Abstract
The purpose of this study was to evaluate the sustained effects of a web-based program for parents of adolescents designed to help them engage in media mediation and high-quality parent-adolescent communication about sex, relationships, and media. A randomized control trial was conducted with parent-adolescent pairs (n = 375 pairs). Adolescents were in 7th-9th grade. Pairs were randomly assigned to either the intervention Media Aware Parent or active control (medically-accurate adolescent sexual health information). This study analyzed the impact of Media Aware Parent six months after pretest. Several outcomes significant at one-month posttest were sustained at six months, including enhanced parents’ media-related cognitions (e.g., media skepticism) and adolescent awareness of family media rules. Parents’ reports of restrictive media mediation and adolescents’ reports of their parent engaging in supportive parenting, which were not significant at posttest, emerged as significant at six months, signifying that the program resulted in changes in parent behavior and the parent-adolescent relationship over time. The impact of the program on parent-adolescent communication quality and adolescent sexual health and media-related outcomes diminished over time, suggesting the need for program boosters to encourage parents to continue engaging in high-quality conversations with their adolescent children about sex, relationships, and media.
Keywords: Adolescent Sexual Health, Parent-Adolescent Communication, Media Literacy Education, Prevention, Program Evaluation
Introduction
Both parents and media act as sexual socializing agents for adolescents (Scull & Malik, 2019; Vandenbosch, 2018; Ward, Moorman, & Grower, 2019). The messages parents convey to their children about sex often focus on health risks and consequences (Vandenbosch, 2018) and encourage adolescent risk avoidance and reduction behaviors such as delaying sexual debut and using protection during sexual activity (D. Flores, Barroso, J., 2017). However, the messages that adolescents receive from media about sex are often not in alignment with the information that parents are trying to convey. Not only is sexual content commonplace in media messages, but it is often portrayed void of information about the use of protection or possible negative health consequences such as sexually transmitted infections (STIs) and unplanned pregnancy (Scull & Malik, 2019; Ward, Erickson, Lippman, & Giaccardi, 2016). Numerous studies have revealed a relationship between sexual media exposure and adolescents’ sexual attitudes and behaviors (Collins et al., 2017), including longitudinal studies finding that higher levels of sexual media exposure encourage earlier sexual behaviors (Brown et al., 2006; Collins et al., 2004) and predict teen pregnancy, even when controlling for a variety of other factors (Chandra et al., 2008).
Parents can attenuate the potential negative impact of sexual media exposure on their adolescent children’s sexual health outcomes through both restrictive and active media mediation (Collier et al., 2016). Restrictive mediation aims to protect their children from unhealthy media influence by setting rules and/or limits around media exposure; whereas, active mediation aims to help their children understand media content, such as depictions of risky sexual behaviors, through discussions (Valkenburg, Kremar, Peeters, & Marseille, 1999). A meta-analysis found that both types of parental mediation were predictors of later sexual debut and fewer negative sexual health outcomes for adolescents (Collier et al., 2016). Research suggests that parental restrictive and active mediation are likely to be most effective when used together (Gentile, Reimer, Nathanson, Walsh, & Eisenmann, 2014). Even if parents limit their adolescent children’s media use, it is highly unlikely that they can completely shield their children from all sexual media content due to the prevalence of sexual content in entertainment and social media. Given that media message processing variables (e.g., perceived realism of media messages) have been shown to have a unique influence on adolescent sexual intentions (Scull, Malik, & Kupersmidt, 2018), parental active mediation may serve as a protective factor by teaching adolescents to critically analyze and evaluate the sexual media messages that they do encounter. However, before parents can effectively teach their adolescent children to critically process media messages, it stands to reason that they must themselves have the skills to do so. Not surprisingly, parents who report more critical thinking about media messages themselves are more likely to engage in both restrictive and active mediation with their children (Rasmussen, White, King, Holiday, & Densley, 2016). However, for parents to successfully engage in active mediation with their adolescent children about sexual media content, they should also have the skills to engage in effective parent-adolescent sexual health communication (SHC).
Parent-adolescent SHC can act as a protective factor that promotes adolescent sexual health. For example, adolescents, ages 13–17, were less likely to have had sexual intercourse if their parents had taught them to say “no,” set clear rules, and talked to them about delaying sexual activity, even after controlling for demographic factors (Aspy et al., 2006). A meta-analysis found that parent-adolescent SHC positively impacts adolescent condom and contraception use, with larger effects found for girls than boys and for communication with mothers than fathers (Widman, Choukas-Bradley, Noar, Nesi, & Garrett, 2016). While research is limited, characteristics of parent-adolescent SHC have been found to impact the effectiveness of these conversations, and research suggests that parent-adolescent communication and relationship dynamics are important factors in the effectiveness of parent-adolescent SHC. Parent-adolescent SHC that is open, comfortable, and respectful is associated with more positive adolescent sexual health outcomes (Rogers, 2016). Adolescents who regularly communicate with their parents regarding sexual health also report feeling closer to and more able to communicate with their parents (Martino, Elliott, Corona, Kanouse, & Schuster, 2008).
Parents face several barriers in effectively engaging in SHC with their adolescent children, including feeling unprepared and uncomfortable (Coakley et al., 2017). This is especially true for fathers, who may underestimate their competency in parent-adolescent SHC (Scull, Carl, Keefe, & Malik, 2022). Parent-based interventions designed to enhance adolescent sexual health can be effective in positively impacting adolescent sexual health outcomes, but rigorous outcome evaluations are necessary to establish and better understand program effectiveness (Wight & Fullerton, 2013). A meta-analysis of parent-based sexual health interventions found that they were associated with adolescent condom use, intentions to delay sexual activity and increased parent-adolescent communication (Widman, Evans, Javidi, & Choukas-Bradley, 2019). Several, but not all, of these programs focus on parent-adolescent SHC as an outcome, and, unfortunately, there has been virtually no research on parent-based programs for adolescent sexual health promotion that are designed to train parents in effective parental media mediation and high-quality parent-adolescent SHC.
