Introduction

Adolescence and early adulthood are often critical periods of sexual development.1 The considerable physical, psychological and sexual transformations characterised in adolescence as well as those found in early adulthood can expose adolescents to risky sexual behaviour.2 This can impact on the incidence of sexually transmitted infections (STIs) and unwanted pregnancies that lead either to childbirth or abortion.3 4

On Reunion Island, a French department in the Indian Ocean, sexual health indicators for young people are very poor and below national standards. The island has the third highest rate of adolescent pregnancies among the five overseas regions of France, known as the Départements d'Outre-Mers after Guyana and Mayotte. In 2018, teenage birth rates were three times higher on Reunion Island at 5.7% than in mainland France, and 300 children were born to minor mothers accounting for 2.2% of all births.5 The rate of abortions among Reunionese minors was also relatively high at 9.5% in 2020, which was twice the rate of mainland France.6 Unwanted pregnancies can have damaging effects on both mental and physical health. High levels of depressive symptoms have been found in women who carried unwanted pregnancies to term.7 Moreover, adolescent women having abortions have stated to experience discomforts such as cramps, pain, abnormal bleeding and gastrointestinal disorders and have reported adverse events such as the risk of eclampsia, puerperal endometritis or systemic infections.8 Regarding STIs, in 2015, the prevalence of chlamydia trachomatis infections and gonorrhoea were 14.3% and 4.4%, respectively, among female minors, and are common among the adolescent population.9–11

Additionally, contraceptive use remains insufficient in the region. According to a knowledge, attitudes, beliefs and practices study by Bardot et al, only 50% of adolescents aged 15–17 years used contraception when they had sexual intercourse for the first time or with new partners.12 During their first sexual intercourse, condoms were reported as the only type of contraception (n=47%) and over 40% of first sexual encounters took place without any protection. This same study revealed the potential negative representation of contraception in which adolescents reported that they felt that the contraceptive pill ‘makes you sterile’, ‘makes you fat’ or ‘presents health risks’.12

In contrast, Reunion Island is equipped with many services and resources corresponding to the recommendations of the French national sexual health strategy 2017–2030, that could enable young adults to make informed sexual health choices.13 14 For example, the first consultation for contraception and sexual health prevention is 100% covered by health insurance that is mandatory for young people up to the age of 25.15 Family planning and education centres known as le Centre de Planification et d'Éducation familiale as well as les Centres Gratuits d'Information, de Dépistage et de Diagnostic (CeGIDD) offer free contraception and STI screening. Comprehensive sexuality education is also provided in middle schools and high schools in the region, and access to abortions is free and has expanded to all healthcare professionals (HCPs). Since many HCPs involved in sexual healthcare, including general practitioners, nurses, gynaecologists, midwives and pharmacists as well as institutional and associative stakeholders16 and sex education instructors17 18 implement strategies that promote healthy sexual behaviours.

To date, the use of sexual health services and resources by adolescents on the island, not only in representation but also their expectations, do not match. Factors that may have conditioned this may be a lack of education, sociocultural norms, religious beliefs as well as the distance an adolescent has from sexual health services.19 To our knowledge, literature concerning the use of sexual health services particularly by the adolescent population on Reunion Island is very limited and could be investigated. This study will be the first in France to allow a detailed exploration of the personal experiences of adolescents concerning the use of sexual health services. Its conception is due to the concerning state of the sexual health of young adults on Reunion Island and where sexual health and the services associated with it seems misunderstood and underused by the demographic despite an offer of care which helps to promote better sexual health and reduce risks for the population concerned (free contraception and abortion services, sexual health consultations, equitable distribution of sexual health facilities across the island and sex education in schools). This study will provide evidence to better understand the sociocultural realities of adolescents, their representation and lived experiences of sexual health services and allow us to examine the relationships between the intentions and uses of healthcare services by young adults. Our findings may present ideas to adapt existing services and provide leads on ways to implement programmes to target the optimal use of sexual health services as well as issue recommendations at different stakeholder levels, in particular for HCPs working with adolescents or on government measures to improve sexual health prevention. Moreover, our work could be extrapolated to populations as well as other countries that similarly face unsatisfactory sexual health indicators.

