Parent-Adolescent Communication About Contraception and Condom Use

A significant number of sexually active youth experience poor sexual and reproductive health outcomes, including unplanned pregnancy, sexually transmitted infections, and human immunodeficiency virus infection.¹ Nearly half (47%) of all high school students in the United States have ever had sex and more than one-third (34%) are sexually active.¹ Every year, more than 600 000 pregnancies occur among teens,² and approximately half of all new sexually transmitted infections are attributed to youth aged 15 to 24 years.³ Youths who are racial, ethnic, and sexual minorities are disproportionately affected by these negative sexual and reproductive health outcomes.³ Public health efforts have targeted adolescents through a variety of prevention strategies, including efforts to strengthen parent-adolescent communication about sexual behavior.⁴ Extensive scientific literature suggests that parents play an important role in shaping sexual behavior among adolescents. However, there is a tendency in this research to prioritize delaying adolescent sexual debut, with less attention devoted to correct and consistent condom and contraceptive use.⁵

The limited studies that have addressed parental influences on adolescent condom and contraceptive use report inconsistent results.⁵ In this issue of JAMA Pediatrics, the meta-analysis by Widman et al⁶ examines correlations between parent-adolescent sexual communication and adolescent use of contraceptives and condoms (hereafter referred to as safer sex behavior). Widman et al highlight that parental communication is positively linked to safer sex behavior among adolescents. The meta-analysis identified sex of the parent and sex of the adolescent as moderators of this association. The magnitude of the overall correlation (r = 0.10) can be interpreted as modest, so issues of magnitude warrant more attention. Although researchers long ago noted that even small correlations can represent societally important effects when one considers population size (>40 million adolescents) and the seriousness of the outcome (unintended pregnancy, human immunodeficiency virus infection),⁷ we expand on the findings by Widman et al⁶ by highlighting conceptual and methodological issues that bolster the effect and association of parent-adolescent communication on adolescent contraception and condom use.

Importance of Strong Theories of Parent-Adolescent Communication

Well-established communication frameworks identify multiple factors to consider to strengthen communication between parents and their children, including who communicates (communication source), what they say (communication content), how they say it (communication style), when they say it (communication timing), how often they say it (communication frequency), where they say it (communication context), and who they communicate with (communication target, such as girls vs boys).⁸ Notable among the studies included in the meta-analysis by Widman et al⁶ is that most (36 studies) reported a single indicator of parent-adolescent sexual communication, and only 15 studies reported 6 or more communication items. Such assessments neglect the complex and multifaceted dynamics of parent-adolescent communication and limit the magnitude of associations between communication and behavior accordingly.⁸ While messages about “general sex topics” can be part of the ongoing discussion between parents and adolescents, specificity in the discussion, particularly about use of contraceptives and condoms, are likely more predictive in shaping these behaviors. A large amount of literature in social psychology shows time and again that general attitudes do not predict specific behaviors but that behavior-specific attitudes do.⁹ Parents discussing general attitudes should not necessarily be predictive of specific adolescent behaviors. In addition, contraceptive behavior itself is a complex construct consisting of method choice, consistency of method use, accuracy of method use, and switching between methods. Research shows that the factors that affect one facet may not be the same as those affecting another facet.¹⁰ Robust communication interventions are those that directly support parents in addressing factors most correlated with the target adolescent behavior. Parents must focus their communication efforts on strong correlates of adolescents’ use of contraception and/or condoms. Increased attention to rich, theoretically driven communication frameworks will strengthen the effect of parent-adolescent communication on use of contraceptives and condoms. The studies included in the analysis by Widman et al⁶ generally do not embrace current theories of communication or behavior.

Specification of Maternal vs Paternal Influence

Too often, research focused on parents is unclear about whether mothers or fathers are the focus. The failure to distinguish this focus represents a challenge for parent-communication analysis. Variations in what exactly defines a parent (biological offspring, kinship network, or primary adult caregiver) are also an important conceptual consideration. The analysis by Widman et al⁶ suggests that maternal communication is more strongly associated with safer sex behaviors among adolescents relative to paternal communication. Yet, as Widman et al⁶ point out, this difference may be attributed to our limited understanding of paternal-adolescent communication. Important factors, such as how fathers communicate and what they say, require attention if we are to support effective father-adolescent communication about safer sex behavior. Given the limited numbers of studies that focus on paternal influences on safer sex behavior, there is a need for applied research that addresses father-based conceptual models of influence.¹¹ The meta-analysis by Widman et al⁶ considers only 5 studies that focus on fathers.

Sex Differences in Parental Influences

The stronger association of parental sexual communication for girls relative to boys suggests potential sex dynamics regarding parent-adolescent communication. The finding highlights that boys potentially have unique determinants (eg, masculinity, gender role identity) of sexual behavior to be addressed in parent-adolescent discussions. Notably, research has tended to focus on girls, with limited attention to boys and their sexual and reproductive health needs.¹¹ Given that young males experience additional barriers to sexual and reproductive health care relative to girls, parents represent a resource for providing clear messages about use of contraceptives and condoms.

