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: Title: A Mixed methods research does have the potential to explore the attitudes of Thai parents towards parental involvement in sex education.
Authors: Chaweewan Sridawruang 1 Kenda Crozier 2and Michael Pfeil 3
Ph.D, RN: Obstretic Nursing Department, Boromarajonani College of Nursing Udonthani, Udon Thani, Thailand.
Ph.D, RM, RN: School of Nursing and Midwifery, Faculty of Health, University of East Anglia, Norwich, UK.
Ph.D, RN: School of Nursing and Midwifery, Faculty of Health, University of East Anglia, Norwich, UK.
Principal Contact: Chaweewan Sridawruang, Mrs, Ph.D, RN: Obstretic Nursing Department, Boromarajonani College of Nursing Udonthani, Udon Thani, Thailand. HYPERLINK "mailto:csom02@hotmail.com" csom02@hotmail.com
Abstract
Background: Parent-child communication about sex is a strong determinant in increasing the age of sexual debut, increased contraceptive use, as well as negative attitudes to early pregnancy in teenagers. Objectives: This is one part of mixed methods study aimed to explore the attitudes of Thai parents in relation to sex and sex education. Methods: The researcher recognized that quantitative and qualitative methods can be combined to provide complementary data that will allow a researcher to understand the issues under consideration more fully. Therefore, a triangulation mixed methods design was taken using survey and interviews in 3 villages in Udon Thani province, Thailand. Surveys of 79 parents took place in 2008-2009. Participants from that sample were recruited to take part in focus groups. Results: Data were analyzed separately then results merged. The survey data were used to identify the attitudes of parents towards sex and sex education. Thematic analysis of the interview transcripts identified attitudes to sex education and barriers to communication in families. The restrictions imposed by traditional Thai culture support the continuing existence of double standards concerning the social norm for premarital sex. Parents felt unable to address issue because of a perception of a lack of knowledge. Conclusions: Parents recognized the need to improve communication and knowledge of sexual health and would welcome interventions that would improve parental knowledge and access for adolescents to effective sexual health services. Discussions: This study exposed the importance of conducting mixed methods research that the survey gave a broad picture of attitudes of parents regarding sex education generally. The interviews allowed the researcher to sample from the same population to explore these perceptions and understand the attitudes in greater depth. Recommendations: Educational interventions are needed at local level to enable parents to develop knowledge and skills to act as educators.
Keywords: Mixed methods study, Attitude, Parents, involvement, Sex Education
Background
It is clear that todays young people are sexually active at an earlier age than previous generations and majority of them become sexually active before high school graduation1. High rates of sexual activity and high risk behaviors teenagers are exposed to unwanted outcomes, including sexually transmitted infections, unintended pregnancy and its consequences2. Teenage pregnancy is one of the consequences of unprotected sexual intercourses and commonly occurs around the world. Over half of teenage pregnancies are terminated, and in the United States (USA) an estimated 40% of teenage pregnancies end in abortion3. In the United Kingdom (UK) where abortion is legal, 41,325 women under the age of 18 became pregnant in 2008 and of these 49% chose to undergo an abortion4. Unsafe abortion is a serious problem in many developing countries. Each year around 18.5 million unsafe abortion cases are reported in developing countries, and 14% of all unsafe abortions in developing countries relate to young women5. As in many other countries, sexual risk behaviors in Thai teenagers have increased and they have sexual intercourse at an earlier age. Premarital sex is not accepted in Thai traditional culture, however todays teenagers in Thailand are embarking on sexual relationships outside the boundaries of marriage. This has been attributed to the increasing influence of western ideas brought by industrialization and urbanization6. The proportion of teenage mothers in Thailand has increased from 10.4% to 12.4% between 2000 and 2003 7. Allen et al (2003)8 indicate that the average age of first coitus was 17.6 years and that 48% of male students and 43% of female students who had experienced sexual intercourse reported not using contraceptives.
Good parents are also expected to be responsive to the viewpoints of their children, to listen and to learn as well as to teach. This is considered in the context that sexual risk behaviors are very much in todays society. Moreover, parents of todays teenagers may find it hard to deny young peoples involvement in sex. Conveying values and information has always been considered central to the role of parenting to help teenagers to establish individual values and make decisions of sexual health that could protect children from harm9. However, research on the issue of parental communication about sex is inconclusive. This is because various instruments were used to measure the amount and quality of parental communication about sex. In addition, when specific sexual topics were explored, the rate of discussion of individual topics varied substantially10.
