The role of parents in providing sexuality education to their children

Background: Parents have an important role in delivering sexuality education to their children. However, Asian parents are reluctant to discuss sexual matters with their children owing to the sensitivity of the topic and their lack of sexual health knowledge. This study aimed to examine Malaysian parents’ knowledge, attitudes, and practices in providing sexuality education to their children. Methods: A self-administered questionnaire was used to conduct this cross-sectional study featuring 200 Malaysian parents. Descriptive and univariate analyses were performed using Statistical Package for Social Study (SPSS) version 23.0. Results: Among the majority (79.5%) of the parents having good knowledge, 82% agreed that sexuality information helps their children recognize and avoid sexual abuse. Most (91%) of them perceived that they have good practices in providing sexuality education to their children. There is no association between the parents’ gender and their knowledge of sexuality education. However, there are no links between age groups, educational level, and the parents’ knowledge of sexuality education. Conclusion: Malaysian parents believe that sexuality education should be provided by the parents to their children at an early age. Hence, a comprehensive sexuality education program for parents consisting of sufficient information, motivation, and strategies, is needed to develop children’s sexual literacy.


Introduction
Sexuality education consists of teachings on human sexuality, including human sexual anatomy, sexual reproduction, gender identity, sexual orientation, reproductive rights and responsibility, intimate relationships, sexually transmitted infections, sexual activity, abstinence, and contraception. 1 Sexuality is not just part of a person's identity; it also influences an individual's considerations, sentiments, activities, and mental and physical well-being. 2 Sexuality education is a basic component of building young people's choicemaking around sexuality and for creating mindfulness and informed understanding of its moral significance. 3 Sexuality education can contribute to the psychosocial advancement of the youth as they eventually become adults. 4 Arguably, parents have the greatest influence on their children's behaviors and sexual identity formation. 5 They are also a primary source of socialization and have a major influence on many aspects of the psychological and social functions of their children. 6 Hence, parents should be the child's primary reference in obtaining information related to sexuality. The effective parent−child communication can delay sexual initiation in the latter and diminish the number of sexual partners. 1 Studies in many parts of the world 7-10 indicate that many parents are aware of their responsibilities to educate their child on sexuality. However, some parents believe that the tasks involved are difficult and complicated, 1 even among healthcare professionals in a conservative society. 11 Parents frequently express the need for help in terms of skills and contents related to sexuality education. 12 It is quite common for parents to discuss with their adolescent female child matters regarding personal hygiene, physical changes, sexual abstinence, and the importance of dignity and family honour. 13,14 Similarly, the qualitative findings of another study suggested that parents instilled in their children the cultural values regarding virginity, and stress the importance of family honor and adherence to traditional gender roles within the family structure. 15 Moreover, some parents expressed that they were more comfortable educating their adolescent girls on sexuality issues as compared to the parents of adolescent boys as a protective measure against irresponsible sexual behavior. This indicates that the priority is given to the daughters even though the responsibility of delivering sexuality education should target both sexes. The factors Meanwhile, from an Islamic perspective, parents or guardians are key agents of Muslim children's learning. They are considered the "primary school" for the education of a child. As sex could be part of fitrah (nature) they need to deal with when they enter the adolescence phase and reach adulthood, this parental obligation must incorporate sexuality education for the children. 11,18 Thus, in this context, the disapproval of parents to engage their children in discussions regarding sexual issues can be considered a failure in performing their parental roles. 19 A recent Malaysian study 20 among healthcare providers reported that parents are responsible for nurturing their children and teaching them about good behaviors, which include matters related to their sexuality. This is because effective parental communication or being responsive to the potential risks to their children's sexual health may help delay their sexual intercourse intention. 21 Considering the importance of parents providing sexuality education to their children and the lack of published studies on this topic in Malaysia, the current study aimed to examine the levels of knowledge, attitudes, and practices of parents in providing sexuality education to their children. The results of the study may contribute toward a better understanding of Malaysian parents' readiness in delivering such critical information to their children.

Methods
Using a Google-based questionnaire, we collected data from 200 parents who have children aged between 13 and 18 years old. This study refers to the population of a parent (574) based on a previous study conducted in Rwanda. 9 The Google-based questionnaire was used mainly due to safety concerns related to the COVID-19 outbreak. Moreover, this online method of data collection is free, fast, and able to reach a large population; it can also automatically record the participants' response in an Excel sheet, resulting in a more convenient data collection and analysis. 22 This method is relevant in the Malaysian context and in many countries where Internet coverage is very good. The parents with children aged between 13 and 18 years old were selected considering the appropriateness of the questions asked. The consent statement was stated at the beginning of the questionnaire. Participation in this study was completely voluntary. Approval was first secured from the Kulliyyah of Nursing Postgraduate Research Committee and International Islamic University Malaysia Research Ethical Committee. Then, data were collected by sending the link to the Google form questionnaire through a WhatsApp group and other social media platforms, such as Facebook.
The descriptive and bivariate analyses, including independent t-test and one-way ANOVA, were performed using the Statistical Package for Social Study (SPSS) version 23.0. The variables used in the study, namely, knowledge, attitude, and practices, were identified through a literature review of relevant articles. The variable represented the roles of parents in providing sexuality education for this study.

