Parent-young communication on sexual and reproductive health issues and its association with sex and perceptions of young people in Ethiopia, 2020: a systematic review and meta-analysis

Background There is no national representative and conclusive data regarding parent-young communication. Therefore, this study aimed to estimate the pooled prevalence of parent-young communication on sexual and reproductive health issues and its association with sex and perceptions of young people about its importance in Ethiopia, 2020. Methods The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) was used during systematic review and meta-analysis. The study included both published and gray literatures which were searched using appropriate key terms. The articles were searched from different databases: PubMed, Cochrane Library, PsycINFO, CINAHL, Global Health, HINARI and Google scholar. Data were extracted in a Microsoft Excel sheet and STATA/SE 14 was used for meta-analysis. I2 and Egger test statistics were used to test heterogeneity and publication bias respectively. Results Twenty-nine articles were included in this systematic review and meta-analysis. The pooled prevalence of parent-young communication on sexual and reproductive health issues in Ethiopia was 42.96% [95% CI: (36.91, 49.02)]. Positive perception of young people towards parent-young communication [AOR = 3.72, 95% CI: (2.87, 4.86)] and female sex [AOR = 1.62, 95% CI: (1.12, 2.34)] were significantly associated with parent-young communication on sexual and reproductive health issues. Conclusions The prevalence of parent-young communication on sexual and reproductive health issues in Ethiopia was low as compared to other literatures conducted outside Ethiopia. Both perceptions of young people towards parent-young communication and sex were significantly associated with parent-young communication on sexual and reproductive health issues. Interventions targeting males and young who had negative perceptions regarding parent-young communication should be the primary focus of the government and their parents. Review registration The protocol of this systematic review and meta-analysis was registered in the PROSPERO International prospective of systematic reviews with a specific registration number: CRD42020161252.


Study design, search strategy and registration
The study was designed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-2009 Guidelines) [40]. It was conducted using published and unpublished articles and the articles were searched from different databases: (PubMed, Cochrane library, PsycINFO, CINAHL, Global Health, HINARI and Google scholar). All potential articles were accessed by using a combination of keywords/indices like; "prevalence", "magnitude", "parent adolescent", "parent youth", "parent young", "communication", "open communication", "discussion", "determinants", "factors associated", "associated factors", "predictors", "risk factors", "sexual", "sexuality", "sexual issue", "reproductive health" which were developed according to Medical Subject Headings (MeSH). All these key terms were searched by a combination of Boolean operators "AND" or "OR" as appropriate and the search was done by two authors independently (MY and BA). The protocol of this systematic review and meta-analysis was registered in the PROSPERO International prospective of systematic reviews with a specific registration number: CRD42020161252. ❖ Study design: All observational studies were included ❖ Time frame: All studies irrespective of data collection and publication year until the end of November 1, 2020 ❖ Publication: Either published in peer-reviewed journals or unpublished studies. ❖ Language: studies published only in English language were included in this systematic review and meta-analysis.

Exclusion criteria
❖ Studies in which the outcome did not clearly reported ❖ Studies in which the full texts were not available after 2 times authors request were excluded from systematic review and meta-analysis.

Study quality appraisal and data extraction
Those articles identified in all databases were exported to Endnote X8 and duplicate files were excluded. The remaining articles and abstracts were independently screened by two groups (YD and BK) for inclusion in  the full-text appraisal. It was assessed using Joanna Brigg's Institute (JBI) critical appraisal checklist according to the study design of each article [55,56]. Two independent authors (SW and AB) assessed the quality of the articles and the differences in the scales result was settled by taking the average result of both reviewers. Data were extracted using Microsoft excel 2010 sheet and the sheet contained the following list of variables for the first objective: authors name followed by initials, year of study, year of publication, study setting, study design, sample size, response rate, quality score, sex of participants, region, study finding. For the second objective, in addition to the above mentioned, studies reported at least one of the above mentioned factors as predictors were identified and extracted. Two authors (MY and YW) extract the data for both objectives and any disagreements between the two authors during extractions were solved through discussion and consensus.

Data synthesis and statistical analysis
The data extracted in the Microsoft Excel sheet format was exported into STATA/SE 14 version statistical software for further analysis. The pooled effect of the point estimate of parent-young communication in Ethiopia was calculated by DerSimonian & Liard's method of random effect model at P-value less than 0.05 [57]. Benishangul-Benishangul Gumze, Both-both preparatory and high school, RR-Response Rate and SNNP-Southern Nation Nationalities and Peoples Representative    Statistical significance for heterogeneity with I 2 tests greater than 75% was taken as high heterogeneity and it was subjected to sub-group and sensitivity analysis. Finally, publication bias was assessed by using Egger's weighted regression test method (p-value < 0.05) which was considered as statistically significant publication bias [58].

