An Exploratory Study of Parent-Adolescent Communication on Sexual Issues and HIV Prevention, at Otjomuise Clinic, Namibia

This research looks at parent-adolescent communication on sexual issues and HIV prevention at Otjomuise clinic in Windhoek-Namibia. The literature review showed that parent-adolescent communication about sexual issues and HIV prevention is rare especially in Africa because of lack of skills, information and cultural beliefs. The aim of the study is to investigate parental communication with their adolescents about sexual issues and HIV prevention. The Specific objectives were: To investigate whether parents communicated with their adolescents on sexual issues and HIV prevention. To explore type of information that was communicated. To determine challenges encountered in communicating with their adolescents. To seek suggestions from parents on how to improve communication between parents and adolescents regarding sexual issues and HIV prevention. Qualitative design was used. A total of 20 participants were purposively selected and semi-structured interviews were conducted for data collection. Thematic analysis was utilized for data analysis. The research revealed that some parents do discuss sexual issues and HIV prevention with their adolescents but not a lot. The information that they discuss is mainly abstinence. The challenges that parents encounter during discussions are lack of skills and information to initiate the discussion and cultural beliefs that do not expect a parent to discuss sexual issues and HIV prevention with their own children. Parents suggested two things in order to improve parent-adolescent discussions on sexual issues and HIV prevention: (i) That institutions like schools should provide education on sexual issues and HIV prevention. (ii) That the government should train the parents on how to discuss sexual issues and HIV prevention with their children The researcher recommends that parent-teachers associations be established so that parents can learn from teachers on how to discuss sexual issues and HIV prevention. Together teachers and parents can discuss on how to educate adolescents about abstinence plus any related issues.


Introduction and Background
This study was on communication between parents and their adolescent children between ages ten and nineteen concerning sexual issues and Human Immunodeficiency virus (HIV) prevention. The article starts with background to the study, problem statement and further discusses methodology of the study. The article also presents the findings, conclusion, recommendations and limitations of the study.
The study was done at Otjomuise Clinic, a poly clinic in Windhoek in Namibia. The estimated total population of Namibia is about two million and the first case of AIDS was reported in 1986. It is estimated that hundred and fifty nine thousand seven hundred and forty four adults over the age of 15 years are living with HIV//AIDS in Namibia (1,159,744). In Namibia adult patients are those reporting to health facilities aged from 13 years old and above [1,2] Adolescent is any person between ages ten and nineteen years [3]. Communication is the act of sharing or exchanging thoughts or information [4]. A parent in this study was any adult person, who was keeping, looking after and living in the same house with an adolescent child. This group of adolescents was targeted because they are particularly vulnerable to HIV infection. UNAIDS attribute this to risky sexual behaviour of being engaged in unprotected sexual intercourse, lack of information and preventive services or for economic, social and cultural reasons [5].
Adolescents look for new experiences which is the nature of their brain development and means that they are likely to seek out new experiences and engage in more risk-taking behaviours of drinking and substance abuse which would lead them to early onset of sexual intercourse [6]. They also start to develop and explore sexual identity and might make them start to have romantic relationships or start dating which can also lead to early onset of sexual intercourse which would expose them to HIV infection [7].

Problem statement and purpose
The Ministry of Health and Social Services and its developmental partners have done a lot in the prevention of HIV targeting specific groups: For example: Ministry of Health and Social Services through collaboration with many individuals, agencies and organisations developed guidelines for the prevention of mother-to-child transmission of HIV to provide the basis for a national standard of care to prevent mother-to-child transmission of HIV infections in all health facilities [2]. Schools educate children from age six to twelve about HIV prevention.
However adolescents in Namibia do not receive enough sexual education in order to protect themselves from HIV new infections the whole period of adolescence. Despite the importance of parentadolescent communication, many parents are reported to be uncomfortable talking to their adolescents about sexual issues. This is due to open mindedness of the adolescents after independence while parents still cling to conservative way of doing things which broadens the gap between parents and their children [8]. Therefore, the researchers wanted to explore what the parents discuss with their adolescents on sexual issues and HIV prevention, if they do so.

