The family organisational culture as a predictor of sexual attitudes and behaviours in adolescents

Theoretical framework: Parental behaviour can have a significant effect on the sexual attitudes and behaviours of adolescents. Objectives: This study objective was to analyse the predictive effect of the family organisational culture in sexual attitudes and behaviours of adolescents in the 9th grade. Methodology: The sample consisted of 364 adolescents of both genders aged between 14 and 18 years. The data collection instruments were the Inventory of the Family Organisational Culture and the Scale of Attitudes about Sexuality in Adolescents. Results: The results showed that the family Culture of Interpersonal Relationships, Hierarchical Culture and Heuristic Culture variables significantly predict the sexual attitudes and behaviours of adolescents. Conclusion: This study highlights the importance of implementing programs and projects in schools on the subject of sexuality, involving not only adolescents but also their families, as an essential element in promoting healthy sexual attitudes and behaviours.

Marco contextual: El comportamiento de los padres puede tener un impacto significativo en las actitudes y comportamientos sexuales de los adolescentes. Objetivos: Este estudio tuvo como objetivo analizar el efecto predictivo de la cultura organizativa de la familia en las actitudes y comportamientos sexuales de los adolescentes del noveno año. Metodología: La muestra se compone de 364 adolescentes de ambos sexos, con edades comprendidas entre 14 y 18 años. Los instrumentos de recogida de datos utilizados fueron el Inventario de la Cultura Organizativa de la Familia y la Escala de Actitudes frente a la Sexualidad en los Adolescentes. Resultados: Los resultados muestran que las variables Cultura de las Relaciones Interpersonales, la Cultura Jerárquica y la Cultura Heurística de la familia predicen significativamente las actitudes y los comportamientos sexuales de los adolescentes. Conclusiones: Este estudio pone de relieve la importancia de poner en práctica programas y proyectos en el medio escolar en el ámbito de la sexualidad, que implican no solo a los adolescentes, sino también a sus familias, como elemento esencial en la promoción de actitudes y conductas sexuales saludables.

Introduction
Adolescence is known as a period marked by profound internal and external changes that occur at a biological, psychological and social level in the identity development process where the adolescent is preparing "for a long process of emancipation from parental guardianship" (Fleming, 2005, p. 61). During this period, the family culture and the educational styles adopted by parents may lead adolescents to risk attitudes and behaviour, particularly in the sexual sphere. Therefore, sex education should be a priority and its approach should be designed and planned to meet their needs. In this sense, nurses have an important role as educators, in promoting a healthy and responsible sexuality. Nurses should participate in the development and operation of these sex education programs that, as observed by the United Nations Educational, Scientific and Cultural Organization (UNESCO, 2009), should aim to increase knowledge and understanding in the context of sexuality; explain and clarify feelings, values and attitudes; develop or strengthen skills in this area and promote and support healthy behaviour, thus minimising risk. Parents should also be included in these programs, since comprehensive sex education programs that include parents can be more effective in delaying the initiation of sexual intercourse by adolescents because family activities can encourage parents to talk to their children earlier and more often (Grossman, Tracy, Charmaraman, Ceder, & Erkut, 2014). So nurses need to understand how certain variables, including educational styles and family culture, relate to adolescent sexual behaviour and attitudes, so that they can design more effective educational and preventive interventions in the prevention of risk behaviours. Thus the objective of this study is to analyse the predictive effect of the family organisational culture on the sexual attitudes and behaviours of the 9 th grade adolescents.

