Parent-youth communication and concordance between parents and adolescents on reported engagement in social relationships and sexually intimate behaviors in Ha Noi and Khanh Hoa Province, Viet Nam

Abstract

Purpose

Parent-child communication is associated with positive outcomes for youths’ engagement in sexual behaviors. Limited data are available regarding parent-child communication in transitional countries. We present data from Vietnamese parent-youth dyads on parent reproductive health knowledge, comfort of communication, frequency of talk, and discordancy between youths’ reported and parents’ perceptions for engagement in relationships and sexually intimate behaviors.

Methods

185 randomly selected parent-youth dyads in four communes in Ha Noi and Khanh Hoa Province. Descriptive and comparative analysis included chi-square tests, independent samples t-tests, and ANOVA. Linear regression analysis was utilized to assess relationships between parental knowledge, level of comfort, frequency of talk, and discordancy.

Results

Seventy-six percent of parents and 44% of youth were female. Youth mean age was 17.2 years. For parental “reproductive health knowledge” mean score was 24.74 (SD 3.84: range 15–34). Lower parental reproductive health knowledge was positively associated with lower levels of education [F=2.983, df 184: p=0.014]. Data indicate a linear model in which knowledge is related to “comfort” (β =0.17; p=0.048) and “comfort” to frequency of “talk” (β =0.6; p<0.0001). Frequency of “talk” is not related to parents’ discordant perceptions regarding their child’s reported involvement in relationships (β =0.002; p=0.79) or sexual touching (β =0.57; p=0.60).

Conclusions

Parent and youth in Viet Nam are engaged in limited communication about reproductive health. There is need for more data to assess the impact of these communication patterns on youths’ engagement in sexual behaviors and for development of family-centered interventions to increase parental knowledge and skills for positive communication.

Introduction

Parental communication with adolescents regarding sexuality is regarded as critical toward informing adolescents of risks and protective behaviors, providing guidelines on values and standards of behavior, and decreasing likelihood of youths’ engagement in risk behaviors [1,2,3]. Outcomes associated with positive parent-child communication about engagement in sexual behaviors include a “buffering” effect in relation to delay of sexual initiation [4,5].

Parent-child communication may be hampered by social stigma and parental reluctance to discuss sensitive issues particularly about sexuality. A review of qualitative global research on adolescent and young adult sexual behavior reveals that social norms and expectations regarding sexuality can negatively impact both the likelihood and the quality of parent-adolescent communication about sex [6]. To date, there are a limited number of studies focused on parent-child communication outside of Western populations and countries. In a qualitative study in Portugal, African immigrant youth expressed discomfort and that they seldom engaged in communication with parents about sexual issues [7]. In a study with 15–19 year old Chinese adolescents, communication about sexuality between children and their parents were infrequent [8].

In Viet Nam, pre-marital sexual relations especially for young women is socially taboo and youth report high levels of perceived stigma associated with engagement in sexual behaviors [9]. Nonetheless, data indicate that premarital sexual relationships have increased in Viet Nam over the past decade [10,11]. Survey research with adolescents and young adults (18–29 years) indicate that among sexually active respondents, about 44% (78% males and 13% females) report engagement in premarital sex. Among sexually active respondents, 57% males and 9% females report multiple lifetime partners. Among sexually active males, 31% of respondents report having sex with a commercial sex worker [12]. In our own research, data suggest rates of sexual activity among young unmarried men (18–24 years) increases significantly after age 20. Among young men 18–20 years, less than 9% report engaging in vaginal, anal, and/or oral sex. However among young men 21–24 years, these rates increase from between 24% to over 33% [13]. Condom use and use of other contraceptives among unmarried Vietnamese adolescents and young adults is generally inconsistent [13] resulting in increased risks for unwanted pregnancies, STIs, and HIV/AIDS [14,15,16,17].

Reproductive health (RH) resources for Vietnamese youth include community-based programs, e.g., through Youth Union activities, written materials, internet sites, and school-based curricula. Access to these programs however is unsystematic and affected by factors such as engagement in state-sponsored organizations, literacy levels, and school-status. In relation to school-based RH education, programming is limited in terms of materials, time allocation, and teacher training. Teachers often feel discomfort teaching RH material and with increasing competition for university placement, both teachers and students are reluctant to use class time for information not included on examinations. In addition, the coursework is provided in mixed-gender classes and a majority of teachers are women, decreasing likelihood that boys and young men will feel comfortable asking questions and participating in discussions.

