Title: Mother-daughter communication of sexual and reproductive health (SRH) matters and
associated factors among Sinhalese adolescent girls aged 14-19 years, in Sri Lanka
Version: 2 Date: 03 Feb 2023
Reviewer's report:
Overall assessment: This is a very important research question, and the findings will push
forward the field of public health. However, the manuscript itself is underdeveloped and lacks
clarity in certain areas.
Overall comments:
• There are several instances where the word “parents” is used when the study and its findings
are specific to mothers. This distinction is important and should be made throughout.
• Please review all parenthetical citations and stick to a unified format throughout. Also, please
make sure all courses cited are in the reference list.
• There are several sentences throughout that refer to preexisting literature, but lack citations.
• Throughout the manuscript the “present study setting” is referred to. It would be more concise
to just was “Sri Lanka”.
Abstract:
• Authors state “school-based and community-based sexuality education has not shown a
significant impact on the sexual and reproductive health (SRH) outcome of Sri Lankan
adolescents.” Is this true? This is certainly not the case for U.S. based literature. If true in Sri
Lanka, needs to be stated and confirmed with several citations in the introduction that focus
specifically on “impact” not just student satisfaction.
• The objective is “to assess the existing pattern of…” This statement would benefit from more
descriptive language. Pattern of what? I’d suggest saying something link “to assess the SRH
topics discussed, barriers to communication, and overall perception of…”
• Results: I’d suggest mentioning the least common topics discussed. Also, “parental perception”
as a phrase is confusing since 1) only the adolescent girls were interviewed; the parents are not
doing the perceiving and 2) the variable is “scared about how my mother will perceive it”. Fear
of mothers’ reaction specifically, not “parents”.
• Conclusion: “Parents' contribution” should be “mothers’ contribution” since that was the focus
of the current study.
Introduction:
• In the first paragraph, I would suggest focusing just on data specific to Sri Lanka. The %
of adolescents globally is not relevant because the SRH needs, communication practices and
cultural influences on sexual behaviors varies drastically based on context.
• The authors state that “with the onset of puberty, intensified sexual interests result in increased
sexual risk-taking among adolescents.” This is not necessarily true. Please add a citation. Puberty
does not necessarily lead to an interest in sex/sexual exploration (there are many folks who are
asexual), and sexual exploration does not necessarily lead to sexual risk-taking. If there is a
high rate of sexual risk taking among adolescents in Sri Lanka (compared to other comparable
groups), then this should be included and cited. Making this point will also help paint the picture
as to why additional education Is needed for adolescents.
• Is the following sentence specific to Sri Lanka? “Recent evidence indicates that at least some
form of intimate activity with a partner is common among adolescents by the age of 15 years”
• The authors state that “A study carried out among unmarried Sri Lankan youth in three
districts in Sri Lanka indicated that a smaller proportion of youth aged less than twenty used
contraceptives during sexual intercourse compared to older youth”. Please include why. Is this
due to a lack of knowledge as implied by the previous sentence, or some other factor such as
access.
• The authors state “However, the literature indicate that these interventions conducted so far,
have been of limited use. Even though SRH has been a part of the school curriculum for over
three decades, very little progress has been observed with the SRH knowledge, attitudes, or
behaviors among the youth in the country” Both of these sentences should be cited.
• With the following sentence “A study that was carried out to assess the success of school-
based sexual education showed that only 58% of the students were satisfied with current school-
based SRH education in Sri Lanka ” please explain why and add a concluding sentence to this
paragraph. The authors could make the case that school-based education is not sufficient, adding
precedence for the current study which explored mother-child communication. There is a missed
opportunity here.
• For the following sentence “Studies across the world have shown that parent-adolescent SRH
communication can prevent unhealthy SRH practices among adolescents and promote their
health”, citations should be from “across the world”. Further, later on in the paragraph the authors
state “Studies that have been carried out across the world have shown that family-based sexuality
education has been effective in improving adolescents’ knowledge, attitudes, and practices on
SRH”. These sentences are very similar. Please restructure/streamline this paragraph.
• It is stated that “the mother was a source of information about puberty for 75% of the adolescent
girls in Sri Lanka, while for 29% of the girls, the parent was a source of information for problems
such as teenage pregnancy. However, no proper study has been carried out so far to explore the
pattern of parent-adolescent sexual health communication in the Sri Lankan context.” These two
things are contradictory. The pattern of parent-adolescent SH communication in Sri Lanka is
reported in the first sentence. Please clarify.