Purposes:
This is one part of mixed methods study, aimed to explore the existing knowledge and attitudes of parents in relation to sex and sex education in Udon Thani, Thailand
Ethical measures:
Parents participants were asked to either give their consent by writing or thumb print (if they were illiterate). Ethical approval was sought from the Faculty of Health Research Ethics Committee, University of East Anglia, and also the relevant provincial health offices of the Thai Ministry of Public Health. Sex and sexuality are sensitive issues in Thai society. Therefore all data produced for this study was anonymous and kept strictly confidential11. All participants had opportunities to decline or agree to take part in the study and they were free to refuse to participate with this research without giving reasons at any time if they disagreed or were unsatisfied during the process.
Design:
The triangulation mixed-methods design was used to address the research problem because neither a qualitative nor a quantitative approach alone could not provide a satisfactory answer to the research question and would not fully explore the attitudes of parents and adolescents towards parental involvement in sex education in the context of village societies in Thailand.
Participants and settings
The target population of the study included parents living in three villages within three districts of Udon Thani province, Thailand. The three districts were selected purposively because of their high levels of teenage pregnancies. From 2005 to 2007 approximately 25-28% of postpartum women in these districts were teenagers. Working on the assumption that each village has around 200 to 300 households and that approximately 30% of households are part of the target population, i.e. they have 15 to 19 year old adolescents in their families, it was concluded that the overall target population included approximately 272 parents within the three villages.
Participants in quantitative approach: A survey sample size formula was used to calculate the sample size. For at 95% confidence level and 10% accuracy level, which mean that there is a 95% probability that the survey response does not vary more than 10% 12, I aimed to recruit approximately 79 parents from the target population within three villages. Every parent within the three villages had the same probability of being included in the sample. The calculation demonstrates a sample size at 71 is required. To allow for drop-out I increased the sample size by 10% to include 79 participants.
Participants in the qualitative exploration: Focus groups were used to collect data for a qualitative exploration. Following the survey 30 parents participated in focus groups.
The selection criteria of participants: Parent participants were asked to either give their consent by writing or thumb print (if they were illiterate). The participant selection criteria was parents who were able to speak well enough in Thai or Isan (a local language), so that they could communicate with the researcher who was fluent in both languages.
Data collections
The validated questionnaire survey (alpha = 0.70) was used to collect data of 79 parents in3 villages, Udon Thani, Thailand. To gain further in-depth experiences and information related to the parents barriers and needs for sex education that 30 parents were recruited through the survey for participation in focus groups. The structured vignette story was used to promote discussions in focus groups.
The questionnaire for parents is composed of ten closed questions with five rating scales of parents attitudes towards sex education, including topics of importance of parents as sex educators, appropriate times to discuss sex with their children, schools as providers of sex education, barriers that prevent parents involvement sex education, and the need of teenagers in relation to reproductive health care.
Difficulties that were encountered in questionnaire survey
The questionnaires were used to collect data from 79 parents within three villages. Parents were asked to complete the questionnaire at their home, which usually took approximately 45 to 60 minutes. Two parents could not read the questionnaire. The researcher (CS) explained the purpose of questionnaire, the questions, and the meaning of the ranking numbers of the answers to them. Then, The researcher read each question at least two times and asked them to make sure that they clearly understood each question. Finally, the parents selected the choices of answers by themselves.
Data analysis
Data analysis in this research consisted of initially analyzing the quantitative and qualitative data separately. For quantitative part, descriptive statistics such as minimum and maximum values means and standard deviations were used to check the range and distribution of the variable. For qualitative data, thematic analysis was used to establish key themes in six steps. Preparing and exploring the data for analysis was carried out in transcribing data that involved the spoken words from focus groups being transformed into a written form. Translation and verifying translation: the researcher (CS) reading through the Thai transcripts line-by-line translating them word-for-word into English. To ensure the accuracy of the translated data, translation checks were carried out by three English and Thai speaking academics. Coding: two coders independently coded the same transcript and then they met to compare and discuss differences in their coding and problems with coding structure. Data display: thematic map was used to display data to understanding the flow, location and connection of events and identifying emerging themes. Themes and categories: manual technique was used to establish key themes. Themes were clarified by all authors in relation to the coded extracts. Representing the data analysis: verbatim quotes, figures, and tables were used to present the findings for the themes.
Results:
The survey findings
Overall attitudes of parents in relation to sex and sex education of both genders were not significantly different. However, there were statistically significant differences in two statements by gender (Fishers exact test): Parents should punish their children if they have sexual relationships; and Children can talk and discuss all matters including sex related matters with parents. 95% parents of both sexes think that it was necessary to talk about sexual health with children when they were adolescents. 81% thought that children should be punished if they had sexual relationships, as shown in Table 1.