In Viet Nam, parent-child communication about relationships, sexuality, and associated health risks is often avoided or limited to parents simply telling their adolescents and young adult children not to have sex. Vietnamese parents often feel embarrassed talking about sensitive issues, but also hold to ‘traditional’ beliefs that information about sexuality, pregnancy, and contraception are not appropriate for adolescents and unmarried young adults. Academic goals may overshadow the need for youth to obtain reproductive information, as parents perceive that young adults should not be engaged in relationships until after completing their studies [18, 19]. Research in the United States suggests embarrassment at discussing sexuality can hinder communication between parents and their children. Alternatively, parent-child communication can be facilitated if parents feel self-efficacious in regards to their ability to talk about sex [20].

In the current paper, we present data from baseline evaluations from parents and their adolescent children (15–20 years) participating in a randomized control trial (RCT) of a gender-based RH intervention (Exploring the World of Adolescents - EWA) [21]. Our primary research questions are: 1) How concordant are youths’ reported engagement in relationships and sexually intimate behaviors and parents’ reported knowledge of these relationships and behaviors; 2) What is the level of parents’ knowledge regarding RH (including pregnancy, STIs and HIV/AIDS); 3) How frequently do parents discuss with their child issues related to sexuality, pregnancy and contraception, STIs and HIV/AIDS; 4) What are parents comfort levels discussing these topics with their child; and, 5) What is the relationship between parental knowledge, level of comfort discussing RH topics, frequency of talking about RH, and concordance between child’s reported behaviors and parents’ reported knowledge of those behaviors. These data provide ground work for greater understanding of parent-child communication in Viet Nam and potential avenues for interventions to improve communication about relationships and sexuality within families.

Methods

Research Sites

The RCT was conducted in 12 communes in Ha Noi, and Nha Trang City and Ninh Hoa District in Khanh Hoa Province, Viet Nam. Communes are geo-political units in Viet Nam. U.S. and Vietnamese collaborators decided commune selection criteria. Communes in each site were purposefully selected based on variations by socio-economic status, population density (urban, suburban, and rural), and location within sites (e.g., central and peripheral areas of Hanoi). As part of the RCT, communes were randomly selected to be in one of three interventions (Vietnamese Focus on Kids [22], EWA [21], and EWA+Parent Intervention). The four sites selected for the EWA+Parent Intervention include one commune each in Ha Noi and Ninh Hoa and two communes in Nha Trang.

Ha Noi, the capitol of Viet Nam has a population of 3,150,000. Since 1986, economic renovation policies have transformed the city from its post-war state to a modern cosmopolitan center resulting in rapid social and economic transitions. Khanh Hoa located on the South-Central coast of Viet Nam includes six districts, one township and the provincial capital, Nha Trang. Nha Trang (population ~380,000) is a small urban area with semi-rural communes on the periphery of the city. It is a popular seaside resort for both domestic and foreign tourists, with tourism as its primary industry. Ninh Hoa District is approximately 35-kilometers north of Nha Trang. Industry in Ninh Hoa includes shipping, fish and shrimp farming, and agriculture. These sites were selected to represent different regions of the country and to ensure that urban and rural youth were included in the RCT.

Research Population and Sampling

Youth aged 15–20 years were randomly selected from commune census lists to participate in the RCT. From the four communes randomly selected to receive the EWA+Parent Intervention, 630 youth-parent dyads were selected, 359 (57.0%) were contacted and 271 youth (75.5%) and 185 parents (51.5%) completed baseline evaluations. Primary reasons for not contacting youth and non-participation included households had moved, youth not living at home (traveling for work, school, military service) and youth unable to commit time for attending the intervention. The current paper includes data from the 185 parent-youth dyads.

