THE INVOLVEMENT OF THAI PARENTS IN THE SEX EDUCATION OF THEIR TEENAGE CHILDREN: A MIXED METHODS STUDY by Chaweewan Sridawruang Thesis submitted in fulfilment of the requirements For the degree of Doctor of Philosophy University of East Anglia School of Nursing and Midwifery Faculty of Health 2011 © This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with the author and that no quotation from the thesis, nor any information derived therefrom, may be published without the author’s prior, written consent. ABSTRACT Background: Parent-child communication about sex is a strong determinant in increasing the age of sexual initiation, increased contraceptive use, as well as negative attitudes to early pregnancy in teenagers. In Thailand there has been some attempt to implement a sex education curriculum in schools with varied degrees of success. However, teenagers still find it difficult to talk with their parents about sexual matters. Objectives: This study aimed to explore the attitudes of Thai parents and adolescents towards parental involvement in sex education. Study design: A mixed method approach was taken using survey and interviews in 3 villages in Udon Thani province, Thailand. Surveys of 79 parents and 79 teenagers (15-19 years) took place in 2008 - 2009. Participants from that sample were recruited to take part in focus groups and in-depth interviews. Results: Data were analysed separately then results merged. The survey data were used to identify relationships between knowledge and practice of safe sexual practices. Thematic analysis of the interview transcripts identified attitudes to sex education and barriers to communication in families. The restrictions imposed by traditional Thai culture support the continuing existence of double standards concerning the social norm for premarital sex. Parents and teenagers felt unable to address issues because of a perception of a lack of parental knowledge. Teenagers faced a dilemma of trying to respect their parents but needing to form their own identity which is influenced by knowledge of western values. Conclusions: Parents and teenagers recognise the need to improve communication and knowledge of sexual health and would welcome interventions that would improve parental knowledge and access for young people to effective sexual health services. Recommendations: Educational interventions are needed at local level to enable parents to develop knowledge and skills to act as educators. ii LIST OF CONTENTS ABSTRACT ii LIST OF CONTENTS iii LIST OF TABLES viii LIST OF FIGURES x ACKNOWLEDGEMENTS xi ABBREVIATIONS xii PUBLICATIONS AND CONFERENCES xiii CHAPTER 1: INTRODUCTION 1 1.1 General background information on Thailand 2 1.2 General information of Udon Thani province 5 1.3 Structure of the thesis 5 CHAPTER2: BACKGROUND 8 2.1 Context of adolescence 8 2.2 Sexual behaviours in adolescents 9 2.3 Sexual behaviours in Thai adolescents 12 2.4 Sex education policies 17 2.4.1 The purpose of sex education 17 2.4.2 Sex education policies across countries 19 CHAPTER 3: PARENT-CHILD COMMUNICATION ABOUT SEX 31 Search strategy 31 3.1 Parent-child communication about sex 34 3.2 Studies on parental communication about sex 35 3.2.1 Communication focused 35 iii 3.2.2 Quality of quantitative methods 37 3.2.3 Quality of qualitative methods 47 3.3 The findings on parental communication about sex 50 3.3.1 Degree of parental communication 52 3.3.2 Content of parental communication 54 3.3.3 Context of parental communication about sex 56 3.3.4 Gender of parents 58 3.3.5 Timing of parental communication about sex 61 3.3.6 Barriers of parental communication about sex 62 3.3.7 The influence of peers 64 3.4 Links between parental communication and sexual risk behaviours 65 3.4.1 Sexual initiation 66 3.4.2 Birth control and numbers of partners 69 3.4.3 Unplanned pregnancy 70 3.5 Gaps in existing knowledge 71 CHAPTER 4: METHODOLOGY AND METHODS 73 Part 1: Methodology 73 4.1 Research philosophy 74 4.2 The reasons for using mixed methods in this research 76 4.3 Challenges in mixed methods research 78 Part 2: Methods 81 4.4 Population 81 4.5 Participants and settings 81 4.5.1 Participants in quantitative approach 81 iv 4.5.2 Participants in the qualitative exploration 83 4.5.3 The selection criteria of participants 83 4.6 Data collection 83 4.6.1 Fieldwork process-gaining access 83 4.6.2 Fieldwork process-recruiting participants 85 4.6.3 Questionnaire survey 86 4.6.4 Focus groups 90 4.6.5 In-depth Interviews 99 4.7 Ethical issues 103 4.8 Rigour 105 4.8.1 The rigour of the quantitative study 107 4.8.2 The rigour of the qualitative study 108 4.9 Data analysis 111 4.9.1 Quantitative data analysis 111 4.9.2 Qualitative data analysis 114 4.9.3 Data analysis within the triangulation mixed methods design 127 4.10 Dissemination 130 CHAPTER 5: SURVEY FINDINGS 131 5.1 Demographic characteristics of