Efforts to promote healthy sexual development and reduce sexually transmitted diseases (STDs) and unintended pregnancies have frequently targeted adolescents through school or community-based programs.¹ Less effort has been focused on enhancing the role parents play in raising sexually healthy adolescents. Yet parents can have a strong influence on their adolescents' sexual health and risk behaviors. For example, adolescents whose parents monitor them and who feel positively connected to their parents have an increased likelihood of delaying intercourse;² if they engage in intercourse, they tend to have fewer partners than other adolescents and are more likely to use contraceptives.³

Parental communication about sex also plays an important role in ensuring adolescents' healthy sexual development. Increased communication, like appropriate monitoring, is associated with delays in teenagers' initiation of intercourse and, among those who are sexually active, greater use of contraceptives and having fewer partners.⁴ Nevertheless, parents and adolescents report that talking to one another about sexual topics is difficult. Parents cite many reasons for not being actively involved in their children's sex education, including feeling incompetent, uninformed and concerned about embarrassing their child.⁵ A parent's communication style (such as lecturing when talking about sex) may also inhibit open discussion about sensitive topics.⁶

Teaching parents good parenting and communication skills offers a promising approach to protecting adolescent sexual health. Most parenting programs, however, have high dropout rates,⁷ possibly because of competing demands and inaccessibility. Parents may not have the time or resources to travel to the program site and arrange for care for young children.⁸ Given that 84% of parents of 12–17-year-olds are employed,⁹ the worksite may be a promising location for a program that focuses on adolescent sexual health.¹⁰

In addition to being convenient for participants, worksite-based health programs, such as weight reduction¹¹ and smoking cessation¹² programs, have been successful in changing health-related behaviors. Although some employers provide programs to help workers with family issues, few offer programs designed for parents of adolescents. A worksite-based parenting program addressing adolescent sexual health, developed and conducted through collaborations between health educators and worksite personnel, could help fill this gap. Nevertheless, it is unclear how parents, employers and adolescents would react to such a program and what challenges such an ongoing, potentially sensitive program would present. Therefore, we conducted a qualitative study with parents, adolescents and employers to explore two aspects of providing such a program: feasibility and desired content.

METHODS

Focus Groups

Focus groups were conducted separately for parents and adolescents between December 1999 and February 2002. Trained facilitators with clinical experience with adolescents or parents of adolescents led the groups. Discussions were audiotaped and transcribed verbatim. The RAND Human Subjects Protection Committee approved all procedures and materials.

•Parent groups. We conducted three parent focus groups, two at a private, for-profit company and one at a public agency. We chose a private and a public worksite to obtain perspectives from distinct environments (e.g., with respect to organizational structure and mission). We hoped to enroll diverse groups of employees within each site.

At each worksite, employees were sent an e-mail or letter describing the upcoming focus groups. To ensure the inclusion of mothers and fathers of adolescents who were at varying stages of development, we stratified interested parents by their gender, their adolescent's gender and their adolescent's age (10–12, 13–14 and 15–16 years old). At the for-profit company, parents were selected on a first-come, first-served basis. Most interested parents called within the first two days; therefore, the likelihood of a significant selection bias between those who responded first and those who responded later was minimized. At the public agency, employees within each stratification group were randomly selected. In both settings, parents who responded, regardless of how quickly, were probably more invested in the discussion topics than other parents were. This potential selection bias is important to consider in interpreting our findings.

Eleven parents participated in each group, for a total of 33 parents (17 mothers and 16 fathers). These participants were parents of youth in grades 6–10; they represented a mix of races and ethnicities, and a variety of socioeconomic backgrounds (Table 1). The groups met over the lunch hour on two consecutive days for a total of two hours. All parents who attended on the first day returned for the second. A free lunch was served each day, and at the end of the second day, each participant received two $25 gift certificates.

Facilitators used a semistructured protocol with open-ended questions and probes to explore parent-adolescent communication, the quality of parents' relationships with their adolescents, parents' experiences talking with their teenagers about sensitive issues such as sex, parents' feelings about their children's sexuality and topics that parents would want covered in a program to help them communicate with their adolescents about sex. Facilitators then gave a one- or two-sentence general description of a hypothetical parenting program that "focused on the parent- adolescent relationship and adolescent sexuality and was held at worksites." Parents responded to questions about such a program (e.g., how best to implement it) and completed a brief demographic survey.