Methodologically, caution is required when comparing correlations between groups (mothers-fathers and boys-girls) in meta-analyses because correlations are simple bivariate associations that fail to control for multiple confounders normally included as covariates in traditional modeling (such as sex differences in depression or sensation seeking, which could alter group correlation differences), and methodologists generally recommend against relying on standardized coefficients (such as correlations) for group comparisons via the analysis of interaction effects.¹²

Inclusion of Diverse Families

Recognition of the importance of racial and ethnic diversity and adolescents who are sexual minorities warrants mention. Variation in demographic, cultural, and social factors regarding how families communicate about safer sex behavior can weaken the overall effect estimate. The meta-analysis by Widman et al⁶ includes studies from several different countries, integrating a broad and diverse population of families. There is growing interest in identifying adolescent sexual health interventions that are efficacious with minority families, which is in part owing to the growth of racial ethnic minority populations in the United States and well-documented disparities in sexual and reproductive health outcomes. Given this interest, greater attention to culturally competent approaches to parent-adolescent communication strategies is needed.¹³ Largely absent in the discussion surrounding adolescent sexual and reproductive health are adolescents who are sexual minorities, who bear a disproportionate burden of sexually transmitted infections and human immunodeficiency virus infections. Adolescents who are lesbian, gay, bisexual, transgender, and questioning their sexual orientation are particularly vulnerable to negative sexual health outcomes relative to their heterosexual peers.¹⁴ The existing data, while limited, suggest that parental communication may not operate in the same way for such adolescents.¹⁴

Parent-Adolescent Communication and the Context of Parental Influences

While Widman et al⁶ focus on the construct of parent-adolescent communication, they acknowledge that other parent constructs, such as parental monitoring and parent-adolescent relationship quality, may interact with communication to affect adolescent sexual behavior. For example, adolescents with positive feelings about their parents and their relationship may be more receptive to communication and to messages about use of contraceptives and condoms.¹⁵ Embedding communication constructs in larger parenting frameworks is essential to understanding the role of communication in shaping adolescent behavior so as to take into account moderators and what methodologists call omitted variable bias. As Widman et al⁶ note, future research can benefit from a more comprehensive understanding of parenting domains that may interact when predicting adolescent sexual decision making.

Effect Size Variability

Figure 2 in the article by Widman et al⁶ reveals definitive variability in study correlations, with about 10 correlations being above 0.25. Safer sex behavior is an extremely complex behavior that is undoubtedly influenced by a multitude of variables that interact in complex ways. When one identifies a single variable that accounts for 5% of the variation in such behavior, it is rather remarkable. What is it about these 10 studies that set them apart from the others? A case study approach to these 10 studies rather than global meta-regressions might prove informative.

Rigor and Methods of Studies on Parent-Adolescent Communication

The complex nature of parent-adolescent communication warrants research that integrates communication-based variables into comprehensive theories of adolescent sexual behavior.⁸ Many studies included in the review by Widman et al⁶ relied on impoverished conceptual frameworks and examined parent-adolescent communication in isolation. Comprehensive theories of parent-adolescent communication with clear links to determinants of adolescent sexual behavior allows researchers to evaluate direct, indirect, moderated, and spurious effects in the association between parent-adolescent communication and use of contraceptives and condoms, as well as to assess reciprocal causality. Such models can highlight the precise mechanisms by which parental communication shapes adolescent use of contraception and condoms.

An additional consideration for strengthening the existing evidence base, including the magnitude of the observed effects of parent-adolescent communication on use of contraception and condoms, is to apply higher standards in overall research designs. Widman et al⁶ highlight that only 7 of the 71 independent effects used longitudinal designs. The limitations in cross-sectional studies, particularly for the topic of adolescent sexual behavior in which timing and development are salient, are widely acknowledged. A push toward the criterion standard in research using randomized clinical trials can encourage increased rigor. Particularly needed are randomized explanatory trials that move beyond a simple focus on whether there were outcome effects. Randomized explanatory designs include empirical data on what factors mediate or are responsible for the observed outcomes. In cases in which no effects or negative effects are observed, the explanatory (or mediator) variables can be used to provide insights into intervention revision.¹¹

In summary, the meta-analysis by Widman et al⁶ provides evidence that parent-adolescent communication is associated with adolescent use of contraceptives and condoms. Most research has focused on parental influences in delaying sexual debut. Sexually active youths also benefit from parental discussions regarding sexual and reproductive health outcomes. Youth want to hear from their parents and overwhelmingly say that parents matter. Hence, public health efforts should support the unique role that parents can play in sexual decision making among adolescents.