Data Collection

Scale Development and Evaluation Instrument

Scales for the youth evaluation instrument were based on those developed and adapted by the current research team in previous surveys and evaluations with Vietnamese adolescents [22]. The parent evaluation instrument scales were developed to be complementary to those on the youth instrument and incorporated items derived from qualitative interviews conducted with parents and adolescents as a part of the initial needs assessment phase of the RCT. All scales underwent a quantitative pilot including test-retest to assess reliability and a qualitative pilot to ensure item clarity and that the meanings and intent of the items were maintained with translation.

Scales and items in the youth and parent instruments relevant to the current analysis are described in Table One.

Table One.

Items and scales from youth and parent evaluation instrument

Youth Items
Demographics	Gender (male/female); Age (continuous); Employed (yes/no); In-school (yes/no); Education (no school/primary school; secondary, high school, college/university, technical school, continuation school1)
Socialization	How much time do you spend per week with friends? (less than 5 hours; 5 to 15 hours; 16 to 25 hours; 26 hours or more); Ever have girlfriend/boyfriend? Do you currently have a girlfriend/boyfriend (yes/no); Length of longest relationships (continuous).
Engagement in sexual behaviors	Ever [sexually] touch a boy/girl? Ever been [sexually] touched by boy/girl? Ever have vaginal sex? Anal sex? Oral sex? (yes/no)
Parent Items and Scales
Demographics	Gender (male/female); Age (continuous); Employed (yes/no); Education (see youth demographics); research site (Nha Trang, Ninh Hoa, Ha Noi)
Perceptions of child’s behavior	Has your child ever had a girlfriend/boyfriend? (yes/no) Has your child ever touched/been touched [sexually]? (yes/no) Has your child ever had sexual intercourse? (yes/no)
Knowledge	Pregnancy knowledge [5 items]; STI knowledge [11 items]; HIV/AIDS knowledge [22 items] (true/false).
Communication	How often start conversation about [relationships, sex, pregnancy/contraceptives, STIs, HIV/AIDS, standards for sexual behavior] (Never, rarely, sometimes, often) [range 0 to 18; chronbach’s alpha= 0.84] How comfortable are you talking with your child about [relationships, sex, pregnancy/contraceptives, STIs, HIV/AIDS, standards for sexual behavior] (very uncomfortable, uncomfortable, comfortable, very comfortable) [range 0 to 18; chronbach’s alpha=0.90]. Parent-child communication scale (14 items; strongly agree, agree, disagree, strongly disagree) [range 14 to 56; chronbach’s alpha=0.89]

¹Continuation school provides a high school equivalency education for adults

Recruitment

Staff from Khanh Hoa Provincial Health Services and Ha Noi Medical University worked with community recruiters in each commune. Recruiters included staff from commune health centers and members of the youth unions. Recruiters were trained regarding the research project objectives and recruitment procedures. Recruiters went to selected households, determined youth eligibility, and provided youth and parents with study information. Eligibility criteria included unmarried and not planning to be married in the next 12 months, and ability to attend the intervention two hours per week for 10 weeks (June-August 2006). The recruiters provided youth with a day and time to meet with research staff. The meetings took place both in youths’ homes and in public meeting spaces, e.g., commune health centers. For youth under 18 years, a parent needed to be present at the meeting for consent. In those communes assigned to the EWA+parent intervention, parents were invited to the first parent program session.

Data Collection Procedures

Youth evaluation data were collected in May-June 2006 at commune health centers and at youth’s homes. Parent evaluation data were collected in June 2006 immediately prior to the first parent intervention session. Youth evaluations were on an individual basis with same-gendered data collectors. Parent data were collected within intervention groups. Parents were instructed at the beginning of the evaluation to consider their responses only in relation to their child enrolled in the program.

To ensure greater confidentiality, data collectors read each item and response options to the respondents. Respondents marked their answer on a separate copy of the survey. Respondents unable to read or follow the survey were provided the opportunity to verbally respond to the evaluation. Data collection took between 60 and 90 minutes. Respondents were provided a stipend (~$3.00) for completion of the baseline evaluation.

