Discussion

To date, very few family-based HIV prevention interventions have been developed for rural Indian youth. The majority of interventions have targeted adolescents in schools or health clinics. As a result, a number of questions regarding the feasibility and acceptability of a family-based intervention remain.

To the best of our knowledge, this study is one of the first to conduct focus groups with rural adolescents, mothers and fathers on the feasibility of a comprehensive family-based adolescent HIV prevention intervention. Our findings suggest that a family-based intervention is feasible provided that it: (1) provides families with comprehensive knowledge and strategies about preventing HIV/AIDS; (2) addresses potential barriers to participation; (3) is adolescent friendly, flexible and convenient; and (4) is developmentally and culturally appropriate for rural Indian families.

Overall, both parents and adolescents believed that a family-based programme was feasible and culturally acceptable. Although India is often characterized as having strong cultural barriers to open communication about sex [24], our findings suggest that families are interested in talking with each other about topics like sexual behavior, correct and consistent condom use, and HIV/AIDS. This is an important finding and suggests that family-based approaches are a culturally appropriate and feasible mechanism to help prevent HIV among rural Indian adolescents.

For their part, adolescents respected their parents’ opinions, were open to learning about HIV/AIDS from their parents, and identified their parents as important and influential sources of information. At the same time, it is notable that none of the adolescents named their parents as a current source of information or knowledge about HIV/AIDS. This suggests that family communication about HIV/AIDS is low, a finding that has been observed in previous research [6].

In turn, both mothers and fathers believed it was their responsibility to counsel their adolescents on matters related to HIV prevention. Although previous literature has described cultural taboos surrounding the discussion of sexual behaviour in India [8,9], the parents in our study were open and committed to talking with their children. While some participants felt that such discussions could be uncomfortable, previous research with rural Indian families in India has noted that education and training can reduce such discomfort [9].

These findings are important, as they indicate cultural norms and taboos are not immutable, and can be addressed with straightforward intervention activities designed to promote open communication about sensitive topics like HIV/AIDS and sexual behaviour [9].

In addition, programmes will also have to address some parents’ fears that talking about HIV/AIDS could have negative consequences for their adolescents. Because the mothers in our study were unable to identify specific negative consequences, additional research is needed to better understand how negative expectancies and other factors influence both parent-adolescent communication about HIV/AIDS and family participation in a family-based HIV prevention programme.

It may be that parents feel they do not have the knowledge to have effective conversations with their children. Indeed, research with families in the US on parent-adolescent communication about sex has identified lack of knowledge as a barrier to communication [52]. Research with Indian families on this topic would be a welcome addition to the literature as it remains underexplored. As a result, it is difficult to make definitive statements about factors at the parental level that may significantly impede or facilitate effective communication about sex and HIV/AIDS.

Theory-based research is necessary to identify the determinants of parent-adolescent communication about sex that can be targeted in the context of a family-based intervention. Such information is necessary if we are to support Indian parents to effectively communicate with their adolescent children about how to reduce their risk of HIV infection.

In addition, research is needed to elucidate the contextual factors associated with increased vulnerability to HIV infection among rural Indian adolescents. One contextual factor that emerged as potentially important was the role of poverty, especially as it relates to youth migration to cities and nearby villages in search of work. A number of researchers have highlighted the complex relationship between poverty and HIV/AIDS [53,54], and there is a need to identify the pathways that underlie this relationship in specific regional contexts.

In our study, poverty appeared to break down the protective role of families when young males were forced to leave home in search of economic opportunities. Mothers believed that this minimized their ability to monitor their children’s whereabouts and fathers were concerned about their children’s exposure to risk factors, such as commercial sex work. Although none of the parents in our study discussed the relationship between poverty and commercial sex work, other research in India has underscored the role of poverty and economic inequality in young women’s entry into sex work [55]. While poverty cannot be ignored as an important contextual factor, HIV prevention interventions targeting HIV risk behaviours must also rely on efficacious methods to prevent or reduce HIV infection.

On a practical level, families provided concrete advice about how best to recruit and retain them in a family-based programme. Parents and adolescents endorsed face-to-face recruitment methods as the most successful way to recruit and retain them in a family-based prevention programme. In addition, parents and adolescents recommended using social networks to outreach to families. This is consistent with previous research, which has identified social networks as an important mechanism to promote communication about sexual health and to inform the design of health prevention programmes in India [9,56].

Parents and adolescents in our study were clear that literacy needs to be addressed. Nationwide, approximately 61% of Indian adults are illiterate [57]. This poses a challenge for delivering information to families where children may have higher rates of literacy than parents. Previous intervention programmes with rural Indian communities have relied on a variety of methods, such as skits, cartoons, pictures and radio programmes, to provide information about HIV/AIDS [9]. Families in our study also endorsed these methods, and future research should explore which mechanism is most appropriate and effective for impacting on behaviour.

Finally, gender emerged as an important consideration, with daughters and fathers voicing support for programmes that fostered same-gender communication in the family system. Numerous studies have observed gender differences in family communication about sex, with mothers communicating more with daughters than with sons [58,59]. Globally, less research has examined father-child communication about sex.

However, recent research with fathers in the US suggests that fathers can be engaged in intervention research focused on adolescent HIV prevention and can be supported to communicate with their sons about topics like sexual behaviour, condoms and HIV [60]. Research on family communication about sex in India is scarce and future studies are needed to more fully understand the nature and extent of such communication, including the role of gender and its potential influence on communication and the development of family-based HIV prevention programmes.