CONTEXT: The relative effectiveness of interventions to improve parental communication with adolescents about sex is not known.
OBJECTIVE: To compare the effectiveness and methodologic quality of interventions for improving parental communication with adolescents about sex.
METHODS: We searched 6 databases: OVID/Medline, PsychInfo, ERIC, Cochrane Review, Communication and Mass Media, and the Cumulative Index to Nursing and Allied Health Literature. We included studies published between 1980 and July 2010 in peer-reviewed English-language journals that targeted US parents of adolescents aged 11 to 18 years, used an experimental or quasi-experimental design, included a control group, and had a pretest/posttest design. We abstracted data on multiple communication outcomes defined by the integrative conceptual model (communication frequency, content, skills, intentions, self-efficacy, perceived environmental barriers/facilitators, perceived social norms, attitudes, outcome expectations, knowledge, and beliefs). Methodologic quality was assessed using the 11-item methodologic quality score.
RESULTS: Twelve studies met inclusion criteria. Compared with controls, parents who participated in these interventions experienced improvements in multiple communication domains including the frequency, quality, intentions, comfort, and self-efficacy for communicating. We noted no effects on parental attitudes toward communicating or the outcomes they expected to occur as a result of communicating. Four studies were of high quality, 7 were of medium quality, and 1 was of lower quality.
CONCLUSIONS: Our review was limited by the lack of standardized measures for assessing parental communication. Still, interventions for improving parent-adolescent sex communication are well designed and have some targeted effects. Wider dissemination could augment efforts by schools, clinicians, and health educators.
Adolescent sexual behavior is a normal developmental milestone. However, the social and public health consequences of adolescent sexual activity are tremendous. Of the 18 million sexually transmitted infections diagnosed in the United States each year,1,2 half occur in adolescents.3,–,5 Pregnancy affects 750 000 adolescents annually, 80% of which are unintended.6 Despite recent declines in the number of sexually active adolescents, engagement in risky sexual behaviors remains problematic.7
Adolescents who recall a parent talking with them about sex are more likely to report delaying sexual initiation8,–,10 and increasing condom8,11,12 and contraceptive11,13 use. In light of these findings, interventions for improving parental communication about sex have been developed.14 Although dozens of interventions exist, they have not been rigorously compared. We sought to examine whether interventions for improving parental communication with adolescents about sex are effective at strengthening multiple communication domains and to assess the methodologic quality of these interventions.
With the assistance of health science librarians, 6 databases were searched: OVID/Medline (1980 to July 2010), PsychInfo (1980 to July 2010), ERIC (1980 to July 2010), Cochrane Review (until July 2010), Communication and Mass Media (1980 to July 2010), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to July 2010). We used terms for parent (eg, parent, caregiver), parenting (eg, mother-child relations, father-child relations), communication (eg, communication, health promotion), sex (eg, sex education, sex counseling), and experimental design (eg, intervention studies, pilot projects, clinical trials) along with Boolean connectors (ie, and, or). To identify additional articles that met our inclusion criteria, we hand-searched the reference list of each article on parent-adolescent communication, including review articles (see Fig 1 for an example of 1 of our search strategies).
We included studies that were published between January 1980 and July 2010; were published in peer-reviewed, English-language journals; empirically measured the effectiveness of interventions for improving parental communication with adolescents about sex; targeted parents of adolescents aged 11 to 18 years in the United States; and used an experimental or quasi-experimental study design that included a control group and a pretest/posttest design. Studies could target mothers, fathers, or both. Studies could target communication by parents with daughters, sons, or adolescents of both genders.
We initially searched each database to create a list of potentially eligible articles on the basis of title review. If there was any question of the article's relevance based on the title, we reviewed the abstract. If an abstract was not available or the articles' eligibility remained questionable after reading the abstract, we read the full text. For instances in which a single intervention was described in multiple published articles, we counted the interventions only once. The paper-based abstract and article review forms were pilot-tested and revised 3 times before the final forms were selected. Each pilot test was performed in a new electronic database. After the third pilot test, the forms functioned well for data abstraction from the remaining databases. We double-entered the abstracted data into a structured Excel database (Microsoft, Redmond, WA). Our review protocol is available on request.
