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Patterns and felt needs among college going adolescents regarding communication on sexual and reproductive health: a descriptive study

India has an adolescent population of 243 million, which constitutes a quarter of the total population of the country. 1 Based on the current status of sexual and reproductive health among Indian adolescents there is an extensive range of unmet needs. Significant proportions of young women in the country get married and bear child in their adolescence itself. More than 40 percent of the women aged 20-24 get married in India by the age of 18. Among the females who are 15-19 years of age, an alarming 16 percent have already gone through pregnancy and childbearing. Adding to the situation is the lack of universal coverage of sexual and reproductive ABSTRACT

health (SRH) programs in the country, even among the married who are given greater focus in these programs. 2 There are also high levels of premarital sex among college going Indian adolescents. The average levels of premarital sex range up to 40 percent and 20 percent among college going unmarried males and females respectively. 3 Age at marriage and childbearing has been historically low in India. But levels of premarital sex among college students can be a newer phenomenon and can be considered relatively higher given the rigid cultural norms still existing in the country. 4 These statistics can only increase with time and indicates that the fight against sexual and reproductive illness is only going to be harder than before.
Communication with parents regarding sexual matters has shown to have significant adverse impacts on risky sexual behaviors like unprotected sex among adolescents. Such discussions between parents and their adolescents, especially close relationship with mothers can reduce the incidence of early sexual initiation by teens and risk of STIs. [5][6][7] Studies has also proved that adolescents who have a good rapport with their parents and has an open discussion with their parents about sex related subjects like birth control, hazards of STDs are much likely to adhere to condom use. Also repeated communications on these topics help in having an open and committed relationship with their parents and more chance of discussing such issues with them in the future. 8 Research evidences also point that, the contents of communication as well as how parents communicate with their adolescents also matters in influencing adolescent risktaking behaviors in sex. 9 Despite the challenges that encompass with parentadolescent discussions on sex and related topics, it is now increasingly proving to be a successful intervention for behavior change among adolescents and parents. Many campaigns which have been initiated in many countries tries to center parents as pro-active change agents are gaining momentum in countries like United States. 10 Though similar evidences show that parents can have a significant role in shaping their adolescent's habits, this area still remains a poorly explored one, in India. Also shifting patterns like drop in the age of puberty attainment and delayed age at marriage has resulted in an increased window of unsupervised interaction between both genders during adolescence. Such circumstances of adolescents have changed rapidly in India, but the social norms have not kept up with these changes. Still communication between parents and adolescents regarding sex is a taboo subject. Parents who could be the best possible support to their children during puberty and a source of information on sex and sexual health, keep them ill-informed. The services in the society too have remained inaccessible and indifferent to the exact needs of adolescents. 11 This study will thus try to explore the patterns of communication between parents and adolescents regarding sexual and reproductive matters to start with and also about patterns and preferences of communication with their family. This can thus try laying a foundation for further researches in this area and try to build further on this theme.

METHODS
Community-based cross-sectional study among arts college students in Puducherry area of the Union Territory. Data collection and analysis was done from January 2015 to February 2015. The proportion of adolescents communicating regarding SRH in their family was considered as 29% from a study conducted elsewhere. 12 Based on this the final sample size was estimated as 381 with an alpha error of 5%, and absolute precision of 5% and taking into consideration a 20% nonresponse rate.
Communication regarding SRH with parents and family members was defined as; any form of discussion with adolescents and family members regarding their doubts about changes in the body, about reproduction, their sexual needs, about their thoughts, desires about sex, rights or wrongs in sex and opposite gender relationships. Discussion on SRH at least once in 6 months during the last 5 years was considered as presence of communication for the purpose of study.
From a list of all arts and science colleges in Puducherry, four colleges were selected randomly for the study. All first-year batch students, who are less than 20 years of old from were considered for the study. 100 participants from two or three batches, according to batch size were selected randomly from each college and approximately 400 students from four colleges were then chosen for the study. Those students who were not present at the date of survey were automatically excluded from the study. Data was collected using a pre-tested structured selfadministered questionnaire.
Data entry was performed using Epi Data version 3.1 and analysis were done using SPSS version 22 software. All the variables in the study were summarized in frequencies and proportions. Statistical analysis using chi-square was performed to find the association between gender and communication and odds ratio were used to determine the magnitude of communication and with parents and family members in the study. Table 1, more than half of the study population comprised of females and around 45 percent were male adolescents. As provided in Table 2, 135 adolescents (34.0%) discussed with mother and 59 adolescents (14.8%) discussed with father out of the 397 adolescents surveyed during the last five years. Also 118 adolescents (29.7%) responded that they have only communicated with family members other than parents regarding SRH. Among the 135 adolescents who reported communicating with mother around 80% were female adolescents and among the 59 adolescents who communicated with father majority (56%) were male adolescents. Among those who communicated with family members other than parents, females were of higher proportion (55%) compared to their male counterparts. 39.5% adolescents in the study have thus communicated with either mother or father regarding SRH at least once during the last five years. Also 50.6% study participants have discussed regarding SRH with at least someone in the family, which included close family members other than parents during the same period.   Parents and family don't know 12 (6.4%)

