الفهرس 
LITERATURE REVIEWOnly 14 pages are availabe for public view
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Abstract
Adolescents and youths account for more than 20 % of the global population and 40% of the Egyptian population. They face many challenges that make them particularly vulnerable to health risks, especially in the area of SRH. In many parts of the world, adolescents’ SRH have been largely neglected because cultural and religious sensitivities surrounding those issues. Adolescent females in particular experience several problems that are different from that of adolescent males; such as early child bearing with high rates of unintended pregnancies, unsafe abortion and the risk of STIs. Moreover, girls younger than 18 years are up to five times more likely to die in childbirth than women in their twenties. In addition to the above mentioned health risks, Egyptian adolescent girls, suffer more SRH risks such as domestic violence, harassment, FGM/C, early and consanguineous marriage and the controversies surrounding use of contraception.
Girls are seen to be at risk of SRH problems because they are poorly informed about their own SRH. Girls in particular, are often kept from learning about SRH issues because of social, cultural and religious barriers. Adolescents may be reluctant to ask for help from adults in their families, communities, or in professional settings. Adolescents’ access to SRH education and services has been identified as a key challenge that is addressed in the post-2015 development agenda.
Parents play the important role in preparing their adolescents for adult life, they are cited amongst the most preferable sources of SRH knowledge and education for adolescents. Effective parent-adolescent communication is an essential aspect of their connectedness, and is associated with improved developmental, health and behavioural outcomes in adolescents. However, they face many barriers in trying to initiate and maintain discussions related to SRH issues with their daughters.
It’s not merely presence or absence of communication but the quality of communication in terms of content, timing, frequency and style of communication that play crucial roles in determining whether parents are able to influence their adolescence behaviour.
Despite the importance of the issue no enough research could be traced in Egypt or Middle East concerning MDC. Therefore, the present study aimed to assess MDC on SRH issues and associated factors and barriers. Based on the assessment data, the study also aimed to design and test the effect of a culture sensitive intervention program to improve both the quantity and the quality of SRHC between mothers and their adolescent girls.
The study took place in two phases; the assessment and intervention phases. The assessment phase was carried out in two stages using a mixed qualitative-quantitative approach. First, qualitative assessment of MDC pattern including SRHC from mothers’ and daughters’ perspectives using 8 FGDs with both mothers and their adolescent daughters. Second, quantitative assessment of MDC using cross-sectional approach and an interview questionnaire. The qualitative results were used as a guide to construct the interview questionnaire. Four hundred girls attending public and private secondary schools in Alexandria were targeted for the cross-sectional survey. The intervention phase was carried out based on the results of the assessment phase. The intervention targeted mothers of adolescent girls. It took place at selected NGOs and at the HIPH clinic. Mothers received three educational sessions to improve their SRH knowledge and their communication skills with their daughters. The intervention was evaluated using a quantitative questionnaire that the mothers were asked to fill before, immediately after the intervention and three months later.
The questionnaires and FGD guides used in the present study covered the following areas:
1. Socio-demographic and family characteristics of the participants.
2. Sexual and reproductive health (SRH) knowledge of the participating mothers and daughters concerning menstruation and menstrual physiology, pregnancy and childbirth, genital health, STIs and FGM/C.
3. Girls’ sources of SRH knowledge and their informational needs.
4. Girls’ preferred source of SRH information.
5. General mother daughter communication and connectedness.
6. Attitudes of mothers and daughters towards SRHC through their perceived importance of these discussions and perceived barriers of SRHC
7. Mothers’ perceived level of comfort towards SRH discussions.
8. Frequency and content of SRHC from both mothers’ and daughters’ perspectives.
The RHC issues included menstruation and menarche, pregnancy and childbirth, genital health, personal hygiene, morals and ethics, colleagues’ misbehaviours and relationship with male colleague. However, the SHC issues included sexual harrassement, how pregnancy occurs, virginity protection, STIs and FGM/C.
Qualitative data was analyzed using framework analysis. Quantitative data included data from the cross-sectional survey and the intervention phase. Quantitative data entry and analysis were conducted using the software SPSSversion 20; figures were made using Microsoft Excel software.