Intervention description and short-term intervention effects
Media Aware Parent is an interactive web-based program for parents designed to provide parents with the skills and resources to effectively communicate with their adolescent children about sexual and relationship health as well as train parents in effective restrictive and active media mediation. The program consists of five interactive self-paced modules that cover wide range of adolescent sexual and relationship health topics including influences on teen sexual decision-making, gender stereotypes, social media and internet safety, teen dating, consent, abstaining from sexual activity, sexually transmitted infections, and contraception/protection. Throughout the program, parents build their own media literacy skills and learn effective ways to discuss media messages with adolescents in order to counter unhealthy media messages that promote risky sexual behaviors. Parents learn characteristics of high-quality parent-adolescent SHC (e.g., be nonjudgmental) and are provided with guidance on how to embody those characteristic when communicating with their child. Parents also have the opportunity to create a customized plan that outlines their family rules about media use. In addition to the main program sections (i.e., the five interactive modules), participants can access supplemental materials including a Spotlights section that contains short videos of adolescents talking about various sexual health related topics (e.g., teen dating) and a Resources section with additional information on health topics (e.g., pregnancy prevention) where parents are provided with links to trusted resources (i.e., U.S. FDA Birth Control Guide). While Media Aware Parent is designed for parents to complete without their children present, there are designated information pages and activities that, if desired, can be shared with their children by clicking a button on the page which automatically posts the content to a teen section of the program. Media Aware Parent can be accessed via computer or mobile device. An iterative process of program development was guided by prominent theories of behavior change and media processing (see Figure 1 for conceptual model). See Scull, Malik, Keefe, and Schoemann (2019) for additional program details.
Figure 1.
Conceptual model that guided program development
A short-term randomized controlled trial of Media Aware Parent found several positive effects of the program on parent and adolescent outcomes approximately one month after pretest (Scull et al., 2019). The program resulted in improved parent-adolescent communication quality as rated by both parents and adolescents. Adolescents were more likely to understand that their parent did not want them to have sex yet, and adolescents reported less willingness to hook-up, more positive attitudes about SHC and contraception/protection, and more self-efficacy to use contraception/protection, if they decide to have sexual activity. The intervention also improved media literacy skills in both parents and adolescents, and resulted in adolescents being more aware of family media rules.
The present study
For several reasons, including the fact that parent-adolescent conversations about sex are most effective when they occur on an ongoing basis (Martino et al., 2008), it is essential that evaluations of parent-based adolescent sexual health interventions go beyond exploring short-term effects (i.e., pretest-posttest). The present study utilized an intent-to-treat randomized control trial (RCT) design with an active control group to explore the impact of Media Aware Parent six months after the pretest data collection.
This study evaluated program effects on parent and adolescent self-reported outcomes related to parent-adolescent SHC and parental media mediation, as well as adolescent self-reports of variables that are known predictors of adolescent sexual activity and contraceptive/protection use and behavioral measures of adolescent sexual activity and contraception/protection use. The aim of this study was to explore whether the intervention effects of Media Aware Parent would diminish, sustain, or emerge at six-month follow-up. In addition, this study explored the impact of the program on adolescent sexual behaviors (i.e., sexual debut) and safe sex behaviors (i.e., contraception/protection use at last sex) at six-month follow-up, which, due to the relatively brief duration between assessments in the short-term evaluation (i.e. one month), were not hypothesized outcomes as posttest.
Methods
Participants
Study participants were adolescents in 7th, 8th, or 9th grade and their parent or caregiver. The analysis dataset was comprised of 339 parents and 331 adolescents. See Table 1 for sample characteristics. Parents in the sample were predominately mothers/female guardians. Most parents and adolescents in the sample identified as white. Parent participants were, on average, 40.75 years of age (SD=5.57) at pretest. Youth participants were, on average, 13.01 years of age (SD=0.87) at pretest. Chi-square analyses revealed that sample demographic characteristics did not differ between the intervention and control groups.
Table 1.
Sample demographic characteristics with results from chi-square analyses between groups
| n (%) | n (%) | n (%) | χ | p-value | |
|---|---|---|---|---|---|
|
| |||||
| Parent Characteristics | Overall (N=339) | Intervention (n=162) | Control (n=171) | ||
| Parent gender | 2.24 | .53 | |||
| Mother/female guardian | 244 (75.08) | 115 (74.68) | 129 (75.44) | ||
| Father/male guardian | 79 (24.31) | 37 (24.03) | 42 (24.56) | ||
| Non-binary/prefer not to disclose | 2 (0.62) | 2 (1.30) | 0 (0.0) | ||
| Missing/not reported | 14 | 8 | 0 | ||