Background
Family culture can tell us a lot about how a certain family functions and how its members relate to and influence one another. Nave (2006), studying the patterns of family organisational culture, found that the types of organisational culture adopted by families are predictors of family satisfaction and of a positive perception of family functionality from the children point of view. In another study, Ferreira et al. (2013), based on the four types of family culture identified by Nave (2006), namely, Interpersonal Relationships Culture, Heuristic Culture, Hierarchical Culture and Social Goals Culture, assessed the type of culture adopted by each family and compared the results with the adolescent attitudes regarding sexuality. These authors found that teens that have a bad attitude towards sexuality mostly have a poor perception of the Culture of Interpersonal Relationships, while the family Hierarchical Culture and Social Goals Culture are moderate. In a multinational study by Madkour et al. (2014), in which respondents were young people aged between 15 and 20 and parents aged from 31 to 65 from 17 European countries, the results confirmed the influence of cultural norms on the sexual behaviour of adolescents, in particular on the timing of sexual initiation. Dias, Matos, and Gonçalves (2007), in their study on adolescent perception of their parents' and peers' influence on their sexual behaviour, emphasised the importance of parenting style, agreeing with several other authors who argue that parenting style must promote autonomy and self-discovery, since these are aspects that "are associated with social and psychological competence and decrease the likelihood of engaging in risky sexual behaviour" (p.631). In the study carried out by the same authors (Dias et al., 2007), young people felt that an authoritarian parenting style can have an adverse effect because it gives them little autonomy or security. As regards a democratic parenting style, the young people think that the adoption of this style can avoid risky behaviour as "parents do not forbid but are vigilant and they point out the dangers, it promotes accountability, provides a sense of confidence, a greater willingness to respect the parents" (p.628). In the same study, the authors found that the adoption of authoritarian or permissive styles are considered by young people as factors that can lead to risky sexual behaviour, as association was observed between less parental supervision and the participation of adolescents in more risk behaviours, including early initiation of sexual activity and unprotected sex. Also that it is the parents who do not feel comfortable talking with their children. They also say that "often, parents do not have the knowledge or the most correct information" (p. 627). On the other hand, young people themselves can avoid talking with their parents because they do not feel comfortable (Dias et al., 2007). Castro and Rodrigues (2009) also found that only 17.1% of teens said they talked to their parents about these issues. The reasons given by adolescents in this study were that this is not a subject to be discussed with parents (33.81%) and shame or fear (32.05%). According to Vilar and Ferreira (2009), girls clearly choose their mothers to talk about all subjects, while with the boys there is no clear preference for either parent. The adolescents in this study considered that the quality of the relationship they establish with parents is very important for there to be effective communication. When this communication on sexuality proves positive, it can help to solve problems, acting as a more important source of support and help than friends. These young people also report that this communication by itself does not have positive results, but when the relationship with parents is distant, "we typically witness an increase of peer influence on sexual matters" (Dias et al. 2007, p. 631).Other authors claim that the frequency and quality of communication between parents and adolescents may not be sufficient to reduce risky sexual behaviours, since it is not the only factor. However, it may be an important step to an open and comfortable conversation about sexuality between parents and adolescents (Schouten, Putte, Pasmans, & Meeuwesen, 2007). Thus, the influence that parents have on their children is largely due to the quality of the relationship they establish with them. While research often addresses the influence of family communication on the sexual behaviour and attitudes of adolescents, family culture is as yet a variable that is not commonly addressed.

Research question
As a result of the purpose of the investigation and based on the theoretical review carried out on the issue under study, the research question raised was: Is there a relation between family culture and the sexual attitudes and behaviours of adolescents in the 9 th grade? The research hypothesis was: The family regarding parents influence on risk behaviour, Huang, Murphy, and Hser (2011) conducted a study on parents monitoring during adolescence, defining four levels of parental monitoring: high, increasing, decreasing and low. Their results showed a higher probability of males having low parental monitoring and being more likely to initiate sex before the age of 14. They also found that high levels of parental monitoring, as opposed to a low, result in later sexual initiation of the adolescent by about 1.5 years. These authors considered it important to promote communication and mutual trust between parents and children, suggesting that it is never too late for parents to increase adolescent monitoring. Hutchinson et al. (2012) sought to identify the ways in which mothers influenced the beliefs and sexual behaviour of their teenage daughters, and identified maternal influence in four areas: the quality of the relationship; sexual communication; monitoring or supervision and modelling of the maternal sexual role. Within each category, mothers and daughters identified some positive maternal influences that promoted health, and also negative ones that promoted risky sexual activity. This enabled them to improve the project on sexual intervention to the adolescents and their mothers. According to Costa, Pereira, and Leal (2012), Portuguese parents seem to most often use behaviours of positive reinforcement, setting of rules and limits and enhancement of autonomy instead of resorting to physical punishment or ignoring their children requests, which can be a positive sign in preventing risk behaviours. For Santos (2010;2011), systemic theory enables us to understand the family, considering it as an integrated and complex whole which has its own characteristics and cannot be reduced to its parts. Families are characterised by constant interaction where each member influences and is influenced. The same author believes that it is the constant repetition of some factors over time -like established communication, interdependence, actions and reactions and transactional patterns -that permit the adjustment of the behaviour of the various members that make up the family. In the shaping of the individual, the family relationship that is established is very important, adolescence being one of the main phases in this development (Santos, Rodrigues, & Almeida, 2010). In the study by Dias et al. (2007), adolescents mostly considered culture has a predictive effect on the sexual behaviour and attitudes of adolescents.