• The following sentence “….and also because this age group is more vulnerable to risky sexual
behaviors” should be cited.
• I suggest removing the sentence about generalization. This is not necessarily true. Instead, add
a paragraph focused on the study “setting” in the methods section and provide more detail than
currently present. This will allow the reader to determine generalizability on their own.
Methods:
• Were study participants compensated? If so, how?
• Please define PHM
• Please list by name and cite the preexisting questionaries that were evaluated, but ultimately
deemed insufficient for the current study.
• Please include the questionnaire in the appendix, or relevant survey questions in the methods.
• Please replace “judgmental validity” with content validity and/or face validity which are more
common.
• Please site the work used to base the categorization of scores around the 60th percentile.
Results:
• Please add a Table 1 describing the sample’s demographic characteristics. After adding, I
would suggest then simplifying the text describing the sample. Refer the reader to the table for
a detailed description of the sample while summarizing key/pertinent points in 1-2 sentences.
• Were participants asked if they were part of a two-parent household? If so, please add to the
description of the sample. This is relevant because “only 6.7% (n=54) of the girls reported getting
sexual health information from their fathers”.
• To say “adolescents’ perception of sharing SH info.” is very broad. I’d suggest using
more descriptive language such as “adolescents’ perceived usefulness of SH mother-child
communication”
• The paragraph describing the SH topics discussed could benefit from some transitional
sentences/restructuring for clarity. Make it clear to the reader that they are listed in order from
topics most discussed to least discussed.
• Table 2 can be presented more concisely. Have a heading “had your mother ever talked to you
about…” on its own row, then list each topic indented on the subsequent rows. The topics should
be ordered (either alphabetically, or by % of most to least discussed)
• In table 2 & 3, why is the “n” in each row different? Missing data? Please explain in the methods
and also explain why the decision wasn’t made to do a complete case analysis or imputation.
• Similarly, for the paragraph describing the barriers I’d suggest adding transition sentences/
phrases to help with readability. (E.g. The top sited barriers were xx and xx, followed by xx and
xx. Other barriers can be found in table 3).
• Again, when describing the “modes of sexual health information”, organize the findings with
transition sentences/phrases. Either list highest to lowest or group some other way such as formal
then informal sources. Will help with flow and readability.
• Consider using the terminology “sources of information” vs. “modes of information”.
• As with Table 2, the modes on information in table 4 should be ordered (either alphabetically,
or by % of most to least discussed)
• Please rephrase the following sentence “It was seen that a mother’s communication of SRH
matters with a daughter aged above 15”. SRH communication matters and is important for all
ages. This is not what the results are indicating. Perhaps say “perceived as more satisfactory”.
• Same comment as above for the following sentence “mother-adolescent daughter
communication of SRH matters was 2.4 times (AOR= 2.4, 95% CI: 1.5-3.8) more in families
with high-income”
• What were the confounding variables entered into the model. Needs to listed as an asterisks
in table 5
• Also report that associations were non-significant in table 5. This too is important
• Why were the “age of adolescent” and “family income” made categorical and for logistic
regression as opposed to being kept continuous which would allow for linear regression?
Discussion
• It would great to include a paragraph on the impact of culture as it pertains to discussing
sensitive topics with one’s parent/child, particularly since for this sample, almost 50% identified
cultural acceptance as a barrier to communication. There is a lot of research on this.
• Although mothers were a source of SRH information for many girls, so were teachers, friends,
books and journals. I would love to see the authors wrestle with this finding. Do we propose
integrated interventions? Has this been done before? What is the utility of teachers given that
adolescents spend just as much (if not more) time at school as at home?
• The following sentence should be cited: “…previous studies which indicate that the mother is
a preferred source of SRH information to the adolescent girls in our study setting”. Also, are the
“previous studies” referenced in countries that are similar culturally to Sri Lanka? This would
be great to include for context.
• Authors highlight that the “results indicated that many mothers tend to talk with their daughters
about menstruation-related information and about protecting their bodies yet less information
was given on safe sex, pregnancy, and conception.” This is an important finding. What does this
mean – connect it back to points made in the introduction. Discuss how this might impact the
overall SRH of adolescent girls?