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As mentioned in Table 4, among the adolescents who discussed with at least one member in the family 39.5% responded that, parents or family members initiated the discussion and 23.6% responded that the discussions were initiated by the adolescents themselves. 36.8% of the adolescents were not sure who initiated such discussions. Almost half of the study population (50.6%) opined that it is necessary to have such discussions with family members regarding SRH. Out of 251 adolescents, who responded to the question on preferred person for discussion on SRH, 38.2% suggested mother as the most prefered and father as the least preferred person (5.9%) for such discussions. Among the adolescents who never discussed about sexual and reproductive health with their family members, the most common barriers were a feeling of inappropriateness (49.5%) to discuss such matters in the family and embarrassment to discuss SRH topics with family (45.7%).

DISCUSSION
The prevalence of communication on SRH with family was found as 34% with mother, 15% with fathers and 30% with other relatives in the family. One in two adolescents surveyed communicated with at least any one member of their family and 40% communicated with at least one parent in the family, during the last one year from the date of survey. Only 10% communicated with both their parents. However, female adolescents in the study had higher odds in discussing about SRH with at least someone in the family and also in communicating with mother, compared to their male counterparts. Similar findings were also reported in Ayalew et al. study, where they reported that males had lesser odds of SRH discussions with their mother and Selvan et al. in his study conducted in Mumbai, India. They found that females communicated more with their parents compared to males in the study. 12,13 Overall in the current study males had very low levels of parent-adolescent discussions related to SRH.
A lower level of parent-adolescent communication may be attributed to the cultural inhibitions and strong social norms that exist in their community. An even smaller proportion among father-daughter communication may be due to an amplification of the same social dimension at this level. Similarly, only a half of the participants thought that it was necessary to have such discussions on SRH in the family. This too, up to an extent may be attributed to a reflection of the existing cultural inhibition in the society. Considering the fact that the proportion of adolescents who felt that communication on SRH with family as necessary and the proportion of adolescents who communicated with at least one member in the family is similar, it may be discerned that, those who felt it is necessary might have communicated with any one member in the family. In a way this implies that, it is possible to achieve more active discussion on SRH issues among family members and adolescents, provided there is a need creation among adolescents from sources other than family like schools for instance.
Among the adolescents who discussed with at least one member in the family about SRH, almost 37% thought that they don't know who initiated such discussions. This is interesting considering the fact that they had discussed regarding SRH at least once in a year with at least one member in their family. Such a response may imply that, even though there are discussions happening, most of these could have been passive or indirect, which might have been initiated with the help of an external stimulus like television commercials for instance. Gailamo et al in their study also points out that in many instances, the communication between parents and adolescent regarding sex in India, occurs in a nuanced or indirect way than being in a direct and one-on-one fashion. 14 The key barrier in discussing about SRH perceived by one in two adolescents in the study were, a feeling of inappropriateness in discussing such matters with their parents and family, and embarrassment to discuss sexrelated topics. These findings were consistent with similar studies conducted in India, like those of Guilama Ramos et al., where the main barriers to parentadolescent communication were observed as embarrassment and inappropriateness to discuss. 14 The main reason that may have resulted in creating such a feeling among adolescents could be the cultural values that community expects from their children. Traditionally most of the Indian families attribute great moral values in chastity and sex is still a highly objectionable topic. Parents expect their children to be uncorrupt of sexual thoughts and feelings in them. These can create a sense of inhibition as well as fear of unexpected responses from their parents. It is also interesting to note that other barriers which many felt, like; parents did not have enough information about SRH, their knowledge in SRH and the availability of easy information on internet. All these in a way corroborates the inadequacy of parents and relatives in providing them with opportunities for discussion, as well as information on SRH. So, it is important that these social taboos around sex are attended with high priority, as much has been changed around the current adolescent's circumstances. It is also imperative that, families and communities should change their attitudes to accommodate the current trends of youth to have a healthy future generation. Though further studies are needed in this direction, it can be pointed out that better sexual and reproductive health among adolescents are achievable, provided there are effective interventions to promote a conducive environment for open discussions among youngsters and family members. It is also important that there is a pro-active demand generation among children right from the beginning years of their life, so that it may become a norm to have such discussions among children and their family.

CONCLUSION
Mothers are the most preferred individual in the family to have discussions on SRH for adolescents. Results suggest that encouraging adolescents and creating a need for