Data Management and Analysis

Data were double entered into the SpSS data entry program [version 4.0] by trained staff. Variables were created for the scales and indices including the parent-child communication scale, frequency of talk (“talk”), level of comfort talking to child (“comfort”) and the knowledge scales (pregnancy, sexually transmitted infections, HIV/AIDS). A RH knowledge variable was created which combined the pregnancy, STIs, and HIV/AIDS scales. Youth reports of engagement in sexual touching (touched/been touched) were combined to create the variable “anytouch.” Categorical variables (discordant and concordant) were developed for youths’ reported behaviors and parents’ perceptions of their child’s engagement in girl/boyfriend relationships, sexual touching (“anytouch”), and vaginal intercourse.

Descriptive analysis was performed using proportions for categorical variables and means for continuous variables. Chi-square test was used to compare proportions among demographic groups and parent-child concordance for relationships and sexual behaviors. Independent samples t-tests were used to compare means across items with two groups (male/female; yes/no) and ANOVA for those items with more than two groups. Linear regressions analysis was used to assess relationships between parental knowledge, level of comfort and frequency of talking to youth, and discordancy between parent and child in reported behaviors.

Ethical Review

The project was approved by the institutional review board of University of Maryland Baltimore School of Medicine and the ethical committee of Khanh Hoa Provincial Health Services. Participants younger than 18 years signed an assent form and their parent/guardian signed a consent form. All other participants signed a consent form. All research staff were trained in ethical research and obtaining consent.

Results

Demographics

Seventy-six percent (140/185) of parents and 44% (81/185) of youth were females. Among parents, male respondents were slightly older (48.8 years) than female respondents (45.7 years) [t=3.321, df,181: p=0.001]. Mean age of youth was 17.2 years. Overall, 13.5% (25/185) youth were out-of-school, with 48.0% (12/25) of those youth having completed high school. Of youth in school, 80.0% (128/160) were attending high school. There were no significant differences in education levels or employment for parents or for youth by gender. Among parents there were significant differences in education by site with 44.5% (8/18) Ha Noi parents completing post-high school education compared to 28.8% (30/104) in Nha Trang and 4.8% (3/63) in Ninh Hoa District [X² =55.00, df 14: p<0.000]. Among youth out of school, there was no significant difference by site for level of education completed [X² =2.083, df, 4: p=0.720].

Youth Social Relationships

Male respondents reported spending more time than females per week socializing with their friends [X²=20.26, df, 3: p<0.001]. A total of 35.6% (37/104) males and 32.1% (26/81) females report ever having a girl/boyfriend. Among those youth ever in a relationship, 66.7% (24/36) boys and 54.2% (13/24) girls reported being in a relationship at the time of the interview.

While approximately one third of youth stated they ever had a girl/boyfriend, only a small percentage of parents reported their child ever having a girl/boyfriend. In paired analysis, for both male and female youth there were significant differences between parents’ perceptions of their child’s involvement in relationships and their child’s reported behaviors (see Table 2).

Table Two.

Parent-youth agreement with regard to relationships and sexually intimate behaviors, stratified by gender of youth

“ever have girl/boyfriend”
		Parents – “yes”		Parents – “no”
		%	N	%	N
Sons***	Yes	27.8%	10/36	72.2%	26/36
	No	3.0%	2/67	97.0%	65/67
Daughters*	Yes	20.0%	5/25	80.0%	20/25
	No	3.6%	2/55	96.4%	53/55
“ever engage in sexual touching”
Sons	Yes	6.7%	1/15	93.3%	14/15
	No	1.2%	1/82	98.8%	81/82
Daughters	Yes	0	0	100%	3/3
	No	0	0	100%	78/78
“ever engage in vaginal sex”
Sons	Yes	0	0	100%	3/3
	No	0	0	100%	100/100
Daughters	Yes	0	0	0	0
	No	0	0	100%	80/80

^*p<0.05:

^***p<0.001 from chi-square test

Youth and Sexual Behaviors

Relatively few youth reported sexual behaviors with 19.2% (20/104) males and 3.7% (3/81) females reporting sexual touching, 1.9% (2/104) males reporting oral sex and 2.9% (3/104) males reporting vaginal sex. No females reported either oral or vaginal sex and neither males nor females reported anal sex. Of males reporting sexual touching, only one parent also reported his/her son engaging in sexual touching. None of the parents reported either sons or daughters ever engaged in vaginal sex (Table 2). In at least two cells of the 2-way tables for females and sexual touching, and for both males and females in regards to vaginal sex the outcomes are “0” and therefore no chi-square and significance can be calculated. However, there is a clear trend indicating parents do not perceive their children to be engaging in sexually intimate behaviors.

