Introduction

The transition from adolescence to adulthood is marked by several reproductive health challenges. In sub-Saharan Africa, these challenges are rarely addressed, frequently resulting in poor reproductive outcomes such as sexually transmitted infections (STIs) and unwanted pregnancies [1, 2]. Premarital sex and discussions about adolescent sexual health are often prohibited. Culture and religion play a major role in promoting adult discomfort in dealing with these issues [3–5]. Young people may be reluctant to seek information from parents due to concern that they will be judged to be engaging in prohibited activities [3]. However, due to urbanization and western influence, sexual and reproductive norms are rapidly changing, with youth becoming sexually active at a younger age [6–8]. There is urgent need to eradicate barriers that youth face in accessing reproductive health information and services [9].

Adolescent girls and young women represent a vulnerable population disproportionately affected by STIs. Globally, adolescent girls and young women 15–24 years old are the most affected [1, 10], with age under 25 years being the strongest predictor of STIs [11–14]. Other risk factors include high risk sexual behavior associated with alcohol and drug use [15], low levels of knowledge about STIs, perceived peer norms, non-use of condoms [16], and intergenerational relationships [17]. With the burden of disease and complications from STIs being higher among young women [18], it is important to identify and address barriers to STI screening, and develop interventions targeted to this population. In Kenya, only 7% of health facilities offer youth friendly services, suggesting that youth access to reproductive health is limited. In addition, the majority of health services, including STI screening, are not free [19].

Adolescents girls are an understudied population due to the ethical and legal challenges that limit their participation in research [20]. For example, in sub-Saharan Africa, few studies have assessed the barriers and facilitators of screening for STIs other than HIV for this age group. Screening for STIs is recommended because STIs can be asymptomatic [21]. Early diagnosis and treatment are useful in preventing the spread and sequelae of STIs. Improving adolescent girls’ participation in research is crucial in defining and developing interventions appropriate to this age group.

To explore adolescent girls’ and young women’s attitudes towards STI screening, we conducted a qualitative study to address the following questions: 1) What do adolescent girls and young women know about STIs? 2) Are adolescent girls and young women willing to be screened for STIs? 3) What are the facilitators and barriers to STI screening in this population? 4) Which STI screening method would they prefer?

Methods

We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with adolescent girls 15–17 years old and young women 18–24 years old, enrolled in educational institutions in Mombasa County, Kenya. Mombasa County region is considered urban. The study was conducted between December 2012 and November 2013. Ethical approval was granted by the ethics committees at the Kenyatta National Hospital, Nairobi, Kenya (P228_04_2012) and the University of Washington, Seattle, Washington (42869C).

We sought permission to conduct the study from institutional heads at six institutions (five high schools and one university) with approval from the Director of Education, Mombasa County. Of these, four agreed to work with us, including one university and three high schools. These four institutions each had large student populations with representation from different socioeconomic strata, ethnic and religious backgrounds, allowing us to capture a wide range of views.

We used purposive sampling to allow us to obtain a socio-demographically diverse sample. We had ethical approval to conduct up to 20 IDIs and 8 FGDs as the target sample size for this study. This sample size was felt to be sufficient based on qualitative work by Halcomb and Sandelowski [22, 23]. Halcomb suggested dividing the groups by type of participant, in our case the age bracket. For each type of participant group, Halcomb recommended that a minimum of 2 FGDs should be conducted to achieve data saturation (no new information emerges from the discussion) [22]. We conducted 6 FGDs (4 with adolescent girls and 2 with young women, total 55 participants). Based on previous experience conducting individual interviews, we expected that 8–10 participants per participant type will be enough to reach data saturation (no new information emerges from the interview) [24]. We conducted 17 individual IDIs (8 with adolescent girls, and 9 with young women) as our sample.