Table1: Attitudes of parents towards teaching sex education in family
Numbers (%) of parents who agreed with the statementsMale (n=23)Female (n=56)Total (n=79)P valueSex education induces adolescents to decide to have sexual experiences8(34.8%)19(33.9%)27(34.2%).94It is necessary to talk about sexual health with children when they are adolescents22(95.7%)53(94.6%)75(94.9%)1.00It is embarrassing when talking about sexual health with children12(52.2%)24(42.9%)36(45.6%).45Sex and relationship should be taught about in school12(52.2%)24(42.9%)42(53.2%).91Teaching about contraception increases the likelihood of sexual relationships in adolescents7(30.4%)12(21.4%)19(24.1%).40Adolescents should not have a boyfriend or a girlfriend19(82.6%)52(92.9%)71(89.9%).22 Parents should punish their children if they have sexual relationships15(65.2%)49(87.5%)64(81%).03* Parents should be the first people to teach their children about sex and relationships5(21.7%)7(12.5%)12(15.2%).32 Children can talk about sex related matters with parents16(69.6%)51(91.1%)67(84.8%).03* There should be reproductive health services available to adolescents20(87.0%)53(94.6%)73(92.4%).35 = P value from Fishers exact test
The interview findings
Thai traditional culture remains a major influencing factor, especially a deeply held acceptance of double standards concerning sexual behaviors Teenagers were unlikely to seek help from their parents when they have negative outcomes from these relationships. In addition, themes illustrated the limitations and barriers that prevent parents from becoming an integral part of the provision of sex education in Thai families. Parents need the knowledge and skills before discussing sex with their children.
Theme 1: Social judgment of girls
Across all the focus groups, a strong theme emerged about the way in which the behavior of young people is judged by the society in which they live. The judgment society made on girls behaviors was perceived by parents as being more important than those made about boys. Fathers and mothers emphasized an expectation towards daughters to preserve their v i r g i n i t y u n t i l m a r r i a g e . I n t h e o p i n i o n h e l d b y o n e f a t h e r ,
I t i s h a r d e r t o l o o k a f t e r a d a u g h t e r t h a n a s o n . N e i g h b o u r s w i l l g o s s i p a n d l o o k d o w n t o h e r , i f s h e h a s p r e m a r i t a l s e x . M e L o o k S a w M u a n M e S u a m Y o o N a B a n !5%9*2'G@+!7-!5*I'!-"9H+I2I2 l i t e r a l l y m e a n s , H a v i n g a d a u g h t e r t a k e s a s m u c h c a r e a s h a v i n g a p u b l i c t o i l e t i n t h e f r o n t y a r d . ( P 3 N f a t h e r )
T h e m e 2 : P r o t e c t i n g t e e n a g e r s a n d / o r e n f o r c i n g t h e r u l e s
P a r e n t s e x p r e s s e d a v i e w t h a t t h e i r s e n s e o f r e s p o n s i b i l i t y t o w a r d s t h e i r c h i l d r en included being strict. Parents affirmed the point that being strict was an appropriate response as their moral duty to their daughters, and parental control is done by setting rules about relationships, particularly for girls.
Rak wua hy puuk rak luuk hy dtee #1'1'C+I 9 #1%9C+I5 , l i t e r a l l y m e a n s i f y o u l o v e y o u r c o w , t i e i t u p . I f y o u l o v e y o u r c h i l d , p u n i s h h e r ( P 1 N f a t h e r )
A c c o r d i n g t o T h a i i d e a l s , T h a i p a r e n t s t e a c h t h e i r c h i l d r e n , e s p e c i a l l y g i r l s t h a t t h e y n e e d t o b e a b s t i n e n t u n t i l m a r r i a g e .
M a li (a girls name in the scenario) would not go to meet Somchai (a boys name in the scenario), because she would respect her parents wishes for her not to have a boyfriend. (P6D mother)
Theme 3: Restrictions imposed by traditional Thai culture
Fourteen parents highlighted that most parents had not taught their teenage children about sex education issues, nor had they spoke openly with their children about sex, feeling embarrassed to bring up the subject.
I am too embarrassed to speak about sexual matters with my children because in previous times, my parents had never taught me about this subject. I do not know how to begin. (P5N mother)
Fifteen parents stated that they would not teach sex education themselves because schools are already teaching sex education to their children.