| Parent race | 1.75 | .88 | |||
| Black/African-American | 43 (13.78) | 24 (16.00) | 19 (11.73) | ||
| White/Caucasian | 235 (75.32) | 110 (73.33) | 125 (77.16) | ||
| Asian | 6 (1.92) | 2 (1.33) | 4 (2.47) | ||
| Native American/Alaska Native | 2 (0.64) | 1 (0.67) | 1 (0.62) | ||
| Pacific Islander/Native Hawaiian | 2 (0.64) | 1 (0.67) | 1 (0.62) | ||
| More than one race | 24 (7.69) | 12 (8.00) | 12 (7.41) | ||
| Missing/not reported | 27 | 12 | 9 | ||
| Parent Ethnicity | .00 | 1.00 | |||
| Hispanic/Latino | 24 (7.41) | 11 (7.10) | 13 (7.69) | ||
| Not Hispanic/Latino | 300 (92.59) | 144 (92.90) | 156 (92.31) | ||
| Missing/not reported | 15 | 7 | 2 | ||
| Parent Education | 1.67 | .80 | |||
| Some High School | 6 (1.96) | 3 (2.05) | 3 (1.88) | ||
| High School Graduate/GED | 27 (8.82) | 13 (8.90) | 14 (8.75) | ||
| Some College/2-Year Degree | 115 (37.58) | 60 (41.10) | 55 (34.38) | ||
| 4-Year College | 86 (28.10) | 38 (26.03) | 48 (30.00) | ||
| Graduate/Professional Degree | 72 (23.53) | 32 (21.92) | 40 (25.00) | ||
| Missing/not reported | 33 | 16 | 11 | ||
| Parent Sexual Orientation | 2.48 | .65 | |||
| Straight/Heterosexual | 296 (93.67) | 140 (92.72) | 156 (94.55) | ||
| Gay or Lesbian | 7 (2.22) | 3 (1.99) | 4 (2.42) | ||
| Bisexual | 11 (3.4) | 6 (3.97) | 5 (3.03) | ||
| Prefer Not To Say/Self-Describe | 2 (.63) | 2 (1.32) | 0 (0.00) | ||
| Missing/not reported | 23 | 11 | 6 | ||
| Single Parent | 2.75 | .10 | |||
| Yes | 88 (26.83) | 49 (31.41) | 39 (22.81) | ||
| No | 240 (73.17) | 107 (68.59) | 132 (77.19) | ||
| Missing/not reported | 11 | 6 | 0 | ||
| SES (Free Lunch) | 1.23 | .57 | |||
| Yes | 99 (33.33) | 51 (35.66) | 48 (31.17) | ||
| No | 180 (60.61) | 85 (59.44) | 95 (61.69) | ||
| Don’t Know | 18 (6.06) | 7 (4.90) | 11 (7.14) | ||
| Missing/not reported | 42 | 19 | 17 | ||
| Adolescent gender | 4.91 | .30 | |||
| Female | 143 (44.14) | 68 (43.87) | 75 (44.38) | ||
| Male | 174 (53.70) | 81 (52.26) | 93 (55.03) | ||
| Non-binary/prefer not to disclose | 7 (2.16) | 6 (3.87) | 1 (0.59) | ||
| Missing/not reported | 15 | 7 | 2 | ||
| Adolescent race | 5.06 | .41 | |||
| Black/African-American | 42 (13.13) | 24 (15.79) | 18 (10.71) | ||
| White/Caucasian | 215 (67.19) | 101 (66.45) | 114 (67.86) | ||
| Asian | 4 (1.25) | 2 (1.32) | 2 (1.19) | ||
| Native American/Alaska Native | 2 (0.63) | 1 (0.66) | 1 (0.60) | ||
| Pacific Islander/Native Hawaiian | 2 (0.63) | 2 (1.32) | 0 (0.00) | ||
| More than one | 55 (17.19) | 22 (14.47) | 33 (19.64) | ||
| Missing/not reported | 19 | 10 | 3 | ||
| Adolescent Ethnicity | .25 | .61 | |||
| Hispanic/Latino | 44 (13.37) | 19 (12.18) | 25 (14.79) | ||
| Not Hispanic/Latino | 285 (86.63) | 137 (87.82) | 144 (85.21) | ||
| Missing/not reported | 10 | 6 | 2 | ||
Procedures
Parents were recruited from across the United States. Online and print fliers informed parents of the study and provided the study website address, where they could complete an online screener to determine eligibility and, if eligible, endorse online informed consent forms. To be eligible, they had to be a parent or caregiver of a child in 7th, 8th, or 9th grade, proficient in English, and have access to a laptop or tablet with Wi-Fi capabilities. Participants’ information was verified by phone. Parent-adolescent pairs were stratified by parent gender and race/ethnicity and randomized to intervention (n=185) or active control (n=190) (see Figure 2). Participants were emailed links to the web-based study questionnaires and parents and adolescents were instructed to complete their respective questionnaires separately. After both adolescents and parents completed the pretest questionnaire, intervention parents received online access to Media Aware Parent, and control parents received online access to professionally produced (e.g., U.S. Centers for Disease Control) medically-accurate sexual health brochures (PDFs) that corresponded to health topics in Media Aware Parent. While parents were asked to review their assigned resource within two weeks, they had access for the duration of their participation in the study. Participant pairs received a gift card incentive for each component of the study (i.e., $30 for pretest; $45 for resource review; $50 for posttest; $70 for follow-up questionnaire). The innovation Research & Training Institutional Review Board (IRB) approved of the methods and measures used in this study 18-003-1-EFF.
Figure 2.
CONSORT diagram
Measures
The analyses in this six-month follow-up evaluation included all measures that were analyzed in the short-term evaluation of Media Aware Parent, in addition to adolescent self-reported behavioral measures of sexual activity and protection use. Antecedent measures (see Table 2) included parent and adolescent reports on constructs related to effective parent-adolescent SHC and parental media mediation. Specifically, measures included parent and adolescent reports on variables related to parent-adolescent connectedness (i.e., supportive parenting; parent-child communication quality), parent SHC cognitions (e.g., perceived importance of parent-adolescent SHC), and parent and adolescent reports of the frequency of parent-adolescent SHC. Antecedent measures also included parent media-related cognitions that assess the degree to which one thinks more critically of and about media messages. These included assessing perceived realism of media messages, skepticism of media messages, and parents’ assessment of how complete the information was in a advertisement that used sexual themes to promote alcohol. Measures also included parent and adolescent reports of parental restrictive media mediation, parental evaluative media mediation, and awareness of family rules about media use (Table 2).
Table 2.