We began by conducting sensitization activities at the institutions. These activities included presentations to adolescent girls and young women at their respective institutions through forums such as club days. At these initial meetings, we introduced the research team and provided background information to familiarize participants with statistics related to STIs in their local setting. We also presented the objectives and procedures of the study, and explained the informed consent process. The presentations were followed by question and answer sessions. Interested individuals were given informed consent forms and asked to take the forms home to discuss with their parents or guardians, family, and friends. Assent/consent forms were available in both English and Swahili. Willing participants were required to give their assent/consent for participation in an IDI or FGD by signing the informed consent form. Parental consent was required in addition to participant assent if the participant was a minor (below 18 years). The students interested in participating were required to return their completed form to the guidance and counselling teacher. The consenting process was completed within two weeks. Participants were then scheduled for either an IDI or FGD, depending on their preference. On the scheduled interview or FGD date, we collected participants’ socio-demographic information prior to initiating the interviews or FGDs. Participants also signed a confidentiality agreement before each FGD to ensure that the content of the discussion would not be discussed outside of the FGD. We had no way of verifying that the parents signed the consent forms. This concern was discussed with the local ethics committee, which felt that the strategy we employed provided a reasonable balance between risks and benefits.

Using semi-structured topic guides, we conducted 17 individual IDIs (8 with adolescent girls, and 9 with young women. The IDIs were conducted at the institutions or at the research clinic, depending on the subjects’ preference. Interviews were carried out in English or Swahili, and all participants were fluent in at least one of these languages. To promote candid responses and discussions, students were assured of anonymity and confidentiality. Preliminary analyses and ongoing adaptation of interview guide content were initiated during the interviews. Interesting themes that emerged in earlier interviews were explored further in subsequent interviews and discussions until saturation was achieved and no new information was emerging from the interviews and FGDs. Interviews lasted about 1 hour. Participants received KES 500 (USD 5) as transport reimbursement.

A total of 6 FGDs were conducted, (4 with adolescent girls and 2 with young women, total 55 participants). The procedures for FGDs were similar to those described for IDIs, including topic guides, languages, and ongoing adaptation of content. In addition, at the start of each FGD, participants were reminded that all content discussed in the FGDs was confidential. Focus group discussions lasted about 1.5 hours.

Interviews were conducted by G.W. and E.A. who were not known to the research participants prior to participating in the study. We audio-recorded all interviews and discussions and took manual field notes. The audio recordings for both the IDIs and FGDs were translated and transcribed into English. Data from the IDIs and FGDs were analyzed using content analysis approach, an approach widely used in qualitative research [25]. This involved multiple readings of the transcripts to capture context and meaning, followed by coding and categorization of recurring concepts and ideas. The transcripts were reviewed separately by two trained independent researchers (G.W. and E.A.) for text element and key word coding. A coding matrix of all categories of overarching themes was developed and codes compared and added or removed based on the agreement between the two investigators. This multiple coding ensures the qualitative analog of inter-rater reliability [25, 26]. After coding, the emerging themes were organized according to the objectives of the study. Recurring themes emerging from the FGDs were noted, and served to validate data obtained from the interviews. Data content was then analyzed manually and digitally using ATLAS.ti (version 5.0, Berlin, Germany), and consensus was reached on the central and specific emergent themes.

Results

Baseline characteristics

We enrolled 72 students in the study, 46 (63.9%) were adolescents and 26 (36.1%) were young women (Table 1). The median age of the adolescents was 17 years (interquartile range [IQR] 15–17) while that of the young women was 21 years IQR (20–23). Twenty eight (61%) of the adolescents and 18 (69%) of the young women reported being Christians, while the rest were Muslim. All the adolescents were single with no source of income. Twenty-five (96%) of the young women were also single, and 13 (50%) reported income from casual labor.