Study setting
The study was conducted at Otjomuise clinic. It is a township in northwest Windhoek, the capital and largest city of the republic of Namibia. The name refers to the hot springs near the city center. The reason Otjomuise was chosen was because of the reports of adolescents being involved in alcohol and drug abuse, teenage pregnancies and sexual working in the specific area

Study design
Research design is an overall framework or "blue print" or researcher's overall plan [9] for conducting a study. It is suggested that to choose a research design requires researchers to specify as clearly as possible what they want to find out and then determine the best way to do it [10]. Qualitative approach is described as "a systematic subjective approach used to describe life experiences and situations to give them meaning [11,12]. " This study adopted qualitative design. This approach was chosen because the researchers were exploring experiences of parents' communication with their children which required deeper understanding of the phenomena in question [13]. Quantitative design was not chosen because the purpose of the study was not to measure or looking for amounts of characteristics but rather exploring experiences of the participants in the study.
The following were the objectives of the study: • To investigate whether parents communicated with their adolescents on sexual issues and HIV prevention. • To explore the type of information that was communicated between parents and adolescents concerning sexual issues and HIV prevention and how communication was done. • To determine the type of challenges parents encountered in communicating with their adolescents. • To determine the type of suggestions parents had in order to improve parent-adolescent communication on sexual issues and HIV prevention.

Study population
Population refers to a group to which an investigation would like the results to be generalized [14,15]. In this study population was all parents that use the services of Otjomuise clinic and have adolescent children in their homes.

Sampling method
Literature states that, the researcher need to determine a sample from the population [16]. Sampling is the selection of subset of a population for inclusion in a study [17]. There are two types of sampling methods: Probability and non-probability [15]. Probability sampling is a type of sampling wherein the selection of samples is done with the members of the population having equal chance to be selected as part of the representative sample [15]. Non-probability sampling participants are chosen non-randomly, examples, convenience, purposive, snowballing and quota sampling [18]. Considering the purpose of this study and nature of population, non-probability sampling (purposive sampling) was considered as the most appropriate. (14) states that purposive sampling is a non-probability sampling method in which the researcher selects participants based on personal judgment about which ones will be most representative or informative. This sampling procedure was based on the belief that parents had the knowledge and experiences with regard to communicating with their adolescents. Probability sampling was not chosen because it would have been difficult for the researchers to obtain a sufficient number of participants if a random probability sampling was to be used at the clinic since patients do not come for services all at the same time [14].
Inclusion criteria included those willing and available parents who had adolescent children and using Otjomuise clinic. These were biological parents as well as guardians as long as they were living with adolescent children in the house. Exclusion criteria applied to those who did not meet the criteria. The researchers chose participants by asking every individual parent if they were living with adolescents (aged 10-19 years) at home or not. If they answered yes then, the study was explained to her/him and its purpose. It was up to the individuals to accept or reject.

Data collection
Most common types of qualitative data collection methods are: Interviews, focus groups and case study. After comparing the three methods, interview was found to be the most suitable data collection method for this study because researchers wanted to have direct verbal interaction with participants so that their mood could also be observed at the same time responding to their responses when necessary. Focus group and case study were not suitable for this study because the purpose of the study was to understand individual experiences of participants and not in group and not qualities.
Semi-structured interviews were appropriate to use in this study in order to collect data because it allows the researcher to be in control of the interview since the interview guide is used to guide the interview and depending on the responses from the respondent the researcher is able to probe for more information. Interviews were conducted in a quiet place, duration of interview varied depending on how much parents could manage and be comfortable to answer questions on sexual issues and HIV prevention. The average length was 30 min. Due to sensitive nature of the topic, more probing was required. According to researchers [15], the researcher should develop a friendly and cordial relationship with the interviewee at the beginning of the interview to enable the interviewee to feel more relaxed and to facilitate freely expressions of the views on the topic being discussed and continue to give updated or additional information needed. The researchers introduced themselves and explained the nature of the study and the purpose of the interview. This was done to remove fears of participants so that they relax and not think that researchers were there to find faults. After obtaining verbal consent, the interview would start. It was important to start with general questions like "how are you?" as it helped to establish a rapport. Following the interview guide, parents were asked questions and at the same time the researchers were listening more attentively to the responses and non-verbal responses were also observed. Probing was used from time to time to get more clarity on issues. A tape recorder was used to capture the interviews so that some of the data should not be lost and this was done only with the participant's permission. Field notes were taken to supplement the tape recordings and soon after the interview the notes were confirmed with the participant for verification. All 20 parents were interviewed on different days and different times until it was clear that no new information or concept could be emerging from data [16].
Throughout the data collection process the researcher used "bracketing" as a method of detaching her own sentiments/believes on the phenomenon and tries to be in the present and took notes as the participants narrate their communication processes with their adolescents. As human being the researcher was always aware of this human subjectivity inclination prejudice, but try to be objective as much as possible and noted what participants are narrating rather than noting her thoughts

Piloting of the interview
Pilot study was done at Wanahendah clinic in Windhoek using the same characteristics of participants and the same questions in the interview guide. This was done one week earlier before the actual collection of data so that if there were any problems they would be corrected. Five parents were interviewed using the same methodology. A tape recorder was used and field notes were taken. Observations were made on non-verbal responses. This increased the researcher's experience in proper construction of questions and of conducting an interview. Some of the questions which were not clear to the participants were changed to make them clearer. Language was understandable and time was enough.