Methods and analysisStudy objectives

The main objective of this study will be to describe adolescent experiences of using sexual health services on Reunion Island. Specific objectives will be to identify the adolescent representation of sexual health, to examine the barriers and facilitators to access sexual health services, to describe the relationship between adolescents and HCPs when using sexual health services and to gather suggestions made by adolescents for improving access to care and quality of sexual health services.

Study design

A monocentric descriptive qualitative study will be conducted on Reunion Island for 8 months from December 2022 to August 2023. This research design was deemed appropriate with aspects of a phenomenological sense of enquiry. Phenomenology is a research method that allows an understanding of the meaning that individuals give to the events and life experiences they go through; by grasping their lived experiences.20 21 The analysis starts from an idiographic description of the intimate experience of each of the participants (phenomenological stage) and highlights a coherent set of views (interpretative or hermeneutic stage). This approach was selected for this study since it is recognised in applied fields such as health and psychology and seems appropriate to reach the objectives.22 23 The investigators will gain evidence on adolescent sexual health and an in-depth subjective account of adolescents’ perceptions of sexual health services offered to them.

The interview team is made up of experts from different health fields: DR who is a nursing health executive and doctoral student at the University of Reunion Island, EC who is a lecturer in nursing sciences at the University of Paris Sorbonne in France and, EL who is a sociologist-anthropologist at the University of Reunion Island. All investigators have experience in conducting qualitative research design. The principal investigator (PI) will be DR. The three researchers are complementary in terms of age and professional background.

Recruitment

Participants will be recruited via various sites. First, educational institutions including colleges, high schools and universities on Reunion Island as well as sexual health service facilities such as the CeGIDD, orthogenics and sexual health clinics will inform adolescents that the study will be conducted and request their participation in the interviews. A poster will be displayed at these recruitment sites as well (figure 1). Recruitment will be facilitated by the ’snowball’ and ‘word-of-mouth’ effects.

Figure 1

Poster for recruiting participants.

To ensure discretion, the recruitment process will begin when participants contact the PI. They will have to identify themselves as a volunteer by sending an email to the PI. Participants eligible for the study will be contacted by email and/or telephone to make an appointment for the interview. We opted for a participative sample and to have a breakdown of genders (girls, boys and Lesbian (L), Gay (G), Bisexual (B) and Trans (T) (LGBTQ+)) with respect to various recruitment sites. If candidates confirm their participation, they will receive detailed information on the form, objectives and value of the research as well as data management before the interviews are conducted. They will be verbally informed that their participation is voluntary and that the data are confidential and anonymous. There is no compensation for the participants in the study. Adolescents will also be informed that the data collected will not be available to their parents/primary caregivers and that their participation is not subject to parental authorisation in accordance with French legislation.

An informational note will be provided before the interview and will contain: (1) the main and specific objectives, (2) the procedure (who will conduct the interviews, where the interviews will take place, how long they will last, whether the interview will be recorded and what measures are taken to ensure confidentiality), (3) criteria of inclusion and (4) their rights to participant. This informational note is to ensure that the adolescents will be able to make an informed choice to participate in the study. Expressed oral consent will be obtained from all participants at the time of the interview and recorded in a field journal. Participation can be terminated at any time without providing reasons for termination, and if this occurs, the data already collected will not be deleted. The date and place of the interview will be defined according to the needs of the adolescents. The place of the interview will have a comfortable, neutral and private setting chosen by the participant and is preferably outside the school establishment.

Inclusion and non-inclusion criteria

Participants will be included if they are: aged 15–19, reside on Reunion Island and provide a verbal agreement for participation. They may have previous or no experience with sexual health services. Exclusion criteria include adolescents that have hearing, visual, or cognitive impairments or the inability to express themselves orally.

Sample size

There is no required number of participants for a phenomenological qualitative study.23 The primary concern of this type of methodology research is to elicit rich and detailed accounts of a specific inquiry and maintain and manage the in-depth analysis of individuals. The study will involve a minimum of 12 participants and a maximum of 15.

Data collection

Data have been collected since December 2022 and will be until August 2023. Individual open-ended interviews will be conducted to collect the data. They will be conducted by the PI. The interviews will be conducted primarily face to face, but may also be conducted by video conference. It is planned to conduct interviews of approximately 1 hour with each participant to allow them to talk about their experiences related to their intimate lives. An interview guide and outline were developed based on literature and the objectives of this study. This outline is presented in table 1. The themes in this outline were used to draft an interview grid and will consist of: (1) sexual health and (2) use of sexual health services. These will be discussed according to the participant’s answers, without any pre-established order, to encourage free expression. Data on past usage of services and STI’s will also be collected to aid the interpretation of the results.