Schools have provided the knowledge of sex education to my children already. It is the job of schools not parents job. (P4D father)
Two parents suggested that other families did not talk about sex-related issues. If it became known that they spoke about sex-related issues with their children, they would appear strange to other villagers. There was a perception that the accepted norm was that parents do not discuss these matters with their children.
Our society here does not have even one family, which actually teaches their children about sex education, and they might think it will be just too different if our family begins teaching sex education to our children. (P3D father)
Theme 4: Talking about sex is difficult
Parents stated that their children avoid asking them about sex because they realise the parents lack education. As a result, parents lack confidence to answer the questions of their children.
I have a niece who asked me to buy birth control pills and when I asked what for, she told me it was to make her hair long. It was the same when my daughter said pills would make her thin, I had to believe her because I did not have the opportunity to study as much as her. (P1D mother)
Discussions
Findings from the survey and the interviews will be merged where they complement each other, differences will be examined and appropriate comparisons made. Merging the data allows a complete picture to be given which draws on the rich data from all elements of the study. In this study the questionnaire provided broad information on knowledge, attitudes, norms and values of parents and in rural areas on sexuality-related issues.
The survey provided a standardized way to collect data as a beginning point for the study. The self-completion questionnaire allowed the respondents to anonymously answer questions on the sensitive issue of sexual behaviors. Self-completion surveys can often have low response rates. One hundred percent of participants were willing to participate in the project, no one declined to participate at all. The respondents were given the option to not complete the survey if they did not want to, but all of them did.
This was likely due to the following factors: The researcher (CS) personally met with each family about the aims of this study including the fathers, mothers, and young people, which facilitated the understanding of the study and re-assured the participants. In addition, there is a natural custom of the rural Thai people to be courteous, fearing offending the ones who provide health services to them. Most importantly they accepted the researcher because the head of health care volunteers, as a highly respected person in the area had introduced the researcher to participants. The researcher later learnt that the head of health care volunteers enjoyed high levels of trust. When they are ill or injured the villagers place their lives into their hands when being treated. They remembered the good deeds of these frontline health care workers because they cared for them while they were ill until they were well again. When this research was endorsed by the head of health care volunteers this trust had been extended to the researcher To successfully complete not just this research, but to ensure future research was equally well supported I had to justify this trust by working in an ethical and trustworthy manner.
Focus group techniques allowed participants to react and built upon the responses of other group members. This was made possible by using vignettes. The vignettes allowed the participants protection from self disclosure in that they were able to disclose their own opinions by considering issues in the lives of others without having to disclose personal details. This helped the participants to feel comfortable and to share their opinions safely among people who knew each other 13. In addition, the focus group technique was useful for obtaining data from parents in rural areas who had low levels of education. It was a suitable way to understand how participants think about sexual issues 14.
The findings of both survey and interview data demonstrated a picture of Thai traditional culture and its influence on the provision of sex education to young people in rural villages. The survey findings demonstrated that most Thai parents in these rural locations had protective and restrictive views about male-female relationships. Parents said publicly that they did not accept their children being involved in relationships and their children respected their wishes yet privately they revealed that they did not have control over their childrens choices and so just tried to limit the potential damage by ensuring they understood something about contraception.
Whilst in the survey data it appears that parents think that children of both sexes should not be considering sex it is clear in interviews that parents are much less concerned about sexual activity of their sons. Within these rural Thai families, parents generally believed that they had a responsibility to control their daughters particularly, to ensure they behaved within the bounds of the expectation of Thai customs. Parents in focus groups commented strongly that they would set rules and exert control in order to protect their female teenagers from the perceived harms associated with premarital sex, the amount of room for negotiation by teenagers varied. Some existing research evidence shows adolescents who perceived their parents to be disrespectful of their individuality demonstrate more frequent risky sexual behavior, while balanced levels of parental monitoring have been shown to reduce the risk-taking behaviors of teenagers 15. Imposition of many rules or conversely the lack of imposition of rules has been related to a greater likelihood of sexually risky behaviors among teenagers 16. Parents may thus be advised to seek a suitable measure of control over their teenagers in culturally and socially appropriate ways.
The parents reported being uncertain about and reluctant to discuss sexuality and sexual matters with their children, and they needed information and skills to talk about such matters with their children. Parents highlighted in interviews how they had difficulties discussing sex with their teenagers because of the fragility of their own confidence, fearing that their teenagers might regard their views as old fashioned. They expected schools to be the primary source of such information because they respected the teachers knowledge. Most parents in this study suggested that their teenagers were too young for sex education and were likely to underestimate their teenagers sexual risk behaviors. As a result, the delaying effect of information on the commencement of sexual activity by the adolescents is missed and safer sexual practices are not encouraged. Research by others has found that parental education is associated with lower adolescent sexual activity, delayed sexual initiation, safer sexual practices and lower risks of pregnancy17,18.