• The following sentence feels out of place since the rest of the paragraph is talking about topics
commonly discussed: “Only a few mothers had discussed pregnancy and conception (34.7%,
n=271), preventing unwanted pregnancy….” As noted in my previous comment, a discussion
around what topics were not discussed as much and the implications of this would strengthen
the discussion section and should be its own paragraph.
• I assume findings from Australia are included to highlight how differences in socio-cultural
values impacts which topics are discussed among mother-daughter dyads? If so, this is a great
point to make, however this paragraph should be expounded so that data from Australia doesn’t
appear out of place. Findings pertaining to the mother-daughter SRH topics discussed in other
countries should be included and organized. For example, have a few sentences talking about the
content of these conversations in western cultures compared to eastern cultures, or individualistic
societies vs. communal societies, or Buddhist cultures vs non-Buddhist cultures.
• Is the following sentence accurate? I don’t see 209 in the results table: “Nearly one-fourth of
the girls (26.8%, n=209) in the present study were uncertain or denied their mothers’ ability to
answer their SRH matters.”
• While the results do indeed indicate that “parent-targeted interventions to improve mothers’
capacity to discuss SRH issues with children” are needed, what difference will this make if
daughters are denying mothers the ability to answer their questions (as stated in the preceding
sentence)? Something needs to be added here around daughter’s trust in their mothers, or the
need for a foundational relationship that allows them to learn together how best to communicate
with one another.
• The paragraph starting with “the present study indicated that mother-adolescent” and the
subsequent paragraph starting with “However, the review of literature from western cultures
indicated” could be better organized. Is the first paragraph focused on Asia and the second
focused on countries in the west? If so, then 1) make this distinction clear with the topic sentences
and 2) interpret what this distinction means. If not, please organize the findings cited in both
paragraphs in some other way that’s east for the reader to follow.
• The following sentence needs to be cited: “This finding agreed with several other studies
carried out in Asia and other similar settings, which reported that parents preferred to initiate
sexual discussions with children at 15, during which the majority…”
• Where it states “The finding brings out several research concerns…” What follows are not
“concerns”, but rather future research questions. I’d suggest moving this content to later in the
discussion section where other future research questions are discussed.
• A strength of this study cited is that “it brought up a new argument for SRH advocacy”. Please
indicate that is “new”. Advocating for improved mother-daughter SRH communication is well
documented in the literature, albeit maybe not in Sri Lanka.
• In the strengths and weaknesses paragraph, rather than focusing on generalizability (which is
up to the reader to assess), I would reframe this strength to instead discuss how representative
your sample is. Similarly, rather than mentioning “study findings cannot be generalized to other
ethnic groups in the country”, I would suggest instead harping on how the characteristics of this
group might be different, so findings should be applied to other populations with caution.
• Where “increased reliability” is mentioned, increased validity would make more sense given
the beginning part of that sentence.
• It is stated that “limiting the study to the Sinhala mothers and adolescent daughters increased
the adaptability of the study findings to the Sinhala community in Sri Lanka”. How so, and what
was adapted? Or is this referring to study feasibility? This should be introduced in the methods
section if done intentionally, before being brought up in the discussion.
• Please define O/L and A/L
• “Failure to examine the impact of the intervention on two or more daughters of the same mother
or to examine adolescent factors that may have contributed to mothers’ communication” are not
limitations. I would argue that these are additional research questions that could be explored in
a subsequent study.
• An additional limitation is that that family income levels were reported by the daughter so may
not be accurate, and we also don’t know family size.
• The statement that “this study provided insight into the ability to get parents involvement in
adolescent SRH education in Sri Lanka” is misleading because only adolescents were surveyed.
Please rephrase.
• Another PH implication stated is that participants “were held back from discussing SRH issues
within the family due to various barriers”. What barriers (e.g., social, cultural, etc.)? Please be
more descriptive.
• The statement that “advocacy programs targeting education staff, including school principals
to get the active involvement of the parents during school sexuality education sessions is also
a requirement” is not substantiated by this study’s findings. Involving parents in school-based
education was not explored or even mentioned in the discussion section. Please reframe and
ground in the study findings.
• In the conclusion, I would suggest adding study findings around income.
• I would suggest adding to the “future research” paragraph content pertaining to dyadic research
since this study only involved adolescence. Current studies (at least in the U.S. context) indicate
that parents’ and children’s’ accounts of what is discussed during SRH conversations are not
always aligned.