Abstracted information included the interventions' inclusion and exclusion criteria, when the intervention was conducted, recruitment strategies, geographic setting, intervention- and control-group characteristics, study design (eg, number of intervention sessions, intervention site and content), data-collection methods, primary outcomes, and attrition rate.
Only findings that resulted from statistical tests of hypotheses assessing relationships between the intervention (exposure) and its effects on parental communication (outcome) were extracted. For cases in which multiple postintervention assessments (eg, immediate postintervention, 3-month, 6-month) were made, we abstracted outcome data for each assessment time point. When insufficient data were presented in the published article to determine outcome results, we contacted the study authors to obtain the necessary data. We contacted the authors of 2 studies to obtain the means and SDs for the communication outcome measures they reported to permit comparison with data reported from other included studies. These data also would have aided in calculating effect sizes. In both instances, we reached the study authors but were unable to obtain the necessary data. However, we did not exclude any data. We report study results as they were cited in each author's original article.
We abstracted data on multiple aspects of communication. Our selection of outcomes was guided by the integrated conceptual model (ICM).15,16 This model had previously been used to examine parental communication about sex. Developed by a National Institutes of Health consensus panel of health behavior experts, the ICM posits that 3 factors are necessary and sufficient for parent-adolescent communication to occur: skills; intentions; and the absence of environmental barriers or presence of facilitators of the behavior. Four factors influence intentions: self-efficacy; perceived social norms; attitudes toward the behavior; and outcomes expected to occur as a result of engaging in the target behavior. Finally, 2 factors influence the previous 4: knowledge and beliefs about the behavior. We acknowledge that systematic reviews usually select only 1 outcome variable to examine. We included multiple domains of parental communication, because we recognized that a strict approach would severely limit the number of studies that would meet our inclusion criteria and, more importantly, would provide a less robust description of interventions' effect on parent-adolescent communication. When available, we included outcomes reported by parents and adolescents, because their perspectives regarding whether and how discussions about sex have occurred are often incongruent.17,–,20
Each study's test of the relationship between intervention participation and a communication domain was counted as a separate finding. Thus, a single study could contribute multiple findings (eg, communication frequency, quality, self-efficacy). Furthermore, when unadjusted and controlled analyses were reported in the same study, only findings from the controlled analyses were abstracted, because they provide a more precise measure of effect. Two reviewers independently abstracted all data and then met to discuss and compare their findings. The interrater reliability for data abstraction was 0.97.
Ideally, each intervention's effect on a given communication domain would have been converted to an effect size that provides a standardized measure of the magnitude of each intervention's effect, which would have allowed us to perform a meta-analysis and calculate pooled effect sizes for each communication domain. However, this was not possible because of variability in how communication domains were defined and measured across the studies.
We systematically recorded information regarding each intervention's methodologic characteristics. We used a previously described and validated methodologic quality scoring (MQS) system.21,22 Scores on the 11-item MQS ranged from 0 to 20. Scores were grouped to denote lower- (score of 0–6), medium- (score of 7–14), and higher- (score ≥ 15) quality studies. The data were again abstracted by 2 independent coders, and the interrater reliability was 0.90.