Results
Sociodemographic characteristic of parents. Table 1 shows the sociodemographic characteristic of the participants. Mothers comprised the majority of participants (71.5%, n = 147) who answered the questionnaire. Most of the participants were between 25 and 40 years old. About 38.5% of the parents were undergraduate degree holders, followed by 22.5% with a diploma, 14.5% with a master's degree, 13.0% who completed high school, and only 11.5% had a doctoral degree. About 35.5% of the participants have children aged 13 to 18 years old, followed by 33.0% who have 2 children, and only 2.5% who have 6 children. The participants came from four regions of Malaysia: 40.5% from the East Coast, 30% from the South, and 18% from the North and Central regions. Parents' knowledge of sexuality education. Table 2 tabulates the details of sexuality knowledge possessed by the participants. They were requested to respond with either "true" or "false" to statements related to sexuality. A total score between 16 and 20 indicated good knowledge. Most of the participants (86.8%) correctly answered the questions related to sexually transmitted diseases, followed by those on puberty and pregnancy (81.0% and 70.8%, respectively).

Parents' attitudes in providing sexuality education.
About 75% of the parents reported obtaining sexuality information from the Internet, and about 36.5% stated that their information came from their own parents.
Most of the parents (82%) agreed that sexuality education should be given to the children, because it will help them recognize and protect themselves against sexual abuse. The parents also agreed that sexuality education can discourage children from engaging in unprotected sexual intercourse and having unwanted pregnancies. The parents in this study perceived that the right persons to provide sexuality education were the parents (75.5%), followed by healthcare providers (66.5%), and teachers (45.5%). The parents reported that the barriers in delivering sexuality education were as follows: feeling embarrassed when discussing sexuality information with the children (47.5%), having insufficient information regarding sexuality (45.0%), and being worried that their information was inaccurate (44.5%). Only 9% of the parents did not have any problem in providing sexuality education. These parents may have good parent-children relationships and are open-minded enough to share any sexual information with their children without any hesitation. 1

Parents' practices in delivering sexuality education.
Overall, 91% of the participants perceived having good practices in providing sexuality education to their children, as shown in Table 3.  The associations between parents' gender, age groups, and educational level and their total score in sexuality education knowledge. The mean total scores for fathers and mothers were 15.6 and 16.1, respectively, with standard deviations of 1.81 for fathers and 1.63 for mothers. There was no significant difference in the mean total scores between fathers and mothers (p = 0.095). In other words, fathers may not necessarily have better knowledge of sexuality education than the mothers or vice versa.  Table 4. Thus, there were significant differences in the mean total scores among parents aged 18-24, 25-32, and 33-40 years with a significance value of 0.004. This means that the age of a parent is associated with the mean total score of the adolescent's knowledge, such that an increasing age is directly related to the better knowledge that they have.  (Table 4). These indicate an association between the educational levels of parents with the mean total score of their knowledge, such that a higher educational level translates to better sexualityrelated knowledge. The results also revealed that none  16.52 (1.59) One-way ANOVA of the sociodemographic characteristics, such as gender, age group, and educational level, were associated with the parents' practices in providing sexuality education.