the participants 132 5.1.1 Characteristics of teenagers 132 5.1.2 Characteristics of parents 134 5.2 Knowledge and awareness of sexual health 135 5.2.1 Information and knowledge of reproductive health 136 5.2.2 Resources for information and knowledge of reproductive health 137 v 5.2.3 Sex education at schools 139 5.3 Awareness of contraception and condom knowledge 146 5.4 Ideas about HIV/ AIDS and sexual transmitted infections 150 5.5 Awareness of health services 154 5.6 The attitudes of parents in relation to sex and sex education 162 5.7 The correlations and comparisons of knowledge and awareness of sexual health 164 CHAPTER 6: INTERVIEW FINDINGS 169 6.1 The influence of traditional Thai society persists 173 6.1.1 Social judgement of girls 174 6.1.2 Protecting teenagers and/ or enforcing the rules 177 6.1.3 Restrictions imposed by traditional Thai culture 184 6.1.4 Westernisation brings change 191 6.2 Talking about sex is difficult 195 6.2.1 Parental limitations 195 6.2.2 Better not bring it up 198 6.2.3 Parents rarely discuss sex directly with their children 200 6.3 Sex happens 211 6.3.1 Fears and concerns 211 6.3.2 Considering risks when having sex 213 6.3.3 Facing risks 216 6.3.4 Parents as problem solvers 217 6.4 Towards to the future 226 6.4.1 Problems are resolved within the family 226 6.4.2 Training and resources for parents and adolescents 227 vi CHAPTER 7: DISCUSSION 233 7.1 The influence of traditional Thai society persists 233 7.2 Talking about sex is difficult 245 7.3 Sex happens 250 7.4 Contribution to knowledge 256 CHAPTER 8: CONCLUSIONS AND RECOMMENDATIONS 258 8.1 Overall conclusion 258 8.2 The strengths of this study 261 8.3 Limitations of the study 264 8.4 Recommendations for health care policy 266 8.5 Recommendations for Practice 270 8.6 Recommendations for Education 274 8.7 Recommendations for future research 275 8.8 Key recommendations 276 REFERENCES 278 APPENDICES 308 Appendix A: Ethical approvals and the permission documents 309 Appendix B: Summarising the main outcomes of studies 312 Appendix C: Information sheets and consent forms 327 Appendix D: Schedule for data collection 332 Appendix E: Instruments of the study 333 Appendix F: Normal distribution tests 357 Appendix G: Coding 362 Appendix H: Themes, and subthemes generated from parents and teenagers 364 vii LIST OF TABLES Table 4.1: The numbers of target population and participants 82 Table 4.2: The vignette used in focus groups of parents and teenagers 93 Table 4.3: Qualitative Data Analysis Strategies by Authors 118 Table 4.4: Codes from data extract 125 Table 4.5: The issues were addressed by quantitative and qualitative approaches 128 Table 5.1: Characteristics of teenagers 133 Table 5.2: Family backgrounds 134 Table 5.3: Characteristics of parents 135 Table 5.4: Whom teenagers talk to about sex 137 Table 5.5: Information resources for knowledge of reproductive health 138 Table5.6: Sex education topics provided by schools 140 Table 5.7: Sex education topics that schools should provide 142 Table 5.8 Recall of sex education compared by gender 145 Table 5.9: Knowledge of prevention of pregnancy, condoms, and AIDS 147 Table 5.10: Condom awareness 148 Table 5.11: The average of the awareness of importance of using condoms 150 Table 5.12: Ideas about condoms and HIV/ AIDS 151 Table 5.13: diseases that teenagers can catch by having sexual intercourse 153 Table 5.14: knowledge of places of treatment for a sexually transmitted infection 154 Table 5.15: Awareness of health services 155 Table 5.16: Posters provided by health care facilities 156 Table 5.17: Sexual health problems or concerns experienced by the sample 158 Table 5.18: Attended a talk by doctors or nurses on sexual health topics 160 Table 5.19: Types of health services 161 viii Table 5.20: Attitudes of parents towards teaching sex education in family 163 Table 5.21: Pearson’s correlation of the knowledge of prevention and the awareness 165 of the importance of using condoms of teenagers Table 5.22: A comparison of means of the knowledge of prevention and the 165 awareness of importance of using condoms with gender of teenagers Table 5.23: A comparison of means of the attitude of parents 166 towards teaching sex education in family with gender of parents Table 6.1: Themes and subthemes from focus groups and in-depth interviews 172 ix LIST OF FIGURES Figure 1.1: Map of Thailand, Udon Thani province and the study settings 4 Figure 3.1: Data sources for the review 33 Figure 4.1: The process of thematic analysis in this study 120 Figure 4.2: The diagram of transcribing and translating data of this study 123 Figure 4.3: Data display by network 126 Figure 4.4: Visual diagram for the triangulation mixed methods design of this study 129 Figure 6.1: The thematic map 171 x ACKNOWLEDGEMENTS I would like to express my appreciation to the many people who made this thesis possible.