The main results of this study could be summarized as follows:
A- Results of the formative/ assessment phase:
1. Qualitative discussions with mothers and daughters revealed low level of knowledge concerning anatomy of the female genital tract, menstrual physiology and menstrual hygiene, puberty and menarche as well as FGM/C and STIs. Both girls and their mothers hold various misconceptions regarding those issues. Quantitative assessment of girls’ knowledge revealed that although both PuSGs and PrSGs showed low level of SRH knowledge, PrSGs showed significantly better overall SRH knowledge score than PuSGs. About 35% of PrSGs and 12.9% of PuSGs attained more than 50% in their overall SRH knowledge score.
2. Regarding the source of SRH knowledge, the sampled girls mainly depend on their mothers, peers and same age family members, school curricula and media (TV, internet) for their SRH information.
3. Despite the cultural sensitivities surrounding SRHC, about two thirds of all the sampled girls (both PuSGs and PrSGs) cited their mothers as the most trusted, reliable and preferred source of SRH information.
4. The sampled girls reported need for information regarding STIs, FGM/C, marriage and family life, menstruation and menstrual hygiene, pregnancy and childbirth and genital health.
5. both qualitative and quantitative results revealed similar result concerning girls’ attitudes towards SRHC. Qualitative discussions revealed that PuSGs were more to perceive the importance of SRH discussions with their mothers than PrSGs. However, quantitative assessment showed that both PuSGs and PrSGs had positive attitude towards SRHC. Their perceived importance was more for RHC than SHC. PuSGs showed more positive attitude towards SHC than PrSGs (63.3% ± 24.7 vs 57.1% ± 25.6, respectively).
6. As to mothers’ attitude, qualitative results showed that though mothers value the importance of MDC and connectedness, they reported different conflicts and were less enthusiastic concerning the importance these discussions. They doubted the influence of such discussion on girls’ behaviour.
7. Qualitative discussions revealed that most daughters and mothers have good general communication. This was emphasized by the quantitative results that showed that the mean general communication score was high for both PuSGs and PrSGs (76% ± 11.2 vs 80.8% ± 15.3, respectively). However, FGDs showed that many of the girls who reported having a good general communication with their mothers, they wished they had better relationship with their mothers.
8. It has been also shown that good general communication was significantly associated with good SRH knowledge among the studied girls.
9. It also showed that RHC between mothers and daughters was higher than SHC for both PuSGs and PrSGs. In addition, both RHC and SHC were higher among the PuSGs than PrSGs but this difference was significant only for SHC. PuSGs were more to have SHC with their mothers than PrSGs (41.4%± 28.8 vs 24.8 ± 19.5, respectively).
10. The present results also showed variability in the pattern and frequency of discussions for various SRH issues between mothers and their daughters. Both qualitative and quantitative data showed that reproductive and behavioral issues (menstruation, pubertal changes, hygiene and cleanliness, relationship with male colleagues…. etc.) were more frequently and explicitly discussed than sexual issues (STIs, FGM/C, harassment...etc.) for both PuSGs and PrSGs. Sexual issues were more to be communicated in a vague way, indirectly and implicitly.
11. Reproductive health communication (RHC) was significantly positively associated with level of SRH knowledge among PrSGs. However, this association was not evident for PuSGs indicating poor quality and content of RHC among PuSGs compared to PrSGs.
12. General communication was found to be positively correlated with RHC for both PuSGs and PrSGs. However, this correlation wasn’t evident for SHC implying that family connectedness doesn’t influence communication of culture sensitive and taboo issues.
13. Both qualitative and quantitative assessment of MDC revealed that mothers and their adolescent daughters face several barriers and challenges communicating about SRH topics. Their poor SRHC pattern is bound by traditional and social norms, cultural taboos, lack of information, and limited skills of discussion, limited ability to initiate topics, religious and cultural values and misconceptions and creating supportive environment for adolescents. Other communication barriers reported by mothers and daughters included embarrassment, parenting style barriers, culture of silence. This was nearly similar for both PuSGs and PrSGs.