•Adolescent groups. We conducted six focus groups at a Los Angeles County public high school with which we have a long-standing relationship. We chose this school, whose student body includes significant numbers of blacks, Asians, Pacific Islanders, Latinos and whites, for its ethnic and socioeconomic diversity. With the permission of the school principal, researchers announced the focus groups in the classrooms of teachers who had agreed that students could miss class to attend the groups. Students took home a consent letter describing the groups and requesting parental permission to participate.

Groups were gender- and grade-specific, took place at school and lasted for about two hours. If nine or more students for a particular group returned permission slips, eight students were randomly selected and invited to attend. Participants agreed to miss their lunch period and one class period (in most cases, missed classes were physical education, health and math). We could not determine how much missing lunch or one of these classes biased student selection. Twenty males and 21 females in grades nine, 10 and 12 participated (Table 2); 11th graders were not available because of competing school commitments. Participants received a $20 gift certificate and lunch.

Facilitators were matched by gender with the focus group participants. Discussion topics included relationships with parents, friends and teachers; general communication with parents and teachers, as well as communication about sensitive issues such as dating, relationships, sex and substance use; perceptions of peers' experiences with dating, relationships, sex and substance use; how teenagers would feel about parents' participating in a program designed to help parents talk with adolescents about sex and to promote healthy sexual behavior; and what topics they would want a program to cover. Facilitators described a hypothetical program, but did not ask specifically about the idea of providing a program at worksites.

At the start of each group, students completed a confidential survey. Their responses indicated that they had diverse experiences with behaviors relevant to topics that might be addressed by a parenting program—specifically, whether they had ever used alcohol, ever used drugs or ever had vaginal intercourse (Table 2).

Employer Interviews

Between February and June 2000, we conducted interviews with executives responsible for overseeing health promotion and family life programs at seven worksites (human resources directors, employee relations directors and a medical director). We contacted these participants through letters and phone calls. The worksites ranged in size from 125 to 4,000 local employees (some were local sites of large national organizations).

Researchers used a semistructured protocol to conduct the 45–60-minute in-person interviews. Topics included the organization's current health promotion, wellness or family life programs, as well as the employer's reactions to the idea of implementing a worksite program to promote parent-adolescent communication and healthy adolescent sexual development. Interviews were audiotaped and transcribed.

Data Analysis

We analyzed all of the transcripts using a standard qualitative analysis method to identify topics (general domains of information covered) and themes (groups of similar ideas found within topics).¹³ First, three researchers reviewed the transcripts and identified major topics of interest. For each data source (parent, adolescent, employer), a team of three researchers then reviewed the transcripts to identify discrete units of text (phrases, sentences or short paragraphs) that were relevant to specific topics; these text units were placed on individual index cards. Each team sorted its cards for each topic on the basis of perceived similarity of content. When the researchers did not agree, they resolved differences through discussion. These piles of index cards defined the thematic categories within each major topic.

The researchers used the pile-sorting results to develop codebooks for the parent, adolescent and employer data. The codebooks included the major topics, detailed descriptions of the thematic categories within each topic and ID numbers of the index cards associated with each category in the pile-sorting task. The teams used the codebooks for a final review of the text units and each theme, eliminating a few text units that no longer seemed to fit in a thematic category and classifying a few previously unassigned units that now fit into one.

Using a redacted version of the codebook, a researcher who had not been involved in the previous steps independently sorted the cards for each major topic into thematic piles. We used Cohen's kappas to assess interrater reliability between the pile sorts of the independent sorter and the initial pile sorts listed in the codebooks for each major topic. Kappas for the parent data, the adolescent data and the employer data were assessed separately for each topic and ranged from .73 to .98. Typically, kappas above .70 are considered acceptably reliable.¹⁴

RESULTS

Most parents reacted with enthusiasm to the idea of a worksite-based parenting program. They anticipated that it would help them navigate the sea of information about how to parent teenagers available from the mass media. They also were eager to learn the perspectives of other parents. One commented: "I would be interested because…I feel like I'm supposed to have all the answers, and I don't. I'm just kinda feeling my way through…so any type of knowledge that I can gain would be helpful."