Discussion
Parents' knowledge, attitudes, and practices in delivering sexuality education. Most of the parents (79.5%) correctly answered all the questions related to pregnancy, puberty, and sexually transmitted disease. Similarly, the results of a previous study in Accra Metropolis, Ghana, showed that 60% of the respondents have good knowledge of sexuality education. 14 Another study reported that 70% of parents have good knowledge of sexuality education. 9 A study conducted in China recorded almost similar  23 From the current study, most of the respondents showed sufficient knowledge, which indicated that they received good education from their teachers or other sources. Out of 20 questions asked, almost half of the participants answered wrongly only on two items: "The boys reach their puberty as early as the age of 15" and "Chlamydia is a sexually transmissible infection that only affects women." Thus, more emphasis should be given on this topic, so that parents are aware of the correct information.
The parents agreed that good sexuality education can help their children recognize and protect themselves from sexual abuse (82%) and discourage them from engaging in unprotected sexual intercourse and having unwanted pregnancies (79%). Similarly, a previous study reported that most of the parents (80%) agreed that sexuality education protects children from risky sexual behaviours. 24 Moreover, Ganji et al. reported that 77.6% of Iranian parents agreed that sexuality education protects children from being involved in sexuality-related problems, such as teen pregnancy and illegal abortion. 25 Another study stated that 49.3% of the respondents agreed that sexuality education must be given to children, as this is the most effective way to reduce related social problems among young people. 26 Local studies have identified that exposure to pornographic materials (OR = 9.9 to 13.48) is one of the risk factors of having pregnancy out of wedlock. 27,28 In fact, although it has been a subject of debates, pornography has been highlighted as an important component of sexuality education. 29 However, some institutions may avoid incorporating elements of pornography in sexuality education programs.
Most of the parents (75.5%) in the current study agreed that they must be their children's first educators. This was supported by a previous study wherein 78.2% of parents believed that they were the first source and first educators providing sexuality education to the children. 25 Jankovic et al. also reported that 86.9% of respondents agreed that the parent was the best and the right source to provide sexuality education for their child. 10 In contrast, a previous study conducted in India stated that the most preferred source to deliver sexuality education to the children was the doctor (91.5%), and the least preferred source was the parents (37.3%). 30 The current study also found that the major problem faced by parents was feeling embarrassed in discussing sexuality with their children (47.5%). Similarly, 82.2% of parents in another study reported not being able to discuss any of the sexual health education topics with their children, because they were too shy to talk about this topic with them. 25 A study done in Nigeria and Kenya reported that the majority of the parents were uncomfortable in discussing matters of sexuality with their children 31 . This strong cultural belief and sensitivity toward sexuality issues are major barriers preventing parents from delivering sexuality education to their children.
The current study also found that 91% of the participants had good practices in delivering sexuality education to their children. However, only three quarters of the parents in this study mentioned that they discussed sexual issues with their children. This can be explained by a previous study's finding that many parents believed sexuality education is the responsibility of schools or colleges. 5 The majority of Iranian parents also reported the same pattern of not discussing any sexual health education topic with their children, including sexual issues, and not knowing how to react to their children's sexual behaviours. 25 The Malaysian parents in this study delivered sexuality education to their children in the early ages of 0-5 years old. The World Health Organization recommends initiating sexual education in elementary school children aged 7-12 years. 26,32 The majority of the parents (93.8%) in this study reported teaching their children about the proper names for their genitals, the limits of unnecessarily touching their private areas, and their right not to have these body parts violated. It has been proven that sexuality education can benefit the parent-child relationship in which children will be more open to share their sexuality problems with their parents. 33 The association between parents' sociodemographic characteristics and their knowledge and practices.
The results showed no significant difference in knowledge regarding sexuality education between fathers and mothers. Thus, the gender of a parent does not have any association with his/her knowledge about sexuality education. This finding is similar to that reported by Baku et al. 14 The present study found significant differences in parents' knowledge among different age groups. In contrast, a previous study reported no meaningful difference in parents' knowledge of sexuality education among different age groups. 14 Meanwhile, we found a significant association between parents' knowledge and their educational level. This finding is similar to a previous study, which reported significant differences in knowledge among groups of parents who are middle school, vocational, and college graduates. 14  In our study, there was no significant difference between genders in terms of the total scores on practices in delivering sexuality education. Practices among fathers and mothers varied, and mothers were assumed to be more active in delivering sexuality education compared to the fathers. This contradicts a previous study conducted in Kwara State, Nigeria, which proved that 60% of children preferred discussing sexuality education with their mother rather than their father; this means that the mother must practice more to deliver sexuality information to their children. 34 In addition, there were no significant differences in practices among parents with different educational levels. A study in Windhoek, Namibia, found that there was no difference in practices among parents according to their age and educational level, and they did not have sex education when they were young, thus contributing to their lack of confidence in delivering sexuality education to their children. 1 Several limitations of the study are discussed here. First, the current study was based on a small sample; thus, it may not be generalized to all Malaysian parents. Moreover, sexuality remains a sensitive topic; thus, the researchers cannot guarantee honest answers or the parents' agreement with the statements, especially in the part of practice. It is recommended that future studies must include parents from different sociodemographic statuses or locations. Future research may also consider other populations, including religious leaders and teachers, who may have been tasked to directly provide sexuality education to children. Moreover, a mixed-method approach could be applied to obtain holistic findings with regards the state of sexuality education in Malaysia.

Conclusion
Although most of the parents in this study perceived having good knowledge, positive attitudes, and good practices in delivering sexuality education to their children, it is recommended that they should be welltrained or exposed to different styles of teaching. They must also obtain soft skills (e.g., communication skills) in delivering sexual education to their children at different levels in their daily conversation within a home environment. Along with efforts to ensure that our children receive accurate information, this kind of training can help parents gain confidence in discussing sexuality matters with their children. This can also help the children explore and develop good values and options regarding their sexual health.