Methodology
This study is defined as a study of a quantitative nature and of a descriptive-correlational and transversal type. The research participants were 364 adolescents from the 9 th grade of mainstream education attending school in the 2011/2012 academic year, corresponding to 76.31% of the population of three school clusters located in the northern interior of Portugal. The age of participants was, on average, 14 years and 6 months, ranging between 14 and 18 years, 144 (39.6%) of whom were male and 220 (60.4%) female. The sample members were selected via the non-probabilistic method, intentionally and on the basis of convenience. The inclusion criteria were considered to be: being enrolled in the 9 th grade of mainstream education and attending an educational institution, being present in class at the time of data collection, having permission from parents/guardians to fill in the questionnaires and not being personally opposed to doing so. This study is part of the research project: Monitoring of Children's and Youth's Health Indicators: Impact on Health Education, approved by the Foundation for Science and Technology, by the research team from the Polytechnic Institute of Viseu (Viseu School of Health), the University of Évora and the University of Trás-os-Montes e Alto Douro, coordinated by Professor Carlos Albuquerque. The project was registered on 5 September 2011 (with registration number 0071200008) and approved by the Directorate General for Innovation and Curricular Development as Project, PTDC/CPE-CED/103313/2008 on 22 September of the same year. All ethical requirements were taken into consideration, with the Directorate General for Innovation and Curricular Development approval of the study and written permission from parents. Also, the adolescent participation in the study was voluntary, with the possibility of withdrawal and guaranteed anonymity and confidentiality of data. The data collection was carried out between March and May 2012 by means of questionnaires that were handed out at each school cluster. The questionnaires were accompanied by an explanatory letter stating the study purpose, the project it was part of, the average time spent in filling it in, and telephone and e-mail contacts for clarifying questions. Before the data collection, a meeting was held with the coordinators of the class head teachers to explain the aims and form of data collection. The data collection instrument we used was the questio nnaire compiled for the abovementioned study. The first part of this questionnaire was used, which included questions regarding sociodemographic aspects (gender, age) and sexual behaviour and attitudes, including whether respondents had dated, had someone to talk to about sexuality, had sexual intercourse, practiced contraception, emergency contraception, the importance of using condoms during sexual intercourse and their experience of intimate and sexual relationships. From the second part we used the Inventory of the Family Organisational Culture (IFOC), which assesses family functioning (Nave, 2006) and Adolescent Attitudes Towards Sexuality (AATS) which seeks to examine the attitudes of adolescents towards sexuality (Nelas, Fernandes, Ferreira, Duarte, & Chaves, 2010). The IFOC, built and validated for the Portuguese population by Nave (2006), is, in the version presented, made up of 25 items distributed over four Likert-type response scales ranging from never (1) to always (6).The score of the inventory is a minimum of 25 points and a maximum of 150. The IFOC evaluates the functionality of families across different cultural patterns of family organisation. The four dimensions or scales comprising the IFOC are: the Culture of Interpersonal Relationships (CIR) scale with nine items (1, 5, 7, 11, 12, 14, 15, 16 and 25); the Heuristic Culture (HEC) scale with five items (4, 18, 20, 21, and 22); the Hierarchical Culture (HIC) scale with five items (2, 6, 9, 13, and 19) and the Social Goals Culture (SGC) scale with six items (3, 8, 10, 17, 23, and 24). The items 11 and 14 that reversed, i.e., they are scored in the opposite direction, so that the total of each scale corresponds to a one-way response. The study of the psychometric qualities of the IFOC revealed Cronbach's alpha values above 0.70, with a 0.93 Cronbach's alpha value for the total inventory. The internal consistency of the four scales points to values that are considered satisfactory: the Culture of Interpersonal Relationships (CIR) scale has an α = 0.81, the Heuristic Culture (HEC) scale has an α = 0.87, the Hierarchical Culture (HIC) scale has an α = 0.73 and the Social Goals Culture (SGC) scale has an α = 0.76. In Table 1 we can compare the internal consistency obtained in this study to the internal consistency figures obtained in the study by Nave (2006). According to Nave (2006), the Culture of Interpersonal Relationships in the family considers aspects such as the gregarious skills that are assessed to determine what the family enjoys doing together, communication skills and skills regarding the feelings of closeness and cohesion. In assessing the heuristic capacity of the family, the author considers essential the skills of co-evolution which assesses the family ability to overcome crises, creativity skills where the solutions to problems are found and innovation skills. Regarding Hierarchical Culture, the author considers it essential to assess the competence for establishing and respecting boundaries, rules and hierarchical space within the family, as well as the competence for establishing and fulfilling roles. In the dimension of Social Goals Culture, one assesses the skills for building and maintaining a certain social image, for establishing social relationships, social integration and the competence for adopting accepted social behaviour. Table 1 Cronbach's alpha values of the current study and of Nave's (2006)  We conclude, like Nave (2006), that the four scales that make up the Inventory of the Family Organisational Culture (IFOC) show temporal stability vis-à-vis different sample sizes, since they keep their psychometric properties. The Adolescent Attitudes Towards Sexuality (AATS) scale is an assessment scale of adolescents' attitudes towards sexuality. This scale was built and validated by Nelas et al. (2010) and consists of 26 items developed into a Likert-type ordinal scale where each item has five response options ranging from Strongly disagree (1) to Totally agree (5). Items 1,2,4,9,10,11,12,13,14,16,18,19,20,22,23,and 24 are scored conversely. Like Nelas et al. (2010) we decided to use this singlefactor scale due to its conceptual relevance and its importance as a construct. The global score of the scale on the assessment of attitudes ranges from 28 to 140, and the higher the value, the more favourable are the attitudes of adolescents towards sexuality. These are some examples of items where adolescents have to indicate how far they agree with the statements presented: statement (5) -The first time you have sexual intercourse should always be with someone you love; statement (14) -I could never talk about sexuality issues with my parents.
As for the assessment of the psychometric qualities of the AATS scale regarding internal consistency, it showed a Cronbach's alpha of 0.81. This figure is equal to the value obtained in the study by Nelas et al. (2010), which involved 840 subjects.