Adolescents responded enthusiastically to the idea of parenting programs in general. They anticipated benefiting from having their parents take a course on talking about sex: They felt their parents would trust them more, understand them better and become more involved in their lives. Comments included the following:

"It would make me feel more comfortable because they'd be more understanding."

"It would show that they care about you."

"I think it's great, because they'd know what we're going through, what we're doing. Maybe they could learn to trust us more…understand us better."

Five specific topics were identified in the focus groups and interviews. Two topics addressed the feasibility of conducting a worksite-based parenting program on sexual matters: recommendations for implementing a program (parent groups only); and employers' reactions, including their interest in such a program and their views on the challenges of providing it (employer interviews only). The other three topics were relevant to the content of a program and came from both the adolescent and the parent focus groups: parent-adolescent communication in general, parent-adolescent communication about sex and recommendations for program content.

Implementation

Five themes emerged from parents' comments about conducting a worksite-based program for parents of adolescents. These themes addressed program scheduling, program format, how to market the program, how to maintain attendance and how parents would feel about participating in a program with coworkers.

Parents emphasized that a program should be held during the lunch hour and not before or after the workday. As one parent put it, "After work is kinda sacred family time." Another said, "You spend so much time commuting and doing all this other junk that…nights are real valuable."

Regarding program format, parents wanted opportunities to interact with each other and program facilitators. They proposed program activities, including nonthreatening exercises that they could do at home with their adolescents and role-plays to help them learn and practice communication skills during program sessions. Additionally, they said that a program should include adolescents' perspectives.

Parents also commented on how to market the program, noting that parents would need to feel that it was relevant to them. They recommended that program advertisements address stigma associated with seeking help. One parent said, "Don't bill it as a clinical…atmosphere." Others suggested using parent testimonials and presenting the program with statements such as "You don't have to be in crisis to come," "Raising a teenager doesn't have to be nonstop agony" or "You're not alone."

Most parents felt that opportunities to learn effective techniques, receive support from other parents and hear what other parents are going through would keep attendance rates high. One said that he would return to sessions if the program created "[the] feeling that somehow we're all in this together, and you know, you suddenly realize, maybe my problems aren't unique."

Finally, parents reacted differently to the possibility that they would be participating with coworkers. Some parents thought it would not be a problem ("It wouldn't bother me"), or that it might even be an advantage: "I think being with coworkers, you feel like you're on a certain level, because we're all professional people working for the same company…whereas if you're in a group of people outside of your company, you don't know those people. [So] I think it would be fine."

Others suggested that their comfort level would depend on the circumstances. One said, "As long as you're not constantly in contact with them…. If they're immediately above you or immediately below you, I think you would have a more difficult time expressing your feelings or concerns." At least one other parent expressed a similar feeling ("If there was someone in the room who worked for me…I might not want to say things"). Still another mentioned that it might not be comfortable discussing family issues with any colleagues.

Employers' Reactions

Two themes emerged when employers were asked about implementing a worksite-based program to help parents promote adolescent sexual health: reasons for providing a program and potential challenges.

Employers described two reasons for offering such programs. First, even at worksites that provide programs focused on family issues, these programs would help fill a gap in services. As the employers noted, worksites may have programs for employees with newborns or elderly parents, but they seldom have programs for parents of adolescents. Second, such programs could improve morale and thus productivity. One participant stated, "If people are happy, then they enjoy work more."

Nevertheless, employers described three potential barriers to offering a worksite-based parenting program. First, drawing on experiences from other wellness programs, they expressed concern that parents would not attend or would come for only a few sessions.

Second, they thought that some workers might not participate because of concerns about confidentiality and the sensitivity of the program content. One employer said, "Issues around sex might be particularly sensitive since many workers are highly religious…they read the Bible during lunch." Another commented that some workers "might be reluctant to disclose information."

Finally, employers stated that the program's cost would be a factor in whether it could be implemented at their worksite. As one participant put it, "Cost is the bottom line. Whether a program is approved or not usually depends on the cost to the company and whether or not the proposed idea will require negotiation with one of the unions."