Parent RH knowledge

Parental mean scores for knowledge were 3.38 (SD1.98: range 0–5) for pregnancy, 7.79 (SD 1.60: range 4–11) for STIs, and 13.56 (SD 2.88: range 5–20) for HIV/AIDS. A composite variable for “RH knowledge” was created from the above 3 scales with a mean of 24.74 (SD 3.84: range 15–34). There was no significant difference in mean RH knowledge by parents’ gender [t=0.397, df 183: p=0.692] or research site [F=1.703, df 184: p=0.185]. However, knowledge was associated with level of education [F=2.983, df 184: p=0.014] with lowest knowledge among parents who attended continuation school (mean=22.0 SD 5.3: range 18–26) and highest among parents who attended college/university (mean=26.7 SD 3.6: range 21–34).

Parents reported communication with child

Parents were asked how often they started conversations with their child about relationships, sex, pregnancy and birth control, HIV/AIDS, STIs, and parental standards for sexual behavior. Parents were also asked how comfortable they were discussing these topics with their child. Parents were most likely to discuss relationships and HIV/AIDS and least likely to discuss sex, and pregnancy and birth control. There were no significant differences in either starting conversations or level of comfort between parents of sons and parents of daughters (see Tables 3 and 4).

Table Three.

Comparison of parents frequency of “talk” with sons and daughters about relationships, sex, pregnancy & birth control, HIV, STIs, and standards for sexual behaviors

Content	Talk with Sons				Talk with Daughters				Gender Differences
Start conversation about	Never	Rarely	Sometimes	Often	Never	Rarely	Sometimes	Often
Relationships	18.3% 19/104	5.8% 6/104	42.3% 44/104	33.7% 35/104	18.5% 15/81	2.5% 2/81	35.8% 20/81	43.2% 35/81	X2 =2.736 df 3 p=.434
Sex	76.0% 79/104	13.5% 14/104	6.7% 7/104	3.8% 4/104	66.7% 54/81	9.9% 8/81	16.0% 13/81	7.4% 6/81	X2 =5.765 df 3 p=.124
Pregnancy and birth control	72.1% 75/104	8.7% 9/104	10.6% 11/104	8.7% 9/104	59.3% 48/81	11.1% 9/81	18.5% 15/81	11.1% 9/81	X2 =3.741 df 3 p=.291
HIV/AIDS	23.0% 23/100	3.0% 3/100	42.0% 42/100	32.0% 32/100	26.3% 20/76	3.9% 3/76	34.2% 68/76	35.5% 27/76	X2 =1.146 df 3 p=.776
STIs	34.6% 36/104	3.8% 4/104	33.7% 35/104	27.9% 29/104	35.8% 29/81	7.4% 6/81	32.1% 26/81	24.7% 20/81	X2 =1.295 df 3 p=.730
Standards for sexual behavior	35.6% 37/104	7.7% 8/104	32.7% 34/104	24.0% 25/014	46.3% 37/80	2.5% 2/80	27.5% 22/80	23.8% 19/80	X2 =3.926 df 3 p=.270

Table Four.

Comparison of parents level of comfort discussing relationships, sex, pregnancy & birth control, HIV, STIs, and standards for sexual behaviors with sons and daughters