Study selection
The review found a total of 780 articles. Sixty-four of them were removed due to duplication and 683 records also excluded after screening by title and abstract. The remaining 33 of them were screened for eligibility and appraised based on JBI checklist. Again 4 of them were excluded due to reason (outcome was not clearly reported or the authors couldn't respond for full text request). A total of 29 full-text articles were included in systematic review and meta-analysis (Fig. 1).

Prevalence of parent-young communication on sexual and reproductive health issues
Parent-young communication on sexual and reproductive health issues was ranged between 8.84 to 82.67% in unpooled estimate [10,52]. The pooled prevalence of parent-young communication on sexual and reproductive health issues was 42.96% [95% CI: (36.91, 49.02)]. As  it was illustrated in the figure, there was considerable heterogeneity (I 2 = 98.6%, P value = 0.0001) among studies included in the analysis (Fig. 2). It was also 45 for those young who talked one and two sexual and reproductive health issues respectively. The sensitivity analysis indicated that there was no single influential estimate that could attributed to source of heterogeneity. The funnel plot of pooled prevalence was symmetrical (Fig. 3) and the Egger test revealed that there was no statistical evidence of publication bias (P = 0.112).

Subgroup analysis
Subgroup analysis was done by different parameters (region, study setting, study year, response rate and type of participants) to observe the possible sources of heterogeneity. Despite heterogeneity was not totally resolved in subgroup analysis, those studies conducted before 2011 had moderate heterogeneity (I 2 = 61.8%, P value = 0.033) (Fig. 4)

Factors associated with parent-young communication
The effect of perceptions of young people regarding parent-young communication on sexual and reproductive health issues was estimated by using seven articles. From those, only one of them was not significant [39] and the others were positively significant [31,33,35,41,47,51]. The pooled odds of parent-young communication on sexual and reproductive health issues among young who had positive perception regarding parent-young communication was increased by 4 as compared to counterparts [AOR = 3.72, 95% CI: (2.87, 4.86)] (Fig. 5). The egger test showed that there was no statistical evidence of publication bias (P value = 0.334). The effect of sex on parent-young communication on sexual and reproductive health issues was estimated by using 11 articles. From those, only one of them was negatively significant [36], three of them were not significant [29,37,38] and the rest were positively significant [10,27,28,35,41,47,48]. Using the random effect model, the pooled odds of parentyoung communication on sexual and reproductive health issue among females was 1.6 times high as compared to males [AOR = 1.62, 95% CI: (1.12, 2.34)] (I 2 = 90.5%, P value = 0.000) (Fig. 6). The egger test shown that there was no statistical evidence of publication bias (P value = 0.073).

Discussion
The pooled prevalence of parent young communication on sexual and reproductive health issue in Ethiopia was 42.96% [95% CI: (36.91, 49.02)]. The pooled prevalence of parent-young communication was in line to a study conducted in Nigeria (46.7%) [6]. But, the result of this   study was low as compared to a study conducted in Kenya (53%) [8] and Zambia (60%) [9]. Again the finding of this study was low as compared to a study in Bangladesh (65.6%) [5]. The possible explanation for this discrepancy may be due to socio-cultural difference related to parenting style [22]. In addition, traditional norms and religious beliefs of the countries may be another source of variation [24]. In addition, the highest prevalence of parent-young communication was observed in studies conducted among young as compared to studies conducted among parents. This may be due to the fact that parents had less exposure to education and information than young. Moreover, the parents might think it as a positive reinforcing factor for early sexual initiation.
The pooled odds of parent-young communication on sexual and reproductive health issues among young who had positive perception regarding parent-young communication were statistically high as compared to   counterparts. The finding of this study was in agreement with a study conducted in Bangladesh [5]. It is also congruent with a study conducted in Myanmar [23]. The possible reason for this association may be their perception was highly affected by the culture what they were growing and sometimes they may also perceived as their parents have negative perception regarding parentyoung communication [17]. The pooled odds of parent-young communication on sexual and reproductive health issues among females were high as compared to males. The finding was congruent to a study conducted in Nigeria [6]. The finding was also in agreement with a study conducted in Rwanda [15]. The possible reason for this association may be due to the fact that males were feeling ashamed and it is culturally unacceptable to talk about sexual matters. Even, they may wrongly perceived it as it would be interpreted as signs of sexual initiation [59]. Moreover, in the context of Ethiopia, females were wasting most of their times in the household which may increase the contact and possibilities of discussion than males.
Despite its strength, the study was not without limitation. The review was restricted to articles published in the English language and it may not be representative for articles published in other languages. Not only this, but also all the studies included in meta-analysis were cross-sectional and the pooled estimate may be influenced by study design.

Conclusions
The prevalence of parent-young communication on sexual and reproductive health issue in Ethiopia was low as compared to other literatures. Both positive perceptions of young people towards parent-young communication and female sex were significantly associated with parent-young communication on sexual and reproductive health issues. So, the government should focus on interventions that could change the perception of young on parent-young discussion. Interventions targeting male and young who had negative perception regarding parent-young communication should be the primary focus of the parents.