Thirty-three parent-adolescent communication interventions were identified; 12 met inclusion criteria. Fig 2 shows the flow diagram for study inclusion and exclusion. Twenty-one studies were excluded. Several studies met more than 1 exclusion criteria. Four studies were excluded because they lacked a control group23,–,26; 9 did not report parent-adolescent communication outcome data27,–,35; 1 did not report outcome data for parent participants, only for adolescent participants36; 3 included parents of younger children but did not stratify outcome data on the basis of the age of participating parents' children25,26,37; 1 only included parents of preschool-aged children38; parents participated in multiple interventions simultaneously in 1 study, which made it impossible to determine the individual effects of the parent-adolescent communication program39; and 4 included non-US samples.40,–,43
Of the 12 included studies, 8 were published between 2000 and 2008.44,–,51 The studies were published in 11 journals that represent a variety of disciplinary fields including psychology,46,50,52 family relations,44,53,54 adolescent health,47,55 general medicine,51 public health,48 nursing,56 and sexual health.49
Overview of Communication Outcomes
Across all 12 studies, we identified 2 measures of actual communication: the frequency of parent-adolescent discussions about sex-related topics and the content of those discussions. Content of communication was assessed by using 3 measures: the number of sexuality-related topics ever discussed, as well as new and repeated topics discussed between follow-up periods. Specific measures regarding skills, intentions, self-efficacy (or comfort), attitudes, and outcomes expectations were identified. No studies assessed communication knowledge, environmental barriers/facilitators of communication, or perceived social norms regarding communication. Although we also found no measures that were explicitly titled “beliefs about communicating,” items contained in measures of perceived quality of communication seemed to tap parental beliefs about communicating. Hence, we review outcome data on quality measures in “Quality (ie, Beliefs) of Communication.”
Studies varied widely in the number of communication domains assessed. The 2 most common domains measured were frequency and content of communication. Eight studies assessed communication outcomes by using both parent and adolescent reports. Every intervention used different measures to assess each of the communication domains. Most of these measures were developed by the investigators for their individual study.
Table 1 summarizes the characteristics of each of the 12 interventions included in this review. Six interventions were conducted in the South,47,48,50,54,–,56 3 in the West,46,51,53 2 in the Midwest,44,52 and 1 in the Northeast.49 Only 2 targeted rural populations.50,53 We assigned each intervention an urban/rural designation on the basis of the authors' report of intervention location and the US Census definition of urban/rural areas.57 Nine studies were conducted as randomized controlled trials, and the remainder used quasi-experimental designs.
Although the studies targeted parents of adolescents in different age ranges, all of them included parents of middle school students aged 11 to 14. Only 2 included high school students.46,51 One-third of the studies specifically targeted fathers48 or mothers,46,50,56 and the remainder included predominantly mothers despite both parents being eligible. Participants in 3 studies consisted mostly of white respondents,53,–,55 6 included predominantly black respondents,44,45,47,–,50 and the remainder included samples with more than 2 racial/ethnic groups.46,51,52
In general, authors of the studies reported that their interventions increased parental reports of parent-adolescent communication regardless of the communication domain assessed (Table 2).
Compared with adolescents, parents seemed more likely to report that interventions had a positive effect on communication domains and reported larger preintervention/postintervention changes. We summarize the findings for each communication domain below.
Frequency of Communication
In 5 of the 6 studies that assessed frequency of communication, parents reported an increase in communication from before to after testing.44,47,52,53,55 No change was noted in 1 study.46 Four studies assessed adolescent reports of changes in the frequency of communication: 2 resulted in increases47,53; the adolescent result was not reported for 1 study52; and 1 resulted in no change.46 Only 1 study compared the magnitude of change in the frequency of communication between parents and adolescents; parents reported a larger change than adolescents.47
Content of Discussions
Six studies assessed the content of parent-adolescent conversations.45,46,48,–,51 Because of heterogeneity in how this communication domain was defined (ie, number of new topics discussed, repeated topics, individual topics discussed, percentage of topics discussed, mean number of topics discussed, and percentage that reported lower scores from scale measures), it is difficult to summarize the findings. In general, parents reported an increase in the content of communication, whereas adolescent reports were highly varied. Only 1 study compared the magnitude of change in the mean number of repeated topics reported by parents and adolescents.51 The study authors found that parents reported discussing more topics at the postintervention assessment than adolescents.
