Supportive family relationships and adolescent health in the socio-cultural context of Iran: a qualitative study

Abstract

Parents have a critical role in adolescent health. The association of adolescents' perceptions of family relationships with adolescent health was investigated using a sample of 67 female adolescents who participated in eight focus group discussions, utilising a purposeful sampling method. All tape-recorded data were fully transcribed and content analysis was performed. Three themes were identified, namely emotional support, responsible parents and well-informed parents. With regard to some of the challenges in Iranian adolescents' relationships with their parents, it is necessary to educate parents to be alert to their role in adolescent health.

Introduction

Adolescents now represent a very large sector of the population. Half of the world population is under 25 years old, and 20% of the world population consists of 10- to 19-year-old adolescents, who represent 85% of the population in developing countries.¹

Adolescence as a bridge from childhood to adulthood is one of the most critical life stages. It marks the beginning of many physical, mental and social changes, resulting in adolescents' special health needs.² Therefore the need to focus attention on adolescent health is emphasised by the World Health Organization and especially by the 1994 International Conference on Population and Development.³ In this regard, female adolescents' health is also cited as key to eliminating the poverty cycle and achieving the Millennium Development Goals.⁴

During this life stage, parents and families are a crucial part of the social environment of adolescents. Their contributions can be effective in improving adolescents' health and development. A trusting relationship between adolescents and their parents encourages these young people to disclose hidden aspects of their health problems to their parents and avoid engaging in risky behaviour as a result of the influence of peers who are less well informed and have less experience of life.^5–9

The Iranian context and related studies

According to the latest Iranian national population census, adolescents represent 15.6 million (21.8%) of the Iranian population.¹⁰ In Iranian society, religious values, cultural norms and traditional practices expect adolescents to respect and obey their parents. However, as in other developing countries, it appears that these traditional attitudes and cultural values have undergone changes in recent years due to factors such as social changes and increases in urban living.¹¹ It is important to understand the health needs of adolescents in relation to their families, as this will promote a pathway to a healthier future for adolescents.

To the best of our knowledge, most of the studies conducted in Iran on the role of the family in adolescent health have been descriptive, and less attention has been paid to conceptual explanations of this issue. Emami et al stated that mental health problems are one of the main health issues experienced by Iranian adolescents, and that girls experience these more frequently than boys.¹² Parvizi et al, in a grounded theoretical study of the perspective of Iranian adolescents on family and health issues, revealed some challenges in adolescents' relationships with their families, such as the wide generation gap, parents with very traditional values, and the family's financial situation.¹¹ Zareian et al, in their qualitative study, suggested that parents and family members have an important role in influencing the lifestyle of Iranian male adolescents.¹³

As quantitative research approaches cannot identify the depth of attitudes, thoughts, and the details of participants' beliefs,^14,15 the present study adopted a qualitative approach based on interviews in an attempt to present a wider view. The aim of this study was to assess the perspectives of female adolescents with regard to the role of the family in meeting their health needs in the Iranian socio-cultural context as a developing country.

Methodology

This qualitative study was conducted with a study population consisting of 67 healthy female adolescents aged 12–18 years who were in middle school or high school, and who were selected by a purposeful sampling method in Mazandaran, North Iran, between March and July 2010. To maximise the diversity of the sample, adolescents were recruited from both urban and rural areas, by different age groups, in the east, west and central part of the province. The sampling process was continued until data saturation occurred.

Eight focus group discussions (FGDs), with 6 to 10 girls in each group, were conducted by the first author as a facilitator and note taker in the school counsellor's office or in one of the health centre rooms. The group discussions were conducted using a semi-structured questionnaire with a few guide questions which had previously been piloted in order to obtain estimates of the duration of interviews and the clarity of the questions. The interviews began with a question about the family relationship and the adolescent's health, and then continued with a few exploratory questions to obtain further information. The average duration of the interviews was 60–90 minutes. The main question that was addressed in this research was the following: As a teenager, when you think about your health, which family factors are health bridges and which are barriers? There were also a few exploratory questions (e.g. requesting more details or requesting a clearer explanation) to obtain deeper information.

All of the interviews were recorded on an MP3 player and notes were taken; all of the files were then transcribed. Next, the transcripts were analysed using the content analysis method, which is a process for identifying, coding and categorising themes in data. The data analysis started with the first FGD, and data collection ran in parallel throughout the study. All of the transcripts were read by the investigators separately to find out the main ideas. The transcript text of the interviews was broken down into semantic units and then into the smallest meaningful units (code) after browsing several times. The codes were then reviewed according to the focal point and semantic similarity to place them in the main categories and sub-categories.