General Parent-Adolescent Communication

•Parents' discussions. Parents' comments about difficulties with parent-adolescent communication in general focused on three themes: adolescent resistance to talking with parents, ineffective communication methods that parents have used and conflicting parenting styles.

Many comments made by parents focused on adolescents' not wanting to communicate with them. One parent said that her teenager "doesn't want to listen. She doesn't want me to explain anything to her." Another commented that her daughter "won't talk about how she feels with us."

Parents also discussed failed attempts to communicate with their teenagers. Some identified parenting behaviors that did not facilitate effective communication: "threatening kids," "saying things over and over," and "talking at" teenagers.

Noting that mothers, fathers and other adults often have different parenting styles, participants observed that such differences can lead to conflict. A mother who said that she is more lenient than her husband observed that overcoming their disagreements about parenting techniques is "one of the biggest challenges."

•Adolescents' discussions. Adolescents' comments on general problems communicating with parents focused on four themes: difficulties talking to parents; parents' tendency to focus on the negative; parents' not listening or understanding; and parents' degree of involvement in their lives.

Discussing difficulties in talking to parents in general, one teenager said, "Sometimes I want to talk to [my mom], but I don't know how." Others described feeling "awkward" and "nervous" talking to their parents. Adolescents also described not talking to their parents. As one said, "I never tell my parents things that are very important to me."

In comments such as the following, adolescents described the feeling that communication with their parent focused primarily on what they had, in their parent's view, done wrong:

"There's always something that she didn't like: 'You didn't do this, or you didn't do that.'"

"You mess up, and they notice it right away."

"I guess they're more interested in the negative aspects of what you do than like the positive aspects."

Some adolescents attributed their lack of communication with their parents directly to their parents' responses. One said, "When she's trying to get a point across, it's like everything she says is like right, and whatever I say, she always has to like disagree or something. So that really makes me mad, and sometimes I just walk out." Adolescents also perceived that their parents did not trust them or were suspicious of them.

Some adolescents claimed that their parents did not listen or understand. For example:

"It doesn't really matter, 'cause they don't really hear me, even if you try and talk to them."

"They don't listen to you, and they just end up like yelling at you sort of, and then forget it, I don't want to talk about it anymore, and then they start assuming things."

Adolescents also described how parents dominate conversations or give a lecture: "It tends to be one-sided. If you try to say your side, it's considered talking back."

Finally, some adolescents expressed a desire for their parents to be more involved, to get to know their friends better or to spend more time with them ("I see other parents, even though they work, they actually make time for their kids to see what they're doing"). Others, however, described what they considered excessive intrusion and involvement. As one teenager put it, "She's all up in my business."

Communication About Sex

•Parents' discussions. Four themes emerged among parents regarding talking with their adolescents about sex: specific doubts and uncertainties, parents' lack of role models, adolescents' not talking about sex and strategies for talking about sex.

Regarding their doubts and uncertainties about discussing sex-related topics with their adolescents, parents mentioned fears about what and how much to say. One parent articulated a dilemma: "How much should I tell her, and if I don't tell her, is she going to get pregnant? Or if I tell her too much, is she going to get pregnant? Which way do I go?"

Parents also expressed concerns about how to get a conversation started and how to talk about sex-related issues ("My problem is I didn't know what or how to communicate with them and at what level"). Many parents commented that their parents had not talked with them about sex when they were younger, so they lacked examples and doubted their abilities to speak effectively about sex. Another commonly expressed sentiment was that adolescents do not want to communicate with parents about sensitive issues like sex. One participant observed that teenagers are "embarrassed to talk to their parents. They want to talk to somebody else."

Finally, parents shared effective strategies for discussing sex-related issues with their adolescents, including raising the issues while riding in a car; talking about the issues during a television show that the parent and adolescent are watching together; buying a book for the adolescent to read and discuss; asking questions when the adolescent's school addresses sex education; and having the adolescent write down questions to discuss. Several parents encouraged the use of real-life situations, because "using examples that are [about] someone that's close…or they know…drives home the point a bit better."