Skills for Communicating
One study assessed parental skills for communicating.46 In that study, parents and adolescents were directly observed discussing both sexuality and AIDS. The skills assessed were how long the mothers and adolescents each spoke, how many questions mothers asked, the number of open-ended questions the mothers asked, maternal display of warmth, maternal display of support, and maternal use of nonjudgmental behaviors. Compared with mothers in a control condition, mothers who participated in the intervention group spoke less and were less judgmental when discussing AIDS at the postintervention assessment compared with the preintervention assessment. Compared with mothers in a control condition, mothers who participated in the intervention group asked more open-ended questions when discussing sexuality or AIDS at the postintervention assessment compared with the preintervention assessment.
Intentions to Communicate
Self-efficacy for Communicating
Five studies assessed parental self-efficacy for communicating.45,47,–,49,51 Data were reported from only 4 studies.47,–,49,51 In all 4 studies, parents reported an increase in their self-efficacy for communicating. Two studies assessed adolescent reports of changes in self-efficacy. In 1 study, adolescents reported an increase in their perception of their parents' self-efficacy for communicating with them about sex.47 In the second study, adolescents reported an increase in their self-efficacy for communicating with their parent about sex.51 Only 1 study compared the magnitude of change reported by parents versus adolescents, and the authors noted that parents reported a larger change than adolescents.47
Comfort With Communicating
Three studies reported communication comfort instead of or in addition to self-efficacy.44,–,46 Parents reported an increase in comfort in 2 studies.44,45 Only 1 study reported data from adolescents, and the authors noted an improvement.46 The magnitude of the change in communication comfort reported by parents and adolescents was not compared in any of these studies.
Attitudes Toward Communicating
One study assessed attitudes toward communicating, and the authors noted no significant change in parents' or adolescents' self-reported personal attitudes towards parent-adolescent communication about sex.54
Outcomes Expected to Occur After Communicating
Two studies assessed the outcomes expected to occur as a result of parent-adolescent discussions about sex.45,48 Both studies assessed only parental perspectives, but the authors of only 1 study reported actual data for this outcome45 and noted no change in outcome expectations.
Quality (ie, Beliefs) of Communication
Quality of communication was included as a marker of parental beliefs about communicating. In both studies that assessed the quality of communication, parents reported improvements.51,53 The duration of this effect seemed to decline over time in 1 study53 yet continued to improve significantly in the other.51 Adolescents reported improvement in the quality of communication in 1 study51 but no change in quality in the other.53 The magnitude of the change in quality reported by parents and adolescents was not compared in either study.
The frequency distributions for each element of the MQS are listed in Table 3. MQSs ranged from 6 to 16 points (mean: 12 ± 3) (Table 4). Only 1 study had an MQS in the lower-quality range54; 7 were of medium quality,44,46,48,49,51,52,55 and 4 were of high quality.45,47,50,53
Studies infrequently reported validity or reliability data for the measures used to assess study outcomes. For 7 studies the communication outcome measures were developed de novo,46,47,49,51,53,–,55 and psychometric data were reported for their scales in only 3 studies.
All the interventions used a quantitative, questionnaire-based analytic paradigm; follow-up cross-sectional study designs were the most frequently used. None of the studies used a qualitative research paradigm or mixed-methods evaluation approach.
Five studies used a longitudinal design (ie, postintervention assessment with at least 1 additional follow-up assessment). Four of these studies conducted 1 immediate postintervention assessment and 2 additional follow-up assessments; the other study included 1 postintervention assessment and 1 additional follow-up assessment. In these longitudinal studies, participants were followed for a maximum of 9,51 12,47,48 or 2445 months.
Sample Size and Design
Nine studies used a medium sample size44,48,50,53,54 (100–300 participants) or larger45,47,49,51 (>300 participants), but the majority of them used convenience, nonprobability samples. None of the studies included a sample that was both randomly selected and nationally representative. Conduction of a power calculation to determine the sample size needed to assess the study outcomes was reported for only 2 studies.