Parent (P) and Adolescent (A) antecedent measures
| Construct | # items | Response choices | Sample item | α |
|---|---|---|---|---|
| Parent-adolescent connectedness | ||||
| Quality of parent-adolescent communication (P)a | 16 | 4-pt scale (Strongly disagree to Strongly agree) | My child tries to understand my point of view. | 0.85 |
| Quality of parent-adolescent communication (A)b | 8 | 4-pt scale (Strongly disagree to Strongly agree) | My parent wants to understand my side of things when we talk. | 0.88 |
| Supportive parenting (P)c | 3 | 4-pt scale (Never to Always) | How often do you let your child know you care about them? | 0.75 |
| Supportive parenting (A)c | 3 | 4-pt scale (Never to Always) | How often does your parent let you know they care about you? | 0.83 |
| Parent sexual health communication cognitions | ||||
| Importance (P)d | 19 | 4-pt scale (Not at all important to Very important) | How important do you think it is to talk to your child about sexual consent? | 0.95 |
| Comfort (P)d | 19 | 5-pt scale (Not at all comfortable to Very comfortable) | How comfortable do you feel talking to your child about sexual consent? | 0.97 |
| Self-efficacy (P)d | 19 | 7-pt scale (Not sure at all to Completely sure) | I can always explain to my child about sexual consent. | 0.96 |
| Outcome expectancies (P)e | 23 | 4-pt scale (Strongly disagree to Strongly agree) | If I talk with my child about sex topics, I will feel like a responsible parent. | 0.89 |
| Reservations (P)f | 21 | 4-pt scale (Strongly disagree to Strongly agree) | It would embarrass my child to talk with me about sex and birth control. | 0.95 |
| Perceived role (P) | 1 | 4-pt scale (Strongly disagree to Strongly agree) | I feel that someone else would do a better job teaching my child about sex and relationships. | -- |
| Parent sexual health communication behaviors | ||||
| Frequency of sexual health discussions (P) | 1 | 4-pt scale (Never to Often) | How frequently do you talk to your child about sex and romantic relationships? | -- |
| Frequency of sexual health discussions (A) | 1 | 4-pt scale (Never to Often) | How frequently does your parent talk to you about sex and romantic relationships? | -- |
| Parent media-related cognitions | ||||
| Perceived realism (P)g,h | 6 | 4-pt scale (Strongly disagree to Strongly agree) | Teens in media are as sexually experienced as average teens. | 0.88 |
| Media skepticism (P)g | 5 | 4-pt scale (Strongly disagree to Strongly agree) | Media are dishonest about what might happen if people have sex | 0.76 |
| Media message completeness (P) | 1 | 5-pt scale (Incomplete to Complete) | How complete is the information in this advertisement? | -- |
| Parent media-related behaviors | ||||
| Evaluative media mediation (P)i | 5 | 4-pt scale (Never to Often) | How often do you explain what something in a media message really means? | 0.91 |
| Evaluative media mediation (A)i | 5 | 4-pt scale (Never to Often) | How often does your parent explain what something in a media message really means? | -- |
| Restrictive media mediation (P)i | 5 | 4-pt scale (Never to Often) | How often do you forbid your child to watch or listen to certain things in the media? | 0.83 |
| Restrictive media mediation (A)i | 5 | 4-pt scale (Never to Often) | How often does your parent forbid you to watch or listen to certain things in the media? | -- |
| Frequency of media/sex discussions (P) | 1 | 4-pt scale (Never to Often) | How frequently do you talk to your child about what they see in media about sex and relationships? | -- |
| Frequency of media/sex discussions (A) | 1 | 4-pt scale (Never to Often) | How frequently does your parent talk to you about what you see in media about sex and relationships? | -- |
| Media rules (P) | 1 | Yes, No, Unsure | Does your family have rules about media use? | -- |
| Media rules (A) | 1 | Yes, No, Unsure | Does your family have rules about media use? | -- |
adapted from Prado et al. (2007)
adapted from Mallett et al. (2011)
adapted from Conger et al. (2011)
adapted from Schuster et al. (2008)
adapted from DiIorio et al. (2001)
adapted from Jaccard, Dittus, and Gordon (2000)
adapted from Scull, Malik, and Kupersmidt (2014)
adapted from Pinkleton, Austin, Cohen, Chen, and Fitzgerald (2008)
adapted from Valkenburg et al. (1999)
Adolescent outcome measures included adolescent media-related outcomes (e.g., perceived realism of media messages), adolescent reports on constructs that are predictors of sexual behaviors (e.g., attitudes, normative beliefs, self-efficacy, willingness and intentions related to teen sexual activity and/or protection use) and adolescent self-reported sexual behaviors. Specifically, adolescents were asked if they had ever had oral, anal, or vaginal sex. If they responded that they had engaged in oral, anal, or vaginal sex, they were asked if they used a condom at last vaginal or anal sex, or a condom or dental dam at last oral sex (Table 3). An attention check was included on each questionnaire (“Answer 3 for this question.”). The learning management system that housed Media Aware Parent captured dosage including accessing and completing the main program sections (i.e., the five modules) and accessing the supplemental materials (i.e., Spotlights videos and Resources). For additional details on the measures see the short-term evaluation (Scull et al., 2019).
Table 3.