In this study, the reliability and validity of the data were confirmed by several methods. Credibility was achieved by allowing sufficient time and long-term involvement for data collection, as well as maximum diversity in sampling (adolescents from different age groups, and from urban and rural locations), and different locations for sampling (health centres and schools). To assess confirmability, the coded transcripts were returned to some adolescents to check their validity. Reliability was confirmed by two fellow researchers assessing and recoding parts of the transcripts. For transferability of the data, a detailed description of the study procedures was presented.

This study was approved by the Ethics Committee of Shahid Behesti University of Medical Sciences. The aims of the study and details of the procedures were explained to the participants, and their written informed consent was then obtained.

Findings

In total there were 67 female adolescent participants, of whom 49 students were in high school and 18 students were in middle school; 32 of the participants were from urban areas and 37 participants were from rural areas.

The primary extracted codes showed that all of the participants emphasised the crucial role of the family in the adolescents' physical, mental and social health. The extracted themes are presented in Table 1.

Table 1.

Main theme and sub-themes of adolescents' health needs in the family

Theme	Sub-themes
Emotional support	Friendly relationship
	Honest relationship
	No favouritism shown towards children
Responsible parents	Appropriate modelling
	Facility provision
	Provision and protection
Well-informed parents	Developmental changes of adolescents
	Generation gap

Emotional support

The majority of the participants stated that they needed to be emotionally supported by their family, and they highlighted the importance of a positive, friendly relationship between parents and children. A 17-year-old adolescent from an urban area said ‘I'd like to talk to my mother, but she does not take me seriously. Sometimes she laughs at me. So it is not easy for me to talk to her. It disturbs my mental health.’

Honest relationship

Many of the participants stated that an honest relationship between the adolescents and their parents was essential for their social health. For example, a 19-year-old adolescent from an urban area said ‘Many children have no intimate and honest relationship with their parents, so they avoid talking to them about their daily life.’

No favouritism towards children

One of the issues that was emphasised by participants was the importance of the harmful effects of favouritism towards certain children on adolescents' mental health. A 16-year-old adolescent from a rural area stated that ‘Discrimination between son and daughter is a problem in my family, which is not tolerable for me in terms of mental health, and that is why I don't like my brother.’

Responsible parents

Appropriate modelling

The participants stated that their parents were their role models with regard to the behaviours that affected their health, and therefore the parents were responsible for demonstrating appropriate behaviour. A 17-year-old adolescent from an urban area stated that ‘If [our] parents show us appropriate behaviour, we learn it and behave properly in society. I know some addicted adolescents which their parents were addicted, too.’

Provision of facilities

The adolescent participants pointed that their parents were responsible for providing educational, therapeutic and welfare facilities for them. For example, a 15-year-old adolescent stated that ‘There are families who do not give money to the adolescents for buying things. They do not pay attention to adolescents' nutrition and hobbies, healthcare services.’

Provision and protection

The adolescents in the present study criticised strict parenting and highlighted their need for independence. Most of them emphasised the importance of moderation in the behaviour of parents with regard to giving freedom or setting limits. A 17-year-old adolescent stated that ‘Giving too much freedom to adolescents may sometimes lead to misbehaviour of some. It is better that parents have a balanced behaviour.’

Well-informed parents

Developmental changes of adolescents

The adolescent participants held the view that parents who were well informed about the physical and emotional changes of adolescence could help their children to pass through this crucial stage of their life without health problems. A 17-year-old adolescent stated that ‘Sometimes we are confronted with serious emotional situations and have some questions about puberty processes. Only well-informed parents can help us to deal with these situations, making appropriate decisions and answering our questions.’

Generation gap

The majority of the participants mentioned the generation gap between adolescents and their parents. They emphasised the need to educate parents about this difference. For instance, a 15-year-old adolescent from an urban area stated that ‘Age difference between parents and adolescents is what adolescents feel about their parents who do not understand them, likewise parents who expect too much.’ A 16-year-old adolescent from a rural area also said ‘Our parents are always criticising us because they are traditional.’