Results
To analyse the predictive effect of organisational culture of the family on the sexual behaviour and attitudes of adolescents, we carried out a regression analysis in stages. The results showed that only the Culture of Interpersonal Relationships, Hierarchical Culture and Heuristic Culture variables significantly predict sexual attitudes and behaviours, with an adjusted determination coefficient [r 2 =.127 and F (360.3) = 18.599, p ≤.001], where the Culture Social Goals variable was excluded from the model. An analysis of the absolute values of standardised regression coefficients enables us to conclude that there is a positive association between sexual attitudes and Culture of Interpersonal Relationships, (β= .236, p=.005) and Heuristic Culture, (β=.312, p ≤ .001), and a negative association with Hierarchical Culture, (β = -.247, p ≤ .001). The Heuristic Culture

Discussion
By analysing the predictive effect of family culture on the sexual behaviours and attitudes of adolescents, the results show a positive association of sexual attitudes with Culture of Interpersonal Relationships and Heuristic Culture, and a negative association with Hierarchical Culture, while the Heuristic Culture variable is the one with the largest relative contribution towards explaining sexual attitudes (β = .312). According to Nave (2006), who studied the patterns of family organisational culture, when assessing the culture of interpersonal relationships within the family it is important to consider aspects like the gregarious skills by means of which one can assess what the family likes to do together, communication skills and the skills related to feelings of closeness and cohesion. With regard to the assessment of the family's heuristic capabilities, this author views as key elements the skills of co-evolution, where one can assess the family ability to overcome crises; creativity skills which helps to find solutions for problems; and innovation skills. Therefore, the positive relationship between sexual attitudes and Culture of Interpersonal Relationships and Heuristic Culture can be explained by taking into account that in a good parent-child relationship, where there is effective communication based on respect between family members and on problem-solving, adolescents see the family as a source of help and support, which establishes a positive relationship between them (Dias et al., 2007). As regards Hierarchical Culture, we once again refer to Nave (2006) in order to understand the key aspects to be assessed in this type of culture. Here the author considers key aspects the competence to establish and respect boundaries, rules and hierarchical space within the family, as well as the competence to establish and fulfil roles. In this study we observed a negative association between sexual behaviour and attitudes and Hierarchical Culture. As stated by Dias et al. (2007), there are family factors that can act as risk or protection factors for adolescents, such as family environment and family relationships, communication about sexuality between parents and children, parenting style and the parental supervision/ monitoring. Hierarchical Culture can be compared to the authoritarian style of education described by Baumrind (1966), which features parents who exercise enormous control by means of orders that must not be questioned and the use of punitive measures. This kind of parental behaviour is centred on a high level of control which focuses on (hierarchical) parental power and the constant use of disciplinary practices with little positive affection. Therefore, as stated by Dias et al. (2007), this authoritative parenting style or hierarchical family culture may have an adverse effect to the extent that forbiddance and setting very strict rules may encourage risky behaviour. According to Nave (2006), Hierarchical Culture (rules, norms, roles and limits) contrasts with Heuristic Culture (autonomy, innovation, creativity).This author argues that there must be a certain balance between the two so that the family can function properly, considering that for "rules and roles to constitute key elements, autonomy and creativity need to be moderators and complementary" (Nave, 2006, p. 107). In the present study, the variable that shows the largest contribution towards explaining sexual attitudes and behaviours is Heuristic Culture. These results can be explained by the fact that greater family satisfaction can partly variable has the highest relative contribution towards explaining sexual attitudes (β = .312).