•Adolescents' discussions. Four themes emerged from adolescents' comments about talking to their parents about sex: Parents do not talk about sex, adolescents do not want to talk about sex with their parents, parents make assumptions, and parents' statements about teenagers' having sex are brief or threatening.

Some adolescents observed that their parents did not talk to them about sex, and their comments included speculation as to why this was so: "They probably didn't talk about it with their parents either; talking with us is probably more uncomfortable for them" and "They're so scared to…find out the truth."

A number of adolescents did not like the idea of talking to their parents about sex because they would feel embarrassed, uncomfortable or nervous. They thought that if they did talk to their parents about sex, their parents would get worried or angry.

Adolescents said they had difficulty talking to their parents about sex because their parents made assumptions about their sexual behavior. Among the comments:

"She has to act in a way like…I'm doing it already [instead of just] wanting to know about it."

"They start thinking that you're having sex."

"If you talk to them about it, it'll end up being you who is sexually active."

Teenagers also described intrusive questions that contained assumptions. For example, one participant commented, "They always question you when you're with a guy: 'Oh, like are you dating him?' or 'Is that your boyfriend?'"

Finally, when adolescents gave examples of what their parents had said about sex, they generally described brief statements admonishing them against having sex. Some speculated that their parents would say it was wrong or tell them not to do it. Others reported that their parents had told them not to "make the mistake," instructed them to wait until they were married or described negative consequence that would occur if they had sex ("You're going to hell if you do it").

In some cases, teenagers said that their parents discouraged sexual activity with threats about what would happen if they became pregnant or got someone pregnant:

"If you get pregnant, I'm going to shave your head."

"I'm going to kick you out of the house, and you're gonna end up by yourself [if you get a girl pregnant]."

Program Content

•Parents' discussions. Parents recommended that a worksite-based parenting program designed to promote adolescents' sexual health cover specific topics, communication skills, and how to develop good values.

They would like such a program to provide information on abstinence, sexual behavior, contraception and STDs, including how to use condoms and other preventive methods. One parent commented that "it is important for kids to know that it is okay to say no, and you don't have to be ashamed to say no. You shouldn't have any negative feelings for saying no." Other topics parents would like a program to cover are adolescent development, ways to talk with teenagers about the changes of puberty, healthy relationships and the emotional aspects of dating.

Parents also would like to learn how to communicate more effectively—specifically, how to listen, how to break down barriers, and what and how much to say. One parent would like to know how to "communicate without seeming too pushy." Another noted, "You have to teach parents how to start talking about simpler things at a younger age so that you can move into the more difficult topics more easily."

Finally, parents would like the program to help them teach their adolescents morals and values. One parent wanted to know how to teach her adolescent "an overall value system, integrity—that kind of thing—a strong sense of your own ideas, as opposed to going along with the crowd."

•Adolescents' discussions. Themes that emerged in teenagers' discussions about what they would want their parents to learn in a parenting program were communication skills, techniques for increasing their parents' ability to understand and listen to them, and information.

Adolescents thought it would be important for parents to learn how to approach them. As one teenager put it, "I would at least like them to learn what to say, how to say it, and like, to come to me calm and composed."

As the following comments reflect, many adolescents wanted their parents to be more understanding, listen better, avoid assumptions, and accept their feelings and opinions:

"When we argue, parents should understand that the teenager has a side of their story. They don't usually let us speak it out, and they just think that they're right, and sometimes they're wrong."

"They should know [that] assumptions about teenagers aren't true for every teenager."

"They need to listen to us."

Finally, adolescents would like their parents to have specific information to pass along to them. Teenagers felt that their parents should talk to them about how to use condoms and how to decide whether to have sex. They also would like their parents to know more about their lives and their points of view, and to know that being a teenager is stressful.

DISCUSSION

Feasibility

Parents' support for worksite-based parenting programs suggests that these programs would be well-received, but the attitudes expressed in the focus groups cannot predict whether parents would actually attend a program. The true test of parents' responses will be to conduct a pilot of such a program at several worksites and evaluate recruitment and attendance. Nevertheless, given parents' enthusiasm and the potential advantages of worksite-based programs, we are encouraged that programs can be implemented successfully if they take into account parents' recommendations. For example, programs should reflect parents' preferences that sessions be held at lunchtime and that advertising strategies not describe the program as oriented toward mental health issues. Ongoing contact with coworkers may provide parents with incentive to continue attending sessions and the opportunity to develop a social network that could reinforce program lessons.