Table 1

Interview guide and outline of questions

Before the interview, a participant will be asked if they prefer to be addressed in the form of ‘vous’ or ‘tu’. In Reunion Island, it is much more common to be on first-name terms with a person even if you do not know them than to formally address them. The use of informal language may allow closeness with an interlocutor which may be necessary given the topic being discussed and the age of the participants.

With the participants approval, the interview will be audio-taped and transcribed verbatim after each interview by the PI. When transcribing, the data will be anonymised and deidentified. Transcripts will not be sent to the participants for comments nor for corrections. Data on gender, age group, education and occupation of the adolescent as well as the socioeconomic category of the parents/primary caregivers will be collected during the interview.

The field diary will be completed with data related to the overall behaviour of the participants at the time of the interview. This diary will contain information on the non-verbal communication including the interviewee’s presentation, overall behaviour, body expressions, gestures and facial expressions. Speech alterations (silences, muffled speech, speech slips, changes in tone and volume of voice, laughter, smiles and shouting) will be recorded. The atmosphere of the interviews and all discussed topics will also be reported. These data will be integrated into the interview findings as additional information to support the analysis. Given the specificity of the qualitative process, the interview guidelines may be modified during the study’s progress and are provided in figure 2.

Figure 2

Flow chart of the interview guidelines used in this study.

Some participants may feel uncomfortable or embarrassed talking about their sex life; if this is the case, we will check that the participant would like to continue or change the subject. The risk of distress or harm from participating in the research is minimal. If the interviewee expressed unease about the topics covered in the interview, they will be advised to contact a medical practitioner.

Data analysis

To maintain anonymity, pseudonyms will be assigned to our participants. All documents relating to the study will be registered by the same identification code for each participant and will not be identifiable by name. Once the results are obtained, the identity of the participants will remain confidential. Electronic files will be kept in separate, password-protected computer storage in a locked location to protect the records from unauthorised access. All records relating to the study will be destroyed 3 years after the end of the study. Data will be analysed according to the principles of interpretative phenomenological analysis (IPA) following the six IPA recommended steps.22 Given the objectives of the study, an IPA will help the investigators to better understand the use of sexual health services.

The six steps are: (1) to read each interview in its entirety several times, in order to become familiar with the participant’s expressive style and to obtain an overall impression of the interview independently, (2) take initial notes corresponding to the basic units of meaning which will be descriptive and will use the participant’s own words (since it is necessary to include linguistic details, such as the use of metaphors, (3) to write conceptual notes through processes of condensation, comparison and abstraction of the initial notes, (4) to synthesise and map links with the notes with emerging themes developed, (5) to analyse each interview separately in the same way and by each investigator and (6) to analyse and compare all interviews between all investigators in order to group themes into categories and subcategories.20 Moreover, data analysis will be performed in triangulation independently carried out by three investigators (DR, EL and EC) and compared throughout the process to reach a consensus. Any discrepancies will be negotiated among the team and in the course of regular meetings.24 Nvivo V.10.2 software will be used to manage the data and perform the statistical analysis.25 Data will be analysed according to the demographic characteristics (gender, socioeconomic status and location).

Regarding the potential limitations of this study, self-selection bias may be imposed since the data collection will be based on voluntary recruitment. Our study may only attract those who are motivated and may not sample those who have difficulty accessing sexual health services, or those for whom sexuality is taboo. Second, this study may incur a sampling bias of an over representation of genders.

Patient and public involvement

Participants will be involved in the design and development of the interview questions. A test phase will be planned involving two adolescent volunteers to assess their understanding of the questions and the structure of the interviews.

Ethics and dissemination

Ethical approval was registered on 6 December 2022, under CER-BDX-2022-55 by the Ethics Committee at the Hospital Center University De Bordeaux, France. Expressed oral consent will be obtained from all participants at the time of the interview and recorded in a field journal. In accordance with French legislation, expressed oral consent is authorised for this study type and participants over the age of 15 years are not subject to parental authorisation. Informed consent from a legal guardian/parent for minor participants is not mandatory. Results will be published in a peer-reviewed journal as well as presented and disseminated at the Regional Health Agency of Reunion Island, at conferences and in meetings with school directors.