14. Mother’s higher level of education, higher family income, smaller family size, non-discrimination in treatment with the brother, regular praying were all factors associated with good RHC but not SHC with the mother. This implies that SHC is mainly under cultural and religious influences, and not greatly affected by the socio-economic status of the family.
15. Qualitative discussion with mothers and daughters showed that in spite of experiencing frustrations and several communication barriers, many mothers expressed strong desire to learn how to communicate effectively with their daughters and to have better SRH knowledge. The study findings demonstrate that both mothers and daughters were willing to talk and listen to each other.
B- Results of the intervention phase:
1. Participated mothers showed improvement in their level of SRH knowledge regarding different SRH issues including menarche and menstruation, pregnancy and childbirth, genital health STIs and FGM/C.
2. Concerning mothers’ attitudes, mothers showed significant improvement in their perceived importance of SRHC with their daughters.
3. Mothers perceived level of comfort was significantly improved for both RHC and SHC. In addition, there was significant decrease in the mean number of communication barriers reported by the mothers between the pre and posttest (4.7 ± 3.1 vs 2.1 ± 1.8, respectively).
4. As to their level of SRHC, mothers showed significant improvement in both RHC and SHC. However, their endpoint level of RHC was higher than that for SHC, especially for issues of sexuality (how pregnancy occurs) and STIs.
Based on these results the following is recommended:
1. The low level of SRH knowledgeamong the studied girls and mothers together with their reported eagerness for knowledge provide a great opportunity and raise the attention to the increased need for provision of a reliable effective culture sensitive source of SRH education and promotion for both mothers and daughters through both formal and informal settings.
2. Wider, larger scaled sustainable interventions are needed to support and educate mothers on different SRH issues and about their adolescent girls needs and conflicts. There is a need to equip them with proper parenting and communication skills using various approaches. Training mothers on communication skills should address MDC barriers and take into account the social, cultural and religious values.
3. Steps need to be taken to develop mothers’ communications skills on SRH related issues which can be included in family life education programs. This could be initiated through introduction of the family life education program to be implemented in community agencies such as NGOs, social clubs and at schools or even at the primary health care services (PHC).
4. The study gave a good implication for policy makers to revitalize the existing national population and RH strategy. Strategies should be developed and implemented at different levels in school, family and community level to increase and improve MDC.
5. The study implied the need for creation of sustainable advocacy works targeting the community to encourage open discussions among family members in general and on importance of communication between mothers and their adolescent daughters on SRH issues. Such advocacy work should involve religious leaders and institutions as well as mass media to encourage MDC, help resolve the cultural and religious sensitivities surrounding the issue and overcome such barriers.
6. Reliable information disseminated through the media (television and internet) and the educational system as schools should be designed and tailored to ensure that young people acquire accurate knowledge about their health, especially information on their SRH. Mass media and religious institutions should address misconceptions about different SRH issues such as FGM/C and should highlight the value of knowledge and dispel myths about withholding information from adolescents.
7. However, further research is needed in the following areas:
a. Intervention studies to improve MDC:
i. It’s recommended for future intervention programs to be based on control groups such as the quasi-experimental design or the RCT with larger sample size and longer term mixed qualitative- quantitative evaluation.
ii. Future interventions to improve MDC should consider a broader scope for evaluation of the effect of the intervention. The intervention should be evaluated not only from mothers’ perspective but also through girls’ perceptions of its effect. Impact of the intervention on girls’ knowledge, attitudes and behaviour should also be evaluated.
iii. Inclusion of parallel interventions for both mothers and daughters to improve MDC, this would increase the girls’ acceptance in order to give better results.
b. Examine the association and interaction between communication pattern and parenting style and Egyptian adolescents’ attitudes and behaviours towards SRH issues including engagement in risky behaviours and adopting protective ones.
c. Determine effective ways and best approaches of implementation and scaling up of parents–adolescents’ communication programs and interventions on SRH related issues under diverse social .