young people has become a major concern throughout the world. In Indonesia, for example, one significant issue is the rising rate of HIV/AIDS cases among adolescents. Data from the Ministry of Health show that approximately 12,279 women have been diagnosed with HIV and many of them may have contracted the infection as adolescents.¹ Therefore, as a part of the response to the HIV/AIDS epidemic, it is imperative to assess the current evidence regarding adolescents’ perceptions of sexual and reproductive health.

Adolescent girls should be informed about their sexual and reproductive health. Having adequate knowledge about female reproductive health can potentially delay the initiation of sexual activity among adolescents,² prevent risky sexual behaviour and sexually transmitted diseases, and avoid unwanted pregnancies that can lead to illegal abortions.³ Based on data from the Indonesian Population and Family Information Network,⁴ 58% of adolescents who experience unwanted pregnancies tend to have abortions, which can endanger both mother and baby. However, discussing sexual and reproductive health in several countries, including Indonesia, continues to be difficult for both parents and adolescents.^3,5,6 Thus, parents tend to avoid talking about sexuality with their adolescents.⁷

Parent–adolescent communication is essential because sexual activities begin at an early age.^8,9 The initial sexual encounter may be delayed if there is good communication with the parents. Through communication, parents have the potential to inform and to encourage young adolescents to delay their first sexual experience, to hone their communication skills, and to obtain information about contraception. A parent-based approach may be an effective strategy for reducing the number of teenage pregnancies and instances of sexually transmitted infection.⁹

Although parents expect their children to learn about reproductive health and sexuality from their schools, that subject is not taught in Indonesian schools. The most relevant subject is biology, which discusses reproductive health. However, it does not specifically address sexuality or intimate relationships between males and females.³ Therefore, adolescents tend to talk about sexuality with their peers, who do not have a better knowledge about reproductive health. This condition may lead to the spread of inaccurate information¹⁰ or inadequate information about reproductive health and therefore may generate false perceptions about the early initiation of sexual activity.¹¹ One survey showed that only 4% of teenagers know that, on average, adolescents experience increased sexual libido.¹⁰

A primary concern regarding adolescents is their risky sexual behaviour. Adolescence is characterized by significant physiological, psychological, and social changes that place them in risky sexual situations. As they grow into adulthood, adolescent sexual desire may eventually increase, leading to unprotected sex, early pregnancy, or a sexually transmitted infection, including HIV. Based on a 2014 Ministry of Health report, 55,779 people with HIV (PLWH) lived in Indonesia during the years 1987–2014, with 33% of these aged 20–29 years. The number of women living with HIV in Indonesia has increased significantly, from 3566 in 2008 to 12,279 in 2013. In 2014, the highest age range of PLWH living in Indonesia was 20–29 years, which indicates that they were infected with HIV at a young age. Teen girls are at a higher risk of getting HIV than boys, because their sexuality, including secondary sexual and biologic aspects, develops faster than that of boys. One survey showed that 17% of teen girls agreed to have a sexual relationship before marriage.¹⁰ Increasing sexual activity among teens can lead to an increase in unwanted pregnancies, abortions, and HIV/AIDS.

Few studies have investigated sexual and reproductive health among girls in Indonesia. The main purpose of this study, therefore, was to explore adolescents’ perceptions of sexual and reproductive health, including their sources of information about puberty and factors that influence communication about SRH, and to determine the extent to which adolescents overcome problems related to discussing SRH.

Method

Narrative research allows adolescents to explore their perceptions about sexual and reproductive health. This study also explored factors affecting their reproductive health and how these affect their lives. We conducted five focus group discussions (FGDs) in five junior high schools in five areas of Indonesia featuring a high prevalence of HIV: Papua, Bali, Jakarta, Riau, and Pontianak. Each group comprised 15–17 participants with a total of 78 female adolescents. The inclusion criteria consisted of females aged 11–15 years who were students at a junior high school. The data collection ended when it reached the saturation point. The duration of each FGD was 60–90 min.

All FGD session were recorded and transcribed verbatim. All transcriptions were reviewed by research team members independently. In the review process, all research team members listened to the discussions and analyzed data based on similar patterns. All members of the research team then met and compared the coding and analyzed data; no discrepancies were found.

Results

The participants in this study were 78 adolescent females who were students at junior high schools in Bali, Papua, Riau, Pontianak, and DKI Jakarta (Table 1). The ages of the participants ranged from 11 to 15 years (Table 1).

Table 1.

Demography of participants (n = 78).

Variables	Frequency	%
Province
Bali	15	19.23
Papua	16	20.51
Pontianak	15	19.23
Pekanbaru	17	21.79
DKi Jakarta	15	19.23
Age (aged)
11	52	66.67
12	12	15.38
13	8	10.26
14	5	6.41
15	1	1.282
Grade
7	57	73.08
8	15	19.23
9	6	7.692
Religions
Islam	49	62.82
Christianity	13	16.67
Hinduism	15	19.23
Buddhism	1	1.282
Menarche		0
Tidak	75	96.15
Ya	3	3.846
Living with parents
Mother only	7	8.974
With both father and mother	71	91.03
Employment status of mother
Bekerja	16	20.51
Tidak Bekerja	62	79.49
Bekerja	16	20.51

Knowledge of sexual and reproductive health

The girls were asked about their sexual and reproductive health; topics included sexual diseases such as HIV. Reproductive health is viewed as menstruation and body changes. All girls agreed that their bodies had changed from childhood to adulthood. Moreover, all the girls were able to identify the body changes, such as menstruation, acne, oily skin, and wider hips that occurred as they entered adulthood.