Adolescent outcome measures
| Construct | # items | Response choices | Sample item | α |
|---|---|---|---|---|
| Predictors of sexual behavior | ||||
| Perceived parental permissiveness | 5 | 4-pt scale (Strongly disagree to Strongly agree) | My parent would disapprove of my having sex at this time in my life. | 0.76 |
| Attitudes toward teen sexa | 4 | 4-pt scale (Strongly disagree to Strongly agree) | I think it is OK for teens to be sexually active. | 0.67 |
| Normative beliefs about teen sex | 1 | Open-ended percentage (0% to 100%) | What percentage of teens are having sex? [0% (no teens) to 100% (all teens)] | -- |
| Self-efficacy to abstain from sexb | 5 | 4-pt scale (Strongly disagree to Strongly agree) | I could say no to someone who is pressuring me to have sex. | 0.87 |
| Willingness to hook-upc | 1 | 4-pt scale (Very unwilling to Very willing) | Suppose you were with a boy/girlfriend. S/he wants to hook-up, but you are not sure that you want to. In this situation, how willing would you be to go ahead and hook-up anyway? | -- |
| Intentions to have sexd | 1 | 4-pt scale (Not likely at all to Very likely) | How likely is it that you will have any type of sexual contact with another person (oral sex, anal sex, vaginal sex, or genital-to-genital contact) in the next year? | -- |
| Predictors of safe sexual behavior | ||||
| Attitudes toward sexual communicationb | 5 | 4-pt scale (Strongly disagree to Strongly agree) | Before deciding to have sex, I believe teens should talk with their parents or another trusted adult. | 0.89 |
| Intentions to communicate with a medical professionale | 1 | 4-pt scale (Not at all likely to Very likely) | Before deciding to have sex, how likely would you be to talk to your Doctor or other medical professional? | -- |
| Attitudes toward teen contraception usea | 4 | 4-pt scale (Strongly disagree to Strongly agree) | I think condoms should always be used if a teen has sex. | 0.86 |
| Self-efficacy to use contraceptionb | 4 | 4-pt scale (Strongly disagree to Strongly agree) | If I wanted to, I could get condoms or another form of contraception. | 0.81 |
| Willingness to have unprotected sexc | 1 | 4-pt scale (Very unwilling to Very willing) | Suppose you were with a boyfriend/girlfriend. He/she wants to have sex, but neither of you have any form of protection. In this situation, how willing would you be to go ahead and have sex anyway? | -- |
| Sexual behaviors | ||||
| Sexual activity (oral, anal, or vaginal sex) | 3 | Yes, No, Not sure | Have you ever had oral sex? | -- |
| Contraception/protection use | 3 | Yes, No, Don’t know | Did you use a condom and/or dental dam the last time you had oral sex? |
-- |
| Media-related outcomes | ||||
| Teen risky online behaviorsf | 8 | 5-pt scale (Never to Always) | How often have you looked for sexual stuff online? | 0.77 |
| Perceived realismg, h | 6 | 4-pt scale (Strongly disagree to Strongly agree) | Teens in the media do things that average teens do. | 0.83 |
| Media skepticismg | 5 | 4-pt scale (Strongly disagree to Strongly agree) | Media do not tell the whole truth about relationships. | 0.73 |
| Media message completeness | 1 | 5-pt scale (Incomplete to Complete) | How complete is the information in this advertisement? | -- |
adapted from Basen-Engquist et al. (1999)
adapted from Soet, Dudley, and Dilorio (1999)
adapted from Gibbons, Gerrard, Blanton, and Russell (1998)
adapted from L’Engle, Brown, and Kenneavy (2006)
adapted from Scull, Kupersmidt, Malik, and Morgan-Lopez (2018)
adapted from Byrne, Katz, Lee, Linz, and McIlrath (2014)
adapted from Scull et al. (2014)
adapted from Pinkleton et al. (2008)
Statistical Analysis
Descriptive statistics were calculated for the intervention group’s use of the program and for the antecedent and adolescent outcome variables. To examine intervention effects, a residual difference score approach was used to provide an estimate of change from baseline (Little, 2013). The residual difference score approach is modeled by regressing follow-up scores onto baseline scores and the treatment variables. Binary outcomes were modeled with logistic regression. All analyses used standard errors which were robust to non-normality and heteroskedasticity and included gender, age, race, and ethnicity (for both parents and youth); youth’s rating of parental relationship quality; and parent’s religiosity as covariates.
Missing data were handled using listwise deletion (i.e., complete case analysis). This technique was chosen to allow us to use robust standard errors in all analyses. Missing data due to dropout was unrelated to intervention condition, demographic variables, and pretest scores on outcome variables. Non-dropout missing data was relatively rare, less than 5% of total responses. Using multiple imputation to handle missing data did not change the pattern of results reported below. Participants were excluded from the analyses if they failed attention checks at both baseline and follow-up, either by not answering the question or choosing the incorrect response (see Figure 2).
Results
Dosage
Parents engaged with the Media Aware Parent program primarily between pretest and one-month posttest. During this timeframe, parents completed, on average, 79% of the main program content (i.e., the five interactive modules) and it is estimated that they completed, on average, 69% of all available program content (Scull et al., 2019). In contrast, only five participants accessed Media Aware Parent after completing posttest. Four of these participants revisited fewer than four lessons in the program, and one participant revisited seven lessons. None of the participants accessed the control content after posttest.
Outcome Analyses
The intervention resulted in several significant changes in adolescent and parent variables at six-month follow-up (Table 4). Regarding antecedent measures, analyses revealed that three effects of the program that were found at one-month posttest were also found to be significant at six-month follow-up. Specifically, parents in the intervention group had greater increases in media skepticism from pretest to 6-month follow-up and greater decreases in ratings of media message completeness from pretest to 6-month follow-up than parents in the control group; adolescents in the intervention group were more likely to report increases in having family media rules from pretest than adolescents in the control group, OR=2.16.
Table 4.