Limitations
This study was conducted in only three rural villages in the north-eastern region of Thailand. Its sample was narrow in its limitation to one province but provided good representation of the parents in those areas and a good platform for the participants to outline their views. Applying these findings uncritically across all parts of Thai society may not be possible, because of even stronger Western influence apparent within large cities. It could not fully encompass the cultural diversity of the country.
The structured use of a case-vignette enabled participants to relax and actively share their views without having to disclose personal information. Nevertheless, not all focus group participants may have felt able to contribute equally and some may have been influenced by peer pressure, feeling unable to voice opinions that countered the views of others. This highlights the importance of using individual interviews as well to capture more personal views that may otherwise have been missed.
Conclusion:
This research, the first to be conducted in a rural context in Thailand, explored the opinions and perceptions of parents towards sexual behaviors of their teenagers. The overall findings indicated a strong influence of traditional cultural values in Thai rural society. Clearly, double standards concerning the social norms for premarital sex as applied to young women on one side and young men on the other existed within these rural villages.
This rural society values seniority as the core position of power in relationships in the family structure. Families continuously affirm the traditional wisdom that children should be respectful and obedient towards their senior adults. Perhaps, the process of identity formation of teenagers might have tensions and conflicts due to the fact that they are traditionally expected to ideally emulate their elders, yet they are struggling to shape their own identities influenced by outside values.
Continuing traditional restrictions, a lack of parental knowledge, and the belief that sex education should occur in schools emerged as the main barriers to parents providing sex education to their teenagers. Resulting in teenagers miss the opportunities to acquire knowledge on sexual matters. Parents and teenagers need help from various sectors to encourage parental knowledge on sex related issues before parents discuss sex with their children.
Implications
Strategies which aim to encourage gender equality should be addressed such as encouraging female students to share and discuss gender equality issues in the classroom and teachers could give suggestions of their views in positive ways. Perhaps, it is the first step to promote the empowerment of female teenagers.
Parents should be able to create dialogue, facilitate an open and receptive interactive environment in which a variety of sexual topics could be discussed with their children securely founded in a good basis for mutual understanding of each other. As a result, the connection and respect for individuality between parents and teenagers would be created.
Thai national policy or program supports a parental role in sex education and a program would need to provide the parents with the relevant knowledge and communication skills and empower parents to have the confidence to provide sex education to their teenagers at home.
Acknowledgments
This study was funded by a PhD scholarship from the Royal Thai Government. We would like to thank all the parents who took part in this study. We acknowledge the contribution of Associate Professor Dr Khanitta Nuntaboot, Khon Kaen University, Thailand, who acted as the field supervisor and Don Craft, who provided translation checks.
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Title : A Mixed methods research does have the potential to explore the attitudes of Thai parents towards parental involvement in sex education
Author (s) Chaweewan Sridawruang, Kenda Crozier, and Michael Pfeil
NoCriteriaCommentsAmendments1Significance- OK
- Spelling check must be done carefully (not sure its because of English spelling between UK and USA system?, however I think this manuscript may prefer US system) Spelling check has been done carefully by using US system 2Methodology2.1Materials/ tools- Should briefly explain the questionnaire survey: how many questions and whats concepts or things that the researchers asking for?The questionnaire survey is explained in the concepts and details, please see page 3-4.2.2Method- OK(2.3Sampling- Not clearly stated the sampling technique.
- Please specify sampling technique and why 3 villages were chosen? In the manuscript.The sampling technique and settings are stated in the manuscript, please see page 3. 2.4Subjects- Not clearly stated the criteria for choosing those 79 or 30 participants.
- Please specify the reason for choosing the participants in the manuscript. The reason for choosing the participants is clearly stated in the manuscript, please see page 3.2.5Design- OK(2.6Data collection- OK 2.7Data analysis- OK and correct as suggestion in the manuscript.
I amened as suggestion.3Results- OK and correct as suggestion in the manuscript.I amended as suggestion.4Discussion/ recommendation- Very good and provide a very rich information. (5Relevance to the themes-A Life-course actions model(6English- Very good , but spelling check must be done carefully (not sure its because of English spelling between UK and USA system?, however I think this manuscript may prefer US system) The spelling check has been done by using US system.7Format- Line spacing between topics is too much. Considered adjusted by go
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p 8 TJthe attitudes of parents towards sex and sex education. 1 2
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i TJRecommendations:
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