Data analysis
After considering different types of analytical methods, thematic analysis was appropriate method for this research. Thematic analysis allows the researcher to identify analyses and organize data into themes and subthemes [19][20][21][22].
Thematic analysis involved six phases: Familiarisation with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report [22]. Familiarisation started with transcribing the data. Data was transcribed verbatim. Proofreading the material and underlining key phrases. Constant comparison was used by moving back and forth between data that was collected and data that was being analysed. The researcher kept looking for similarities and differences in the transcripts [23]. This increased the credibility of the themes developed [24]. All these steps helped to build a picture of what the parents said.

Ethical considerations
This Study was conducted in conformity to ethical guidelines and approval of Welwitchia University Ethics committee and Ministry of Health and Social Services. Relevant permission was sought at the clinic from the Registered Nurse In-charge of the clinic. Verbal consent was obtained from individual participants prior to participation. Participation was voluntary and participants were free to withdraw from participating at any time. To ensure anonymity and confidentiality each participant was assigned with a number instead of actual names and only the researchers had access to the collected data.

Trustworthiness of the data
Reliability is the degree of consistency or dependability with which an instrument measures the attribute it is designed to measure and validity is the degree to which an instrument measures what it is intended to measure [14,25]. The word "trustwothness" is used to describe the validity of qualitative research and also proposed the alternatives of validity and reliability which are credibility, dependability, confirmability and transferability. The four factors have been demonstrated in the research process to ensure the rigor of the findings [26].

Credibility
This refers to a criterion for evaluating data quality in qualitative studies, referring to confidence in the truth of the data [14]. Credibility can be equated to validity. This study ensured credibility through triangulation: by interviewing both male and female individual parents from different backgrounds and at different times. Peer review was used which involved colleagues in the data analysis. The supervisor of the research also constantly checked how data was analysed by being a co-coder of the transcripts. Both voice tape recording and field notes were used to collect data.

Dependability
Dependability refers to "the stability of the data over time and over conditions" [27]. Dependability can be equated to reliability. The "enquiry audit" which requires external reviewers to scrutinise the data was used to achieve dependability. The supervisor of this research acted as an external auditor who constantly scrutinized the data and had discussions during the field work and data analysis.

Confirmability
A way of establishing the objectivity or neutrality of the data by establishing that the conclusions and interpretation arise directly from them [27]. This has been demonstrated in this research through participant debriefing and the thick description of the process.

Transferability
Transferability is the degree to which the findings of qualitative research can be applied to another contexts or other groups [28]. Literature suggest that it is difficult for qualitative researchers to specify the transferability of the study [27]. However, the qualitative researcher can provide only a "thick" description necessary to enable someone interested in making a transfer to reach conclusions about whether this transfer can be done. This has been achieved in this research, a "thick" description of the findings has been made.

Results
This section presents the study results. Quotations from participants are included to provide a clear picture of the communication between parents and their adolescents.
As stated earlier, the study was to explore parent-adolescent communication on sexual issues and HIV prevention at Otjomuise clinic in Khomas region of Namibia.

Background of the participants
Participants were from different backgrounds. None of the parents attended school above grade 10. Only one parent was married and the rest were either co-habiting or single. 13 parents were females and the rest were males. The ages of the adolescents were from ten to nineteen years. Almost all parents were Christians except a few who belonged to other religions like Potters House, Evangelical and Baptist. It was important to find out about religion, as religion forms part of culture and culture has influence on health behavior [29].
Among these parents, there were parents who claimed that they did discuss sexual issues and HIV prevention with their adolescents and those who did not do so (Table 1).

Parents Frequency Sex
Parents who do discuss 10 (50 %) 9 females (90 %) 1 male (10 %) Parents who do not discuss 10 (50 %) 4 females (40 %) 6 males (60%) 20 parents were interviewed. The study revealed that only 50 % of the parents were discussing sexual issues and HIV prevention with their adolescents. Those who did not discuss with their adolescents were also 50 %. Those who did not discuss sexual issues and HIV prevention with their adolescents, stated reasons like lack of knowledge, sex differences, shame, culture and others felt that their adolescents were still young.
Themes and sub themes: In this study four themes and sub themes emerged from the data as discussed below. Four themes and sub themes of the study are in the Table 2 below.
Themes from the data Sub-themes

Sexual issues
Adolescent not to be involved in sexual activity.