	Sons				Daughters				Gender Differences
Level of comfort discussing	Very uncomfortable	Uncomfortable	Comfortable	Very comfortable	Very uncomfortable	Uncomfortable	Comfortable	Very comfortable
Relationships	8.8% 9/102	13.7% 14/102	49.0% 50/102	28.4% 29/102	11.1% 9/81	21.0% 17/81	45.7% 37/81	22.2% 18/81	X2 =2.429 df 3 p=.488
Sex	27.3% 27/99	34.3% 34/99	26.3% 26/99	12.1% 12/99	29.1% 23/79	31.6% 25/79	29.1% 23/79	10.1% 8/79	X2 =0.435 df 3 p=.933
Pregnancy & Birth Control	21.6% 22/102	29.4% 30/102	35.3% 36/102	13.7% 14/102	20.0% 16/80	26.3% 21/80	40.0% 32/80	13.8% 11/80	X2 =0.479 df 3 p=.924
HIV	9.7% 10/103	9.7% 10/103	52.4% 54/103	28.2% 29/103	11.3% 9/80	18.8% 15/80	46.3% 37/80	23.8% 19/80	X2 =3.476 df 3 p=.324
STIs	8.7% 9/104	24.0% 25/104	43.3% 45/104	24.0% 25/104	12.3% 10/81	22.2% 18/81	45.7% 37/81	19.8% 16/81	X2 =1.106 df 3 p=.776
Standards of Sexual Behavior	7.7% 8/104	25.0% 26/104	46.2% 48/104	21.2% 22/104	16.3% 13/80	25.0% 20/80	38.8% 31/80	20.0% 16/80	X2 =3.508 df 3 p=.320

Two variables were created to measure parents’ overall assessment of frequency of talking to their child about issues related to sexuality and relationships (“talk”) and level of comfort with these discussions (“comfort”). The overall mean score for “talk” was 7.74 (range 0–18) and for comfort was 9.86 (range 0–18). There were no differences in either frequency of “talk” or level of “comfort” by parent’s or child’s gender. There was a difference in frequency of “talk” by research site [F=3.421 df 184: p=0.035]. There were also significant differences in frequency of “talk” [F=2.863 df 184: p=0.016] and “comfort” [F=3.693 df 184: p=0.003] by parents’ education with lower education associated with less frequent talking to child and lower level of comfort (Table 5).

Table Five.

Mean scores for frequency of talking about relationships and sexuality (“talk”), “comfort” of talking about relationships and sexuality, and “parent-child communication” by parent and child gender, research site, and parent education

		“talk” (range 0–18, 0=never talk, 18=often talk)	“comfort” (range 0-18, 0=very uncomfortable 18=very comfortable)	Parent-child communication (range 14–56, with higher score indicating more communication barriers)
Parent gender	Male	7.2	10.3	37.0
	Female	7.9	9.7	36.6
Child gender	Male	7.6	10.1	36.4
	Female	7.9	9.6	37.1
Research site	Ha Noi	9.6*	10.8	36.3
	Nha Trang	8.1	10.2	36.9
	Ninh Hoa	6.6	9.0	36.4
Parent Education	Primary or less	5.2*	7.6**	35.1
	Secondary	7.1	9.2	37.0
	High School	8.7	10.6	36.4
	College or University	9.3	11.7	37.9
	Technical School	8.8	11.4	37.2
	Continuation School1	6.0	6.7	34.3

¹Continuation School is for individuals who have dropped out of high school but want to return to school for a certificate

The parent-child communication scale was designed to assess barriers for parents talking to their child about sex. The mean score on the parent-child communication scale was 36.67 (SD 6.67: range 14–55, with higher score indicating more barriers to communication). There were no significant differences for the parent-child communication scale by parent’s or child’s gender, research site, or parent’s education (Table 5). Specific barriers to communication with high percentages of parents agreeing or strongly agreeing included, “if I talk with my child about sex, he/she will be interested in sex” (86.8%, 156/184), “I would feel embarrassed” (65.2%, 120/184), “I am too busy” (65.4%, 121/184), and “I do not feel I have enough information” (63.1%, 116/184).

Linear regression analysis was run to assess the relationships between parents’ knowledge of RH, “comfort” with talking, frequency of “talk” about relationships and sexuality, and discordancy between parents and children in regards to boy/girlfriend relationships and sexual touching. Controlling for level of parental education, data indicate a linear model in which knowledge is significantly related to “comfort” (β=0.17; p=0.048) and “comfort” to frequency of “talk” (β=0.6; p<0.0001). However, frequency of “talk” is not related to discordancy for relationships (β=0.002; p=0.79) or discordancy for sexual touching (β=0.57; p=0.60).