Results from intent-to-treat analyses for parent (P) and adolescent (A) variables
| Measure | b | SE | p-value | d (CI) |
|---|---|---|---|---|
| Antecedent measures | ||||
|
| ||||
| Parent-adolescent connectedness | ||||
| Quality of parent-adolescent communication (P) | 0.00 | 0.04 | 0.93 | 0.01 (−0.22– 0.24) |
| Quality of parent-adolescent communication (A) | 0.01 | 0.05 | 0.83 | 0.02 (−0.22 – 0.25) |
| Supportive parenting (P) | −0.02 | 0.03 | 0.65 | −0.03 (−0.26–0.20) |
| Supportive parenting (A) | 0.15 | 0.07 | 0.02 | 0.24 (0.00-.48) |
| Parent sexual health communication cognitions | ||||
| Importance (P) | 0.03 | 0.03 | 0.27 | 0.08 (−0.15–0.31) |
| Comfort (P) | −0.04 | 0.03 | 0.31 | −0.07 (−0.31–0.15) |
| Self-efficacy (P) | −0.06 | 0.07 | 0.41 | −0.07 (−0.30–0.16) |
| Outcome expectancies (P) | 0.00 | 0.03 | 0.89 | 0.01 (−0.22–0.24) |
| Reservations (P) | 0.07 | 0.04 | 0.11 | 0.14 (−0.09–0.38) |
| Perceived role (P) | 0.06 | 0.03 | 0.09 | 0.17 (−0.07–0.40) |
| Parent sexual health communication behaviors | ||||
| Frequency of sexual health discussions (P) | 0.00 | 0.07 | 0.95 | 0.01 (−0.23 – 0.24) |
| Frequency of sexual health discussions (A) | 0.06 | 0.08 | 0.47 | 0.08 (−0.16 – 0.31) |
| Parent media-related cognitions | ||||
| Perceived realism (P) | −0.09 | 0.06 | 0.15 | −0.14 (−0.38–0.09) |
| Media skepticism (P) | 0.13 | 0.06 | 0.04 | 0.24 (−0.01–0.48) |
| Media message completeness (P) | −0.46 | 0.15 | 0.003 | −.38 [(−0.61)−(−0.15)] |
| Parent media-related behaviors | ||||
| Adolescent’s sexual media diet | 0.74 | 1.32 | 0.96 | 0.01 (−0.24–0.25) |
| Evaluative media mediation (P) | −0.08 | 0.06 | 0.18 | −0.15 (−0.38 – 0.08) |
| Evaluative media mediation (A) | −0.04 | 0.08 | 0.67 | −.04 (−0.28–0.19) |
| Restrictive media mediation (P) | 0.23 | 0.06 | <0.001 | 0.33 (0.10–0.57) |
| Restrictive media mediation (A) | 0.16 | 0.09 | 0.06 | 0.18 (−0.05–0.41 |
| Frequency of media/sex discussions (P) | −0.05 | 0.07 | 0.48 | −0.08 (−0.31 – 0.15) |
| Frequency of media/sex discussions (A) | −0.09 | 0.09 | 0.36 | −0.09 (−0.33 – 0.15) |
| Media rules (P) | 0.99 | 0.54 | 0.07 | 2.70 (0.97 – 7.02)OR |
| Media rules (A) | 0.77 | 0.33 | 0.02 | 2.16 (1.14 – 4.09)OR |
|
| ||||
| Adolescent outcome measures | ||||
| Predictors of sexual behavior | ||||
| Perceived parental permissiveness | 0.04 | 0.06 | 0.57 | 0.06 (−0.17 – 0.29) |
| Attitudes toward teen sex | −0.03 | 0.06 | 0.57 | −0.05 (−0.29 – 0.18) |
| Normative beliefs about teen sex | 0.06 | 3.4 | 0.98 | 0.00 (−0.30 – 0.31) |
| Self-efficacy to abstain from sex | −0.03 | 0.06 | 0.65 | −0.05 (−0.28–0.19) |
| Willingness to hook-up though unwanted | 0.10 | 0.08 | 0.20 | 0.14 (−0.09–0.38) |
| Intentions to have sexual activity | 0.09 | 0.08 | 0.24 | 0.12 (−0.11 – 0.35) |
| Predictors of safe sexual behaviors | ||||
| Attitudes toward sexual communication | 0.00 | 0.06 | 0.98 | 0.00(−0.23 – 0.24) |
| Intentions to communicate with a med professional | 0.18 | 0.11 | 0.12 | 0.17 (−0.07–0.42) |
| Attitudes toward teen contraception use | 0.00 | 0.06 | 0.95 | 0.01 (−0.23–0.24) |
| Self-efficacy to use contraception | 0.02 | 0.08 | 0.84 | 0.02 (−0.22–0.26) |
| Willingness to have unprotected sex | 0.00 | 0.01 | 0.91 | 0.00 (−0.24–0.24) |
| Sexual Behaviors | ||||
| Sexual activity (oral, anal, or vaginal sex) | 1.01 | 0.92 | 0.27 | 2.75 (0.52 – 14.61)OR |
| Media-related outcomes | ||||
| Teen risky online behaviors | −0.05 | 0.05 | 0.35 | −0.08 (−0.32–0.16) |
| Perceived realism | −0.04 | 0.07 | 0.56 | −0.06 (−0.30–0.17) |
| Media skepticism | 0.09 | 0.06 | 0.13 | 0.18 (−0.07–0.44) |
| Media message completeness | −0.04 | 0.15 | 0.77 | −0.04 (−0.27–0.20) |
OR = Odds ratios. These analyses used logistic regression and effect sizes are reported as odds ratios
Two new findings emerged at six-month follow-up that were not significant at one-month posttest. Adolescents in the intervention group had greater increases from pretest to six-month follow-up in their reports of supportive parenting as compared to the adolescents in the control group, and parents in the intervention group had greater increases in reports of engaging in restrictive media mediation than the parents in the control group.
The impact of the program on parent-adolescent communication quality, which was significant at posttest, was no longer significant at six-month follow-up. Media Aware Parent favorably impacted several adolescent media- and health-related outcomes at posttest, none of which were sustained at 6-month follow-up. At one-month posttest, adolescents whose parents were given access to Media Aware Parent reported greater decreases from pretest in perceived realism of media messages than youth in the control condition (Table 5). Additionally, adolescents in the intervention condition had greater increases from pretest to posttest in positive attitudes toward sexual communication, greater intentions to communicate with a medical professional about sexual health, and felt more efficacious to use contraception than adolescents in the control condition. Finally, adolescents in the intervention condition reported greater decreases from pretest to posttest in perceived parental permissiveness towards sex and willingness to hook up with a girlfriend/boyfriend if they were not sure that they wanted to than adolescents in the control condition. There were no significant differences between conditions regarding adolescent sexual behaviors from pretest to follow-up. Given that only about 3% of the sample responded to the contraception/protection use questions, the n was too small to analyze this variable.
Table 5.
Comparision of one-month and six-month results
| Results Sustained | Results Emerged | Results Diminished |
|---|---|---|
| Results sig. at one- and six-month timepoints | Results sig. only at six-month timepoint | Results sig. only at one-month timepoint |
| Media skepticism (P) | Restrictive media mediation (P) | Quality of parent-adolescent communication (P) |
| Media message completeness (P) | Supportive parenting (A) | Quality of parent-adolescent communication (A) |
| Media rules (A) | Perceived parental permissiveness (A) | |
| Willingness to hook-up though unwanted (A) | ||
| Attitudes toward sexual communication (A) | ||
| Intentions to communicate with a med professional (A) | ||
| Self-efficacy to use contraception (A) | ||
| Perceived realism (A) |
See Scull et al. (2019) for results at one-month timepoint.