Employers were also enthusiastic about offering a program to parents of adolescents. Since they are the gatekeepers of worksite-based programs, their receptivity is critical to the feasibility of implementing these programs. Given the small number of employers we interviewed, their comments may not have represented all existing opinions and ideas of employers. Nevertheless, their descriptions of potential challenges to implementing worksite-based programs are valuable, and point to areas that program planners can address to maximize the success of their programs. For example, employers were concerned that some workers might not approve of the program content. A strong program, however, could promote communication and parenting without dictating values. And an emphasis on respecting divergent perspectives and values may help employees feel comfortable participating in a program. Finally, because participation would be voluntary, workers who did not like the program simply would not enroll.

Employers also thought that employees might not want to disclose personal information, but program procedures could address the loss of privacy that would occur if participants revealed personal issues during program sessions. For example, on the first day of a program, participants could establish their own group guidelines about confidentiality, and facilitators could explain that they do not provide information from the group to the employer.

Worksite decision-makers were also concerned about program costs. Researchers and employers could work together to address cost issues by evaluating not only whether a program would benefit employees, but also whether the sponsoring worksite would benefit. Research could determine whether a program is likely to reduce absenteeism or stress, how much time is necessary to administer it, and whether the benefits to workers and the employer exceed the costs of conducting programs.

Program Content

In our focus groups, many parents said that their adolescents did not want to communicate with them; adolescents concurred. Parent and adolescent descriptions of general communication problems can be used to determine the program content most likely to facilitate more effective discussions.

First, parents should be encouraged and taught to notice and respond to what they approve of in their children's behavior. Positive comments can help adolescents feel better about themselves and promote desired behavior. Second, parents could be taught active listening skills (e.g., paying attention, listening without interrupting to give advice, restating what they have heard their child say, identifying the feeling their child is expressing). Active listening shows adolescents that their parents are interested and trying to understand, encourages adolescents to express themselves, and helps adolescents identify their own thoughts and feelings.¹⁵ Third, parents could be taught to increase their use of open-ended questions to encourage their child's expression of feelings and to increase the likelihood that parents and adolescents will engage in a discussion that involves expressing their ideas and opinions. Asking open-ended questions can help to increase turn-taking, so that neither the parent nor the adolescent dominates the conversation. Turn-taking and other techniques that encourage dialogue may facilitate the communication of sexual information.¹⁶

Many parents and adolescents also noted the absence of sex-related discussions. In addition to teaching the general communication skills described above, a program could target specific skills to encourage sex-related discussions between parents and adolescents.

First, program activities could motivate parents to discuss sex-related issues with their children. Parents could identify reasons why they might be reluctant to talk about sex with their children (e.g., they do not know what to disclose about their own past or they fear that talking about sex might encourage sex) and then jointly devise strategies for addressing these concerns.

Second, parents could learn other effective strategies for starting conversations about sex with their children. For example, they could learn about using teachable moments—everyday situations, such as watching a movie with a love scene—to start a conversation about sex. They could also be taught how to get past roadblocks—things adolescents say and do that make it hard to talk about sex—by using communication skills such as active listening and asking questions.

Third, a program could teach parents how to teach their children decision-making and assertiveness skills to handle various pressures they might encounter. By practicing these skills in conversations with other parents during program sessions, parents may become more comfortable discussing sexuality with their adolescents.

Finally, parents wanted a program to have activities that would engage their adolescents at home. Home assignments could be used to encourage parent-adolescent conversations in general and in regard to sex education, and could be an important program feature for extending the impact of the program beyond session hours.

Conclusion

Recommendations from adolescents, parents of adolescents and employers could help make worksite-based parenting programs that promote healthy adolescent sexual development appealing and effective. However, to understand fully the feasibility and effectiveness of such a program, the next steps needed are to design a program and conduct a pilot. Reviewing effective adolescent-targeted sex education programs, identifying a theoretical foundation for the program and adopting principles of adult education could increase program effectiveness. A rigorously designed evaluation of a worksite-based parenting program would be useful.