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Table 1. Baseline characteristics of adolescent girls and young women.

https://doi.org/10.1371/journal.pone.0169388.t001

Seven main themes regarding feasibility of STI screening among adolescents and young women were identified. (1) Knowledge about STIs, (2) Acceptability of STI screening, (3) Facilitators of screening for STIs, (4) Barriers to screening for STIs, (5) Suitable location to offer STI screening, (6) Preferred mode of STI screening and (7) Disclosure of STI screening results for adolescents girls

Discussion

This qualitative study of adolescent girls and young women in Mombasa, Kenya provides insight into this population’s knowledge and attitudes towards STIs and STI screening. Many adolescents and young women may be willing to participate in STI screening. A major facilitator for screening was participants’ desire to know their STI status. Among the women 18–24 years old, this was especially true following high-risk sexual behavior. Lack of symptoms and fear of positive test results were identified barriers to STI screening at the individual level, while parental notification and stigmatization from parents, family members and the community were identified as barriers at the community level. Uncomfortable or embarrassing methods of specimen collection presented an additional barrier, with urine sampling being the preferred mode of specimen collection.

The barriers and facilitators of STI screening reported in this study are similar to those reported by participants in Africa and other parts of the world [27–29], highlighting a potential set of cross-cutting concerns for adolescents and young women across a range of populations. Similar barriers across the studies include limited STI knowledge, especially the fact that STIs can be asymptomatic, pelvic exams as a mode of specimen collection, perceived judgmental service providers and affordability of health care services. Across these studies, participants were more likely to go for STI screening if the services were accessible, facilities were well equipped, confidentiality was guaranteed, and urine testing was offered.

The education curriculum in Kenya provides basic sexual and reproductive health education, including an overview of STIs. The majority of students were knowledgeable about STIs, transmission modes, methods of diagnosis, and means of preventing STIs. Some participants were able to associate signs and symptoms to a particular STI. However, some knowledge gaps were evident. For example, being asymptomatic was identified as a barrier to STI screening, as lack of symptoms was incorrectly considered a sign of being free of STIs [21]. And some believed that condoms may not be effective as they have holes. Improved sexual health education can be beneficial to adolescent girls and young women. For example, comprehensive sex education has been associated with delayed initial sexual activity and responsible sexual behavior in adolescents, reducing the risk of STIs [30]. In our sample of adolescent girls and young women in Mombasa, media, internet, and youth groups were mentioned as sources of information. These are powerful platforms that could be utilized to provide high quality sex education [31, 32].

Sex is a taboo subject in most African cultures, and discussion between parents and children about STIs is rare [4]. Although aunts and older siblings are often used as a proxy in providing communication on sex and reproductive health issues, greater emphasis should be placed on parental communication. Participants noted that parental communication on reproductive health matters came mostly in form of warnings against unplanned pregnancy. Meaningful discussions around sexual matters were limited suggesting possible cultural influences or gaps in parents’ reproductive health knowledge [33]. Good parental communication can influence a child’s sexual behavior and decisions, and should be encouraged [34, 35]. Parents ought to be empowered to discuss sex, birth control, pregnancy, and other sexual and reproductive health topics with adolescents.

An important strength of this study was our collection of views from a sizeable group of girls and young women in high schools and a university in Kenya. The IDIs provided insight into individual’s perspectives, while FGDs enabled us to focus on cultural norms. Moreover, most of the studies on barriers and facilitators to STI testing have been done in developed countries. In Africa, the focus has largely been on HIV testing. Hence these rich data add to the limited literature on reproductive and sexual health among adolescents and young women in sub-Saharan Africa.

This study also had limitations. First, we used non-probability (purposive) sampling of participants. Second, the religious and cultural influences in our study population may be different from other settings. Third, the institutions that participated in the study are located in an urban setting. These three factors may limit generalizability. In addition, limited access to free or cheap youth friendly reproductive health service centers in the country was an obstacle to access. Our experience with this study would seem to indicate that when such services were available, young women would be willing to screen for STIs. Finally, due to limited data in this area and the exploratory nature of our study, we did not initially utilize a conceptual framework in the development of our interview guides. However, based on findings from this study, an ecological model would be an appropriate choice for similar studies in the future. Nonetheless, we feel that the study has provided valuable information about the feasibility of providing STI screening to adolescents and young women in a resource-limited setting where this type of screening has not previously been the norm.

Acknowledgments

The authors would like to thank the four institutions that allowed us to work with them. We thank the teachers and instructors who facilitated the study and the students who enthusiastically volunteered to participate in the interviews and focus group discussions.