The results of this study enable us to state that there is a positive association between sexual attitudes and Culture of Interpersonal Relationships and Heuristic Culture, and a negative association with Hierarchical Culture, while Heuristic Culture shows the largest relative contribution towards explaining the sexual attitudes. The existing positive association between sexual attitudes and Culture of Interpersonal Relationships and Heuristic Culture corroborates findings from previous studies in which the family is seen as a source of help and support, based on good parent-child relationships, effective communication and help in solving problems (Baumrind, 1966;Cardoso et al., 2010;Darling & Steinberg, 1993;Dias et al., 2007;Dias & Rodrigues, 2009;Ferreira et al., 2013;Grossman et al., 2014;Hutchinson et al., 2012;Santos et al., 2010;Schouten et al., 2007;UNESCO, 2009). Other authors help us to understand this predictive effect by explaining how various family factors influence the sexual behaviour and attitudes of adolescents. This study enables one to raise awareness on the importance of implementing programs and projects on sexuality in schools, which has been the responsibility of nurses, involving not only adolescents but also parents and the rest of the educational community. Parental behaviour should be considered one of the key factors in the relationships established between parents and children, since parenting styles and practices can determine the attitudes and behaviours of adolescents towards their involvement in risk behaviours. Therefore, these results will enable nurses to build and implement more structured sex education programs in more structured school environments, thus meeting the real needs of adolescents at school. In future studies it would be important to find out which dimension of family culture most closely relates to healthy practices, for which we suggest research with older adolescents who have more active sex lives. It would be equally important to determine the family organisational culture with parents, since this study only considered the perceptions of adolescents. In this way, future studies with other variables and other participants could generate additional information necessary for an understanding of the sexual attitudes and behaviours of adolescents in order to enable better planning of nurses' work in a school context. correspond to a strong investment of the part of the family in heuristic skills which facilitate change and resilience (Nave, 2006).These skills can therefore be seen as essential in dealing with a teenage child, since adolescence is a difficult period marked by biological, psychological and social changes that require the family's creativity and adaptation in order to deal with the various situations. Consequently, the family heuristic capabilities justify adolescents' more positive and balanced sexual attitudes. When we analysed the family's predictive effect on the sexual behaviour and attitudes of adolescents, we found that the results of this study are in line with the results of previous studies. Cardoso, Rodrigues, Nelas, and Duarte (2010), in a study of the 9 th grade adolescents, found that satisfaction with their family was one of the predictors of affectivity, beliefs and attitudes towards sexuality. In another study, Dias and Rodrigues (2009) concluded that the predictors of relationships between parents and children, as a whole, contributed significantly to adolescent sexual attitudes. Other authors also reinforce this idea by asserting that in shaping of the individual, the quality of the relationship established by the family and the values and attitudes they convey influence sexual attitudes and behaviours (Dias et al., 2007;Ferreira et al., 2013;Grossman et al., 2014;Hutchinson et al., 2012;Santos et al., 2010;Schouten et al., 2007;UNESCO, 2009). These results can be explained based on Darling and Steinberg's contextual model of parenting style (1993), according to which parenting style as well as parental practices have an effect on the specific results of child development. We also considered the findings of Dias et al. (2007), who state that a positive relationship and parental supervision are important factors that could contribute to positively influence sexual attitudes and behaviours of adolescents by promoting their autonomy and selfdiscovery.

Conclusion
Regarding the predictive effect of Family Culture on sexual behaviour and attitudes, it was found that the Culture of Interpersonal Relationships, Hierarchical Culture and Heuristics Culture variables significantly predict sexual attitudes and behaviours of adolescents.