Half the studies used multiple or logistic regression techniques to analyze their data,45,47,48,51,53,55 whereas one-third reported only bivariate methods (eg, correlations or analysis of variance).44,46,52,54 The authors of only 2 studies cited using a repeated-measures design.49,50 Similarly, few authors reported using analytic techniques to account for nested study designs for studies in which the participants participated in group-based facilitated interventions or when they were recruited from multiple settings (eg, schools, community organizations). Use of multivariate analytical techniques (eg, structural equation modeling) was not reported from any study.
Inferences of Causality
Given many of the studies' sample and design limitations, we were interested in assessing each researcher group's awareness and acknowledgment of their study's limitations and ability (or not) to establish cause-effect relationships. Among the reviewed studies, limitations of the findings were accurately reported for 10; authors of 2 reports inappropriately stated or implied that their intervention was effective despite multiple threats to internal validity (eg, sample size, analytic approach, limited follow-up data) that made such determination difficult.
We compared the effectiveness and methodologic quality of select interventions that met our inclusion criteria and were designed to improve parents' ability to communicate with their adolescents about sex. Our evaluation was limited by the fact that every study used a different measure to assess the same communication domain. Which measures are used will certainly affect whether significant findings are observed. Despite this heterogeneity among the communication-outcome measures, the data suggest that parent-adolescent communication interventions have some targeted effects. Compared with controls, parents who participate in these interventions experience improvements in multiple communication domains. We noted improvements in the frequency, quality, intentions, comfort, and self-efficacy for communicating. We did not find any effect on parental attitudes toward communicating or the outcomes they expected to occur as a result of communicating.
Communication is a complex process. We assessed specific aspects of the communication process defined by our guiding conceptual model. However, other facets of communication and other conceptual frameworks are likely equally important. For example, Jaccard58 identified 5 aspects of parent-adolescent communication as important: the extent of communication as measured by frequency and depth of discussions; the style or manner in which information is communicated; the content of the information discussed; the timing of communication; and the general family environment or overall relationship between the parent and child. Had we assessed a different set of communication outcomes, our overall perception of the effectiveness of these interventions may have differed.
Although positive effects on the frequency, content, and psychosocial mediators of parental communication with adolescents about sex were noted for most interventions, few studies assessed the durability of these effects over time. Those that did found mixed results. Because adolescents' sexual knowledge and behaviors change throughout adolescence, parents' approach to discussing sex with their adolescents must change as well. It remains unclear whether participation in these interventions provides sufficient support for parents' communication efforts throughout their child's adolescence. Future studies should seek to clarify the long-term effect of these interventions on parent-adolescent communication about sex.
The explicit teaching and measurement of communication-skills acquisition received little attention in the studies included in this evaluation. Yet, the results indicate that the approaches parents take when talking with their adolescent about sex may have a tremendous influence on the adolescent. For example, parents who dominate conversations (ie, talk more) have adolescents who are less knowledgeable about sexual health topics.59,60 Because communication skills are important, researchers have suggested that parents be taught certain general communication skills such as how to talk less and listen more, be less directive, ask more questions of their adolescent, and behave in a nonjudgmental fashion.46,61,–,63 Adolescents whose parents engage in these behaviors report greater comfort discussing sex with their parents and discussing more topics.46 Research in this area needs a greater focus on identifying which communication skills are most effective for transmitting sexual health knowledge and decision-making skills to their adolescents.
With 1 exception, mothers were the primary participant in all interventions. None of the studies compared intervention effects on fathers and mothers. Although mothers primarily communicate with adolescents about sex,11,64,–,66 fathers do play a role in their adolescents' sexual socialization.67 However, mothers and fathers play different roles.68,69 Kirkman et al68 examined the role of fathers in family discussions about sex through in-depth interviews with parents and adolescents of both genders. They found that the pubertal transition often disrupts the relationship and communication patterns fathers have with their children; that fathers find discussions about sex difficult and distressing; and that fathers generally leave the task of talking about sex to mothers, although fathers perceive the responsibility of communicating to be a shared one. Additional work is needed to explore intervention effects on mothers versus fathers, because interventions for improving parental communication about sex may require tailoring to maximize their effectiveness among each. Similarly, none of the included interventions explored whether intervention effects varied according to adolescent gender. Given that parental discussions about sex vary in frequency and content for adolescent boys and girls,66,69,70 additional work is needed to determine if these interventions produce differential effects based on adolescent gender.