Discussion

This is one of the limited qualitative studies of the effects of family relationships on the health of Iranian female adolescents through FGDs. The findings of this study, which were based on a qualitative method and conducted on adolescents from different urban and rural areas, could add to our knowledge about the effect of adolescents' relationship with their families on adolescent health. The main strengths of the present study are the truthful, unbiased character of the expressed points of view, the positive approach to gathering various experiences and views, and the comprehensive manner in which the subjects dealt with the research topic.

The findings of this study demonstrated that emotional support and friendly relationships within the family were among the basic requirements for adolescent mental health. Our study is similar to those which revealed that emotional support increased self-confidence, a feeling of life satisfaction and the ability to cope with stress, as well as decreasing the incidence of depression in adolescents.^16,17 It seems that a friendly and reliable relationship with their family encourages adolescents to consult with their parents, rather than with inexperienced peers, about their private problems, and thus reduces the likelihood that they will make unwise decisions.⁵

Our study showed that adolescents need to be mentally supported by their family, and expect their parents not to discriminate between male and female children in the behaviour they show towards them. Although some of the participants thought that parents' strictness with female children about clothing, friends and going out represents a kind of discrimination between them and male children, others considered this strictness to be a form of responsible behaviour. A study in the Philippines demonstrated that boys generally have more freedom than girls, and that families set more limits for and are more protective of girls.¹⁸

The present study emphasised that the family serves as a model for adolescents' behaviour. The participants believed that adolescents learn values and ethics within the family. Along with our study, other research has shown that adolescents embark on sexual relationships earlier if their parents engage in high-risk behaviours.¹⁹ Furthermore, drug abuse is more common among children with addicted parents.²⁰

The participants in this study stated that parents were responsible for providing the basic needs of adolescents, and it seemed that those needs included parental efforts to improve adolescents' health. As Parvizi et al have shown, adolescents expect their parents to provide welfare and educational facilities and to prepare them for social life in the real world.²¹ It seems that although in developed countries the need of adolescents for parental support decreases, in the social conditions that prevail in developing countries, parents have further responsibilities to supervise and advise their children – for example, in choosing their future fields of study, career and friends, and familiarising them with the risks in the community and society and challenges during life crisis.

Another theme that emerged from this study was that of provision and protection. The study participants emphasised that parental monitoring is a construct that incorporates both supervision and communication between parents and adolescents. According to the findings of our study, a balance between adolescents' freedom and limitations set by the family is an important factor in influencing adolescents' health. The participants also stated that imposing illogical and unreasonable limits results in adolescents engaging in hidden high-risk behaviours. On the other hand, freedom without any parental supervision can also lead to high-risk behaviour. Hudson and Rapee showed that the highest levels of anxiety are reported among adolescents with authoritative parents.²² There seems to be a need to define a middle ground between too much freedom and too many limitations, and parental monitoring is needed to protect teenagers who are uncontrollable.

Another finding of this study was that parents needed to obtain the necessary information about physical, mental and spiritual changes in adolescence, as well as the social realities of this life stage, in order to maintain the health of their adolescent offspring. Partnership between parents and healthcare providers is an important step towards addressing adolescent health problems.²³ Female adolescents expected their mothers to prepare them for the onset of menstruation, and to provide them with a clear explanation of the physiology of reproduction.²⁴ In addition, parents should be informed about sexual health and the adolescent's perception of relationships with the opposite sex. This has been shown to decrease the number of unwanted pregnancies among adolescents.²⁵

Adolescents usually desire to be different from their parents in many aspects of life, and this sometimes leads to conflict. The participants in the present study stated that these conflicts were due to issues such as relationships with boyfriends, choice of clothing and use of make-up. It seems that in the developing eastern countries, adolescents can fairly rapidly adapt themselves to modern world values, whereas their parents cannot change their traditional ways nearly as easily. Some adolescents mentioned that their parents' low level of education was the main reason for their conflict with them.²⁶

Conclusion

Taken as a whole, these findings support the critical importance of programming for parents as part of a comprehensive strategy to improve the health and development of adolescents. With regard to the critical role of the family relationship with the adolescents in influencing their health, education of the parents is necessary so that they can be prepared to face the issues that are affecting their adolescents, which will in turn improve the adolescents' health. In addition, counselling parents about their role in adolescent health promotion should be an important focus of assessment and management in adolescent healthcare services.

The main limitation of this study was the inability to interview some of the adolescents because they had already left school or started working.