HIV status
Self or relations HIV status reference.

HIV Prevention
Abstain from sex

Information discussed between parents and their adolescents on the following:
Sexual issues: Abstinence: This study revealed that 50 percent of the participants warn their children not to be involved in sexual activity, in other words to wait until they are married. "I tell my child "stay away from sex until she is married. " (Female parent no. 5). Another parent state "I tell her to stay away from boys" The study revealed that participants communicated warning messages to their adolescents on sexual issues. In most cases the discussion is done indirectly with no plan, but in a form of warning without clear explanation. Other studies support these findings such as HIV status: The study revealed that some participants use their own HIV positive status or of other members of the family or other relations to talk about HIV. They refer to themselves or others who are HIV positive. One participant's state "Her grandmother, who is also my mother is HIV positive and it is this child that gives the grandmother ARVs to drink every day. She knows how the grandmother is suffering." (Female parent no. 1).
"I tell her that she should not be like me, I am HIV positive and she should not sleep around until when she is married" (Female parent no.

5).
Other studies support this finding reporting that parents frequently used examples of those who died of AIDS to initiate a discussion to reiterate the disease [31].
HIV prevention: It was noted that almost every participant who discuss sexual issues and HIV prevention with their adolescents, when it comes to prevention they discuss in a form of abstinence. They, i.e., participants tell their adolescents not to be involved in sexual activity until they are married as expressed: "I tell my child to stay away from sex until marriage. " (Female parent no. 16). Another one participant stated: "I tell her to look after herself and not to sleep with boys" (Female parent no. 17).
These phrases imply that the participants tell their adolescents not to be involved in sexual activity until they are married however, they do not explain what it means to those children. Only one parent claimed that she discussed condom use with her adolescent, regarding HIV prevention. She stated that "I tell my girl to use condom because you can see how your grandmother is suffering because she is HIV positive. " (Female parent no. 1). Although she talks about condom use the discussion is still shallow with deeper explanations e.g. when and how to use condoms and the frequency of using one condom In this study condom use was very silent, only one female parent tells her adolescent to use condom at the same time referring to the grandmother, which shows that it is very difficult to discuss condoms with your own child. Even this participant failed to talk about condom use alone, but she had to combine it with reference to the grandmother of the child. This finding is supported in literature that the use of condom is not usually talked about by parents [31].

The process of discussion
Parents were asked about when and how they discussed these issues with their adolescents. The study shows that the discussions were not planned; they just came as the situation occurred, especially when the parent is not happy with a certain situation that has upset her/him. The answer to this question was: "I just talk whenever, when the child comes home late" (Female parent no. 20). This finding is supported by literature as reported that parent-adolescent discussions about sexual issues and HIV prevention was triggered by the behaviour of the child such as coming home late [32].

Challenges encountered by parents during discussion
Shame due to culture, sex difference and age of the adolescent: It was revealed that it was shameful for parents to talk to their adolescents about sexual issues and HIV prevention. Parents felt that if they talk about sex to their children it meant that they were introducing the hidden topic of sexual issues to them and in this way they are encouraging the children to start being involved in sexual activity. It was evident that parent's traditional norms were also preventing them from discussing sexual issues and HIV prevention with their adolescent. Parents felt that it was not right for them to talk to their own children about sexual issues, it is a taboo. Some of the parents both male and female were not discussing sexual issues and HIV prevention with their adolescents because of sex difference. This was demonstrated by such phrases: "I cannot talk to my own child about sex, it is not right and it cannot happen" (Male parent no. 6). The other one said "I tell her not to play with boys, because it is shameful to mention sex. " (Female parent no. 17). Other expressions were: "I tell her not to sleep around" (Female parent no. 20) and or I cannot talk to my own child about sex because culture does not allow, it is a taboo. " (Male parent no. 6).
"My child is too young for me to start talking about sex" (Female parent no. 2, adolescent age 10 years) or "I am female and the child is a male, so his father should be the one talking. " (Female parent no. 10).
It was therefore noted that parents were not talking straight to the point. Their answers were "I tell her not to sleep around". This statement is vague concerning sexual issues and HIV prevention without any motivation for the warning. This finding is supported by other researchers who states that when it comes to talking about sex, bits of unclear information are passed between parents and their children and no real heartfelt attempts are made to create open communication [33].
Parents were finding it difficult to talk to their adolescent because they perceived the children as too young to discuss sex and HIV infection. This is not unique to this study, few studies have been identified supporting this claim [30,34] and the common perception is that children are too young to have sex so they do not communicate with them about sexual issues and prevention of HIV. Parents worry that talking about sexuality will take away their children's innocence; by making them grow up too fast or become overly interested in sexuality [35].
Although some parents claimed of not discussing sexual issues and HIV prevention with their adolescent because they were not of the same sex, still parent and adolescent being of the same sex were not discussing sexual issues and HIV prevention. In other families sex difference did not matter, talking about sex to young children remained a taboo [36,37].
Lack of skills and information: Some parents felt that they did not have proper skills and information to initiate a discussion on sexual issues and HIV prevention. This might be attributed to educational level of parents.
"We parents find it difficult to talk to our children because we do not know how to start and how to do it" (Male parent no. 18).
Research supports this finding by saying that parents are not competent in providing sex education to their children because of lack of information. Parents face the usual difficulties in discussing sex with their children, that is, what to say, how much to say [38]. Other studies also supports this finding by commenting that parents do not know enough about sex themselves to be able to teach health sexuality to a child [33,39].