Discussion
It is well established that high-quality parent-adolescent SHC can enhance adolescent sexual health outcomes. Parental restrictive and active media mediation can also enhance adolescent sexual health by attenuating the potentially negative impact of sexual media messages on adolescent sexual decision-making. This can be done by parents effectively setting media rules for their children to limit exposure to unhealthy content and teaching their children to critically think about media messages so they can analyze and evaluate the messages they encounter. Media Aware Parent was developed to be a web-based program for parents designed to enhance parent-adolescent SHC and media mediation with the goal of improving adolescent sexual health outcomes. Short-term impacts of Media Aware Parent include enhanced parent–adolescent communication quality, increased adolescent awareness of family media rules, and improved adolescent outcomes related to sexual activity and safe sex (Scull et al., 2019). The purpose of the present study was to evaluate the effects of Media Aware Parent over a longer (six month) timeframe.
Media Aware Parent resulted in sustained effects on parent media-related cognitions and behaviors. Specifically, at both one-month posttest and six-month follow-up, the program resulted in increases in parents’ skepticism of sexually-themed media messages and decreased their perception that a sexually-themed alcohol advertisement was complete. This suggests that parents thought more critically about the message and evaluated the message as missing important information. This demonstrates that teaching adults media literacy skills can result in sustained changes in media-related cognitions and critical media message processing skills. Interestingly, while the short-term evaluation of Media Aware Parent revealed that the program decreased adolescents’ perceived realism of teen behavior in media, this change was not sustained over time. It is possible that once adults learn media literacy skills and become more advanced critical thinkers about media messages, these changes endure, whereas, adolescents may need ongoing media literacy education in order to remain critical media processors. While parents themselves likely continued to critically analyze and evaluate the media messages that they encountered in the months after using the Media Aware Parent program, it appears that they did not engage their adolescent child in ongoing critical conversations about media messages as suggested by the lack of a significant findings for either parent or adolescent reports of active mediation. Adolescents’ continued exposure to media messages that normalize and glamorize unhealthy sexual and relationship behaviors in the absence of ongoing critical media analysis practice may have led adolescents to regress toward baseline perceptions of media realism. While younger children lack the cognitive abilities to elaborate on and critically process media messages, as youth proceed through adolescents their cognitive processing abilities become more sophisticated (Buijzen, Van Reijmersdal, & Owen, 2010). More research is needed to explore developmental differences along the lifespan in the acquisition, retention, and application of critical media processing skills and factors that influence changes in media-related cognitions, such as the perceived realism of media messages.
Interestingly, there were two findings not found in the one-month evaluation that emerged over the course of six months: parent reports of restrictive media mediation and adolescent reports of their parent engaging in supportive parenting. The emergence of a significant findings for parental restrictive media mediation suggests that, over time, parents began implementing more restrictive media mediation techniques that may have been learned in Media Aware Parent. The positive impact of the program on parental restrictive media mediation is particularly encouraging given that media restriction predicts later and fewer unhealthy adolescent sexual outcomes (Collier et al., 2016). It is important to note that changes in adolescent reports of parental restrictive media mediation were not significant at either one-month posttest or six-month follow-up. It is possible that over time parents did not actually change their behaviors regarding restrictive media mediation, but did become more aware of them. It is also plausible that parents did increase their restrictive media mediation over time, and may have done so in a way that did not make adolescents feel that their parent was putting restrictions upon them or forbidding them from using certain media. The latter explanation is supported by the fact that the effect of Media Aware Parent on adolescents reporting that they were aware of family rules about media use was sustained overtime. This suggests that the program resulted in parents effectively communicating family media rules. Adolescents may distinguish, to some extent, between the presence of family media rules and parental restriction of their media use (i.e., they were aware of their family’s media rules, but may not have felt that their parent was restricting/forbidding their media use). As young adolescents progress through the teen years and seek greater independence and autonomy, their resistance to parental media rules and restrictions is likely to increase. It may be increasingly important for teens to feel that they are part of the media rule making process as they get older. Media Aware Parent encourages parents to include their children in the media rule making process and revisit media rules with their children on an ongoing basis. However, future research is needed to understand the relationship between adolescents’ awareness of family media rules and their adherence to those rules.
The other finding to emerge over the course of six months was related to the parent-adolescent relationship. Adolescents in the intervention groups had greater increases from pretest to six-month follow-up in reports of parental support than adolescents in the control group. The emergence of this finding suggests that Media Aware Parent resulted in longer-term positive changes in aspects of the parent-adolescent relationship beyond communication quality. Specifically, the program impacted parents’ behaviors toward their child over time resulting in adolescents feeling that their parents let them know they cared about them, helped them, and listened to them more. Warm supportive parenting is associated with a plethora of positive child and adolescent outcomes. Research has consistently found that parent-adolescent closeness and connectedness is a protective factor against adolescent risky sexual behaviors and negative sexual health outcomes (Markham et al., 2010; Miller, Benson, & Galbraith, 2001). It is important to note that the main focus of Media Aware Parent was not to enhance the parent-adolescent relationship, yet the program resulted in parents engaging in more supportive parenting behaviors months after using the program. Parent reports of supportive parenting did not significantly increase, suggesting that parents may not have felt that they were engaging in more supportive parenting behaviors, but their children perceived them as being more supportive.