With respect to sexual diseases, participants compared HIV to any other disease that can be cured by taking specific medication. One participant said, HIV is just like flu and can be cured.

Mothers as the main source of information about reproductive health

Participants in this study identified their mothers, siblings (sisters), health care providers, books, and the Internet as sources for information on reproductive health. However, most of the adolescent girls relied on the information from their mothers.

I get information from my mother because she also experienced the same pubertal changes when she was young.

I ask my parent—my mom—because she knows better than others.

Factors facilitating daughters’ communication with their mothers

The results showed that mothers are the most trusted people on which adolescent girls can rely for information about sexual and reproductive health because they feel close to their mothers and because their mothers have also experienced female pubertal changes.

I have a close relationship with my mom; I mostly ask her a lot of questions, and we have more time to chat.

Another participant mentioned that having open communication with her mother makes it easy for them to discuss such topics.

I have open communication with my mother; sometimes I spend time talking with her; I can ask her anything about the things I don’t know about my reproductive health.

Some participants mentioned that they had an open communication style with their mothers and therefore are comfortable discussing anything with them. As a result, they feel ready for, and comfortable with, pubertal changes, including their first menstruation.

Sharing some jokes with our mothers is essential. As a result, we don’t get bored or feel negative pressure when discussing sex with them. And also, we always get updated information about reproductive health from our mothers.

Problems faced when discussing SRH

The study also explored some of the general problems faced by adolescent girls when talking about their sexual reproductive health. Feeling Suggestion: “embarrassed” the idea of discussing sexual and reproductive health is one of the major problems faced by adolescent girls.

I’m too embarrassed to ask about reproductive health.

Another problem is that there are a limited number of books and other resources about sexual and reproductive health that can be used as sources of information for young people.

I do not have any books about reproductive health. There are minimal resources.

More importantly, in Indonesia it is taboo for young, unmarried people to discuss sexual and reproductive health, as was mentioned in this study.

I have never had a discussion about it with my parents, with the doctor, and I don’t read books or use the Internet because it is taboo for us, as young people, to talk about reproductive health.

Discussion

The study revealed that participants were more likely to have obtained information about sexual and reproductive health from their mothers. This may be because adolescent daughters feel close to their mothers (fellow women) and therefore feel that it is safe to talk about sexual and reproductive health with them. Consistent with other studies.¹² Mothers reported less sexual communication with their daughter. Similarly, a study in Ethiopia found that only 20% of them discussed reproductive health issues often with their adolescent children, while another 20% never discussed such issues with them.¹³ In general, the participants demonstrated the belief that they are supposed to communicate with their mothers. However, some of them may find it difficult to talk about their body changes and sexuality. Feelings of shame and embarrassment about their body changes cause them to feel too uncomfortable to discuss sexuality with their parents.¹⁴

In this study, adolescents perceived that open communication with mothers about sexuality and reproductive health issues is essential and should occur on a daily basis.^15,16 This is because all mothers expect the best for the future of their adolescent daughters. All participants expressed the feeling that their mothers know better about reproductive health due to their own experience as parents, a conclusion supported by Bo Hang, whose study investigated sexual and sexuality information in the mother–daughter relationship.¹⁷

This study found that the best way for mothers to build better relationships with their children is to start by having an openness and willingness to communicate. This study corroborates this with its finding that mothers need to demonstrate a more positive attitude regarding communicating with their adolescent daughters. Additionally, several studies have highlighted the importance of parental communication, which may influence the tendency of their adolescent children to engage in risky sexual behaviour.^14,18,19 On the other hand, adolescents who are exposed to social norms and dogma in their religion need to respect their mothers.

Several challenges confronting when discussing about SRH include resistance from parents, attitudes of adolescents, a communication gap between adults and adolescents, and attitudes of health care providers. In addition, adolescents also perceive good attitude from health care professionals, such as those who were helpful, nonjudgmental and nondictatorial

Having a close relationship with their mothers is one of the factors that influence the ability of adolescents to achieve good communication with their mothers. The participants in this study highlighted that trusting their mothers and having close relationships with them helped them to engage in open communication. This finding is similar to one obtained in a qualitative study in Tanzania, which found that a lack of connectedness between parent and adolescent was linked to young people's low levels of self-esteem and risky sexual behaviour, while unplanned pregnancies seriously undermined young women's connectedness with their parents.¹⁶

The results of the study reveal that having relaxed time and sharing some jokes when discussing sexual and reproductive health when discussing with parents is perceived to be important for daughters. Communication between mother and daughter about sexuality is more complex than that between mother and son. This means that discussions about reproductive health may differ based on the biological sex of the parent. Moreover, the content and intensity of such communication may vary based on both the biological sex of the parent and children.

Conclusions

It is clear that the topic about sexual reproductive health is rarely discussed by mother and daughter. The role of mother as the main resources for daughter can facilitated good communication with daughter.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This work is supported by Hibah PTUPT 2018 funded by Ministry of Research, Technology and Higher Education Republic of Indonesia No. 440/UN2.R3.1/HKP.05.00/2018.