Despite the limitations inherent in parent-adolescent communication interventions, our interpretation of the data is that these interventions, at a minimum, improve the frequency and content of discussions about sex between parents and their adolescents. Wider dissemination of the interventions seems warranted but should be done in conjunction with additional studies that clarify these interventions' effects. For example, communication measures should be standardized, and differential intervention effects among mothers versus fathers and among adolescent boys versus girls should be explored.
The need to expand delivery of interventions for improving parental communication with adolescents about sex is exemplified by a recent troubling report. The report cited data from 1988, 1995, and 2002 and showed significant declines in US female adolescents' reports of parent-adolescent communication about contraception and sexually transmitted infections and stable but low reporting by adolescent boys of discussions with parents about contraception.71 These declines coincided with decreases in adolescent reports of receiving school-based sex education and increases in adolescent birth rates.72 Thus, adolescents seem to be experiencing a historic reversal in reproductive health trends while receiving less information about sexual health topics from both parents and schools. Increasing delivery of content via parent-adolescent communication interventions could play a critical role in reducing adverse outcomes among adolescents.
A major challenge in scaling up delivery of parent-adolescent communication interventions is achieving economy of scale. As noted in our review, most existing interventions involve face-to-face facilitated formats. Face-to-face interventions require trained personnel, require significant time commitments by parents, and have limited reach because few parents can be accommodated per training cycle. Mass media, multimedia, and some of the new social-networking programs may be critical for disseminating these interventions more widely. They are less costly once development costs have been expended, which makes them potentially more affordable and easier to disseminate. Few of the interventions included used mass-media formats, and none of them used small media (eg, Web, text-messaging).
When evaluating interventions, it is useful to know not only whether an intervention is effective but to understand what intervention components are most correlated with success. Because we were unable to calculate effect sizes, we cannot state whether more effective studies have specific characteristics or components in common. Moreover, few authors reported whether their sample size was sufficiently powered, which makes it is impossible to know whether the findings are truly significant. Each study used different communication measures, often creating them de novo and infrequently providing details about the measures' psychometric properties. Lack of detail about the measures' generalizability or reliability when tested in different populations makes it difficult to compare results across studies. It also means we were unable to determine which communication domains are most strongly affected by parent-targeted interventions.
Parent-targeted interventions for improving parental communication with adolescents about sex have been well designed and improve multiple facets of family communication. However, communication measures need to be standardized to make it easier to compare the effectiveness of various interventions. The relative effect of these interventions among mothers and fathers are unknown. Given that parental communication is associated with positive effects on adolescent sexual behavior, these interventions may represent a valuable tool for improving adolescent sexual and reproductive health.
This project was supported by National Institutes of Health Roadmap Multidisciplinary Clinical Research Career Development Award grant 1 KL2 RR024154-01. Support was also provided by the Robert Wood Johnson Foundation Amos Medical Faculty Development Program. Information on the NCRR is available at www.ncrr.nih.gov, and information on Re-engineering the Clinical Research Enterprise can be obtained from http://commonfund.nih.gov/clinicalresearch/overview-translational.aspx.
Anne E. George and Karen Derzic assisted with data abstraction.
- Accepted December 2, 2010.
- Address correspondence to Aletha Y. Akers, MD, MPH, Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, 300 Halket St, Pittsburgh, PA 15213. E-mail:
Dr Akers designed the study; Dr Akers and Ms Holland abstracted the data; and Dr Akers, Ms Holland, and Dr Bost analyzed the data and prepared and reviewed the manuscript.
The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources or of National Institutes of Health.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Funded by the National Institutes of Health (NIH).
- MQS =
- methodologic quality score
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- Copyright © 2011 by the American Academy of Pediatrics