Media Aware Parent resulted in many immediate positive impacts on parent and adolescent outcomes. However, it is a relatively brief intervention and most parents did not engage/revisit the program after the initial completion. Therefore, it’s reasonable to expect that some findings would not be sustained. The short-term impact of Media Aware Parent on enhancing the quality of parent-adolescent communication appeared to have degraded over six months, which suggests that the program’s impact on communication-quality may be dependent on parents using the program and immediately following the guidance, activities, and prompts in the program to engage their adolescent child in high-quality conversations about sexual health. As parents completed the program between pretest and one-month follow-up, they were likely engaging their adolescent child in conversations about sexual health on a regular basis as instructed in the program and employing the specific communication strategies taught in the program, which were designed to directly enhance parent-adolescent communication quality.
Similarly, the short-term impact of Media Aware Parent on adolescent sexual health outcomes also diminished over time. The dosage data show that virtually no participants engaged with the program after one-month posttest. This suggests the need for boosters, text messages, or additional content in the program (e.g., text messages with new activities and reminders) to encourage parents to continue to engage with the program overtime, and directly instruct them on ways to engage their child in ongoing high-quality conversations about sexual health. It is likely that the changes in adolescent sexual health outcomes were dependent on parents engaging in on-going high-quality conversations with their child about sexual health and having these conversations on a regular basis. Interestingly, this suggests that parents did not continue to engage in these conversations on their own after completing the program and need specific reminders and guidance to continue these conversations. Future research is needed to better understand the effect of boosters on program effects over time and to identify which aspects of the program drives program effects.
Media Aware Parent did not significantly improve parents’ cognitions related to SHC either in the short- or longer-term. For example, the results did not show improvements in parents’ perceived importance of or comfort with parent-adolescent SHC or the reported frequency of parent-adolescent SHC after one month in the short-term study or after six months in the current study. The active control group was provided with high-quality information about adolescent sexual health. Therefore, it is plausible that parents, regardless of condition, felt that they had the information to prepare them to communicate with their adolescent children about sex and felt fairly confident in doing so; however, the communication that was taking place did not appear to have been as effective for the active control group based on the fact that adolescents in the intervention group experienced more positive outcomes over time. Research has shown that the impact of parent-adolescent communication about sex is dependent on the content that is discussed as well as the communication quality and characteristics of the parent-adolescent relationship (D. Flores & Barroso, 2017). Simply having medically-accurate information about adolescent sexual health does not appear to be sufficient for effective parent-adolescent SHC. Future research should continue to explore how these factors may mediate the relationship between parent-adolescent SHC and adolescent sexual health outcomes.
There are several strengths to this study. This study expanded on research exploring the short-term effects of Media Aware Parent to evaluate program effectiveness over time. Parent-adolescent SHC is most effective when it is not a one-time talk, but rather when it takes place on an ongoing basis. Therefore, it is essential to understand the effectiveness of parent-based programs over time. Another strength of this study is that it included both parent and adolescent reports to identify not only how this parent-based program impacted parents but, importantly, how it impacted their adolescent children. The study also benefited from a rigorous randomized control trial design that included an active control of high-quality medically-accurate information about adolescent sexual health. Finally, this study employed an intent-to-treat analysis allowing for a realistic evaluation of the program due to the fact that in a real-world setting parents sometimes may not start or complete a program.
It’s important to consider the limitations of the study. First, a very small percentage of adolescent participants at follow-up had ever had engaged in sexual activity (i.e., less than 4%). Future research should follow a large group of adolescents over a longer period of time to evaluate if the program impacts sexual debut and contraception/protection use behaviors. Second, this study used an intent-to-treat design which, while also a study strength, may underestimate the program’s impact due to the fact that participants who did not engage or fully engage with the program were included in the analyses. Future analyses should employ complier average causal effect (CACE) analysis to investigate the impact of program dosage on effects. Another limitation is that the parents in the sample were predominately white/not Hispanic or Latinx. Future research should include a larger more diverse sample, which would improve the generalizability of the results. Parents in this study were also predominately mothers/female guardians. It is important that future research explore the impact of this program on fathers and male guardians. Fathers are underrepresented in research on parent-child SHC and recent research suggests that fathers may underestimate their abilities to engage in effective SHC with their adolescent child and would benefit from evidence-based programs and resources (Scull et al., 2022).
Conclusion
An abundance of research has established that parents can have a positive impact on the sexual and relationship health of their adolescent children, specifically through high-quality communication within the context of a supportive parent-adolescent relationship. Parent-adolescent communication about sexual health is most effective when it takes place on a regular basis and over time. Research has also established that parental restrictive mediation, active mediation, and enhanced media literacy skills can have a positive influence on adolescent sexual health. It is essential that programs designed for parents with the aim of enhanced adolescent sexual health outcomes are rigorously evaluated over time. This study found that over six months, the evidence-based Media Aware Parent program demonstrated sustained improvements in parent media cognitions as well as the emergence of parental restrictive media mediation behaviors and improvements in the parent-adolescent relationship that were not revealed in the short-term program evaluation. However, few parents revisited the program in the six-month timeframe after the initial intervention and the short-term positive impacts of the program on adolescent sexual health outcomes and parent-adolescent communication quality were found to diminish over time. This study enhances our understanding of the sustained impact of an evidence-based program for parents with the aim of improving adolescent health outcomes and suggests the need for web-based programs to leverage interactive features to provide parents with additional content (e.g., boosters, text reminders) to encourage repeated program engagement and subsequent parent-adolescent communication over time.
Implications and Contribution.
The positive impact of Media Aware Parent on parents’ media-related cognitions and adolescents’ awareness of family media rules were sustained at six months after pretest.
Media Aware Parent resulted in parents reporting that they engaged in more restrictive media mediation and adolescents reporting that their parents engaged in more supportive parenting at six-month follow-up.
The short-term impact of Media Aware Parent on adolescent sexual health outcomes, adolescent media cognitions, and parent-adolescent communication quality diminished over time, suggesting the need for program boosters to maintain positive outcomes.
Acknowledgments:
This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number R44HD082968 to Dr. Tracy Scull. Research reported in this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Disclosure of conflicts: The first two authors are employed by a small business. The business has a financial interest in the copyright and sale of the Media Aware Parent program for research and clinical purposes.
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