Suggestions from parents to encourage parent-adolescent communication
Participants were asked to suggest ways which they felt would encourage communication on sexual issues and HIV prevention at a household level, especially what the government would do for both parents and adolescents in order to improve the communication.
Their answer was that institutions should provide sexual issues and HIV prevention education. The government should continue teaching children about sexual education and HIV prevention in schools or Non-Governmental Organisations should do the educating instead of doing it at a household level. The teachers should emphasize on abstinence instead of putting an emphasis on other methods of prevention.
Some parents suggested that the government should provide training for the parents and provide them with proper information on sexual issues and HIV prevention. Parents feel that they do not have the skills and proper information on this topic that is why they fail to discuss such issues with their adolescents as expressed: "The government should help parents and children by continuing to teach children about sex in schools putting emphasis on staying away from sex until they are married, instead of putting emphasis on other methods of prevention. "(Male parent no. 6). Another participant said: "The government should train us and provide the right information to parents about sexual issues and HIV prevention. We feel we do not know what to say and how to say it to our children. " Parent no. 16.
Literature is of the opinion that schools are important partner in helping children prevent negative sexual health outcomes through comprehensive sex education and went on to say that parents play most important role in sex education but need resources and support [39,40]. Furthermore it is believed that parents think that their children will learn better about healthy sexuality in school which is a neutral ground and take the responsibility from them.

Conclusion
According to research adolescents are at the center of the HIV/AIDS pandemic. The young people are particularly vulnerable to HIV infection. This attributed to risky sexual behaviour or substance abuse, lack of information and preventive services, or for economic, social and cultural reasons. It is clear from this study that adolescents generally do not get enough information either from schools or parents. The findings have implications for clinical practice and education [5,6].
This study has demonstrated how difficult it is for parents to discuss sexual issues and HIV prevention with their adolescents, largely because of lack of knowledge, skills and also cultural issues influencing the discussion. Although some studies support the findings of this research, more research is required to test some of the findings of this research [31,34].

Recommendations
Further research should be conducted in different cultures because each culture has its own values and beliefs. As a result of this research the following recommendations are made: This research has shown that a lot of parents do not discuss sexual issues and HIV prevention with their adolescent the way they should. It is proposed that government should do health promotion campaigns concerning awareness on the importance of parent-adolescent discussions on sexual issues and HIV prevention. Example the role of parents in sexual issues and HIV prevention among adolescents. This would help parents realise that they have a role to play in the lives of their children especially adolescents concerning HIV prevention.
It has been established in this research that parents lack skills and information on how to initiate and what to talk about concerning sexual issues and HIV prevention with their adolescents. (38) states that parents face difficulties in discussing sex with their children, they do not know what to say and how much to say. It is proposed that parents be trained by the government on parent-adolescent discussions concerning sexual issues and HIV prevention through workshops. Community nurses should encourage parents who have adolescent children at home to discuss sexual issues and HIV prevention with their children.
It is imperative that curricula for adolescents in schools about sex education and HIV prevention should be evaluated to ensure that more of abstinence is being taught to adolescents as preferred by parents. A study showed that it is very difficult for parents do discuss condom use with their children [31]. Even in this study condom use at house hold level is silent. Let the schools put an emphasis on abstinence while parents also put an emphasis on abstinence, they will be talking the same language of abstinence.
This research has established that parents do recognize that the discussion of sexual issues and HIV prevention is important, therefore establishment of parent-teachers association is essential, in a way that teachers would help parents on how to discuss sexual issues and HIV prevention with their adolescents. Parents would also feel in control of their children by constantly discussing with teachers how best they would want their children taught. Literature encourages parents to know what their children are being taught at school as well as what they are not being taught [39]. Parents-teachers together should encourage adolescents to go for voluntary HIV counselling and testing.