Discussion

Over the past decade, Viet Nam has undergone significant political-economic and social changes, and adolescents and emerging adults are maturing in a socio-cultural environment significantly different from their parents. Viet Nam’s increasing involvement in the world economy creates both greater opportunity and more competition as these youth go to school and enter the labor market. Likewise, ‘open door’ policies provide youth with increasing resources regarding reproductive health, e.g., via internet, NGO programming, but also greater exposure to negative sexual images and information, e.g., pornography, chatting rooms.

These changes have brought about new social roles and relationships, and an often discordant integration of ‘modern’ and ‘traditional’ attitudes. In this ‘transitional’ setting, the generation gap between parents and children is exacerbated creating significant barriers for positive communication [18, 23].

Parents report low levels of communication with both their sons and daughters. Parents are least likely to discuss issues related to sex, pregnancy, and birth control. Topics about relationships and standards of behavior are more frequently broached by parents possibly because these issues can be discussed with less embarrassment and provide an opportunity for parents to present ‘traditional’ values. Parents also express less discomfort discussing HIV/AIDS. This may be a consequence of social perceptions of HIV as a disease of “high risk” behaviors and discussions can focus on drug use and promiscuity rather than protective behaviors, e.g., condom use. HIV/AIDS is also a visible topic within the media, e.g. through billboards, public service announcements, and therefore opportunities are presented for parents to discuss this issue with their children.

Our linear regression analysis suggests a significant relationship between RH knowledge and comfort with talking and a relationship between comfort and frequency of talk. These data suggest a need for interventions that provide RH knowledge and communication skills to parents of adolescents. Some specific topics which were included in our EWA curriculum included introduction of basic communication, active listening skills, and specific skills for discussing sensitive issues with adolescents. General parenting issues were discussed along with information on adolescent physical, emotional, and social development within the context of Vietnamese society. Activities also focused on gender, sexuality, sexual expectations, and discussions about how these constructs and associated values are changing in Viet Nam [24]. One challenge we faced is recruiting both parents and adolescents into the intervention program due to conflicts with other higher priority time commitments mostly related to work, school and examinations. There is a need for the development of communication campaigns targeting parents emphasizing the importance of RH knowledge for adolescent and young children.

Interventions may be particularly important in rural areas and for parents with lower education as these factors were associated with lower levels of RH knowledge, greater discomfort in talking to children, and less frequency of talk. Given that nearly 80% of Viet Nam’s population is still rural-based, programming needs to be implemented throughout the provinces. And while the prevalence of HIV/AIDS is highest in urban settings [17], rural areas are not immune to HIV or other poor RH outcomes. In Viet Nam, the general population and especially young people, are increasingly mobile with development of the transportation infrastructure, liberalization of residency registration procedures (ho khau), and concentrated educational and employment opportunities in urban centers [25, 26, 27].

Limitations for our data include a small sample size and relatively low recruitment rates particularly for parents. Our data did not show a relationship between frequency of talk and discordance between youths’ reported behaviors and parents’ perceptions of those behaviors. This may be a consequence of low reported sexually intimate behaviors in our small sample despite other evidence which clearly indicate adolescents and young adults are increasingly engaging in sexual relationships [12, 13]. There is an urgent need for more RH information and resources for young people in Viet Nam to decrease risks for unwanted pregnancies, STIs, and HIV. These resources need to be multifaceted in order to be inclusive of Vietnamese youth in varying life situations, but for the majority of youth parents remain a key potential resource. To date, however RH communication between Vietnamese parents and their children is minimal and challenged by multiple barriers.

Further research is warranted in Viet Nam and other low- and middle-income countries to increase understanding about relationships between parental communication, parents’ knowledge of their children’s behaviors, and youth’s engagement in sexual risk and protective behaviors. Research in the United States has suggested that combined adolescent-parent RH programs provide additional and sustained protection compared to adolescent only interventions in relation to reducing youths’ engagement in risk behaviors [28,29]. There remains an overall unmet need for evidence-based RH education for adolescents and emerging adults in low- and middle-income countries [30]. One avenue toward development of effective programming within these settings will be inclusion of parents and caregivers as a part of intervention strategies.