Study population

The participants in this research consisted of both male and female adolescents who were pursuing their studies in twelve years of basic education in selected districts. This particular group of adolescents was considered because they can potentially face the vulnerability of participating in unsafe sexual activities, either as a means of personal exploration or due to the influence of older individuals. This susceptibility arises from the fact that they commute to and from school independently, without the presence of a caregiver. Furthermore, their age and lack of protection make them susceptible to being deceived or becoming victims of sexual assaults and advances from adults they come across during their daily travels.

The inclusion criteria for this study were set as follows: the participants had to be between the ages of 10 and 19 and residing in either rural or urban areas of Rwamagana, Kayonza, and Gatsibo districts. In order to participate in the study, each adolescent boy or girl was required to obtain an assent form, while their parents or guardians were required to provide consent. The study focused on six target twelve-year-basic education secondary schools, with two schools selected from both rural and urban areas in each district, allowing for a representativity of the sample in order to balance the insights. The recruitment of participants and the data collection exercise for this study took place between 10^th August 2022 and 8^th December 2022.

Sampling approach

Purposive sampling was used to identify and selected adolescents with predetermined inclusion criteria of this study [24]. The application of purposive sampling enables researchers in choosing participants with a greater understanding of the specific phenomenon under investigation [24]. Within the context of this study, purposive sampling was employed to identify and select adolescent boys and girls from each year of study and who were willing to provide their views and their personal experiences regarding the issues affecting their sexual and reproductive health within their respective residence areas.

Sample size determination

The study targeted to involve 120 adolescent students including 60 girls and 60 boys to participate in the 12 focus group discussions each having 10 participants. The determination of sample size for qualitative studies involving focus group discussions still lacks an evidence-based guideline. Nevertheless, recent research indicates that two key factors, saturation and the identification of codes, play a crucial role in this process [25, 26]. Drawing from existing literature and considering practical constraints such as financial resources, it is recommended that conducting six focus groups with 60 female students and an additional six focus groups with 60 male students would likely capture over 95% of the necessary themes derived from the insights of participating adolescents [26, 27].

Data collection

In order to gather comprehensive data from participating adolescent boys and girls, a semi structured interview guide with open questions asking about barriers young adolescents encounter as they navigate adolescence and what they need to leverage this transitional journey was employed to facilitate the focus group discussions. The interview guide was initially prepared in English and later translated into Kinyarwanda, the national language of Rwanda, to ensure inclusivity. By providing both English and Kinyarwanda versions of the interview guide, eligible participants were given the freedom to select the language they felt most comfortable with during the interview, accommodating their preferences.

To capture the viewpoints of adolescent boys and girls, a focus group discussion was utilized during the data collection process. By employing focused group interviews, participants were given the opportunity to express their viewpoints, fostering a safe and supportive environment among peers. To ensure a balanced and inclusive dynamic within the focused groups, the researchers organized them into clusters based on gender. This strategy aimed to mitigate power imbalances and promote a sense of comfort among the participants. By creating an environment where either adolescent boys or adolescent girls felt at ease, they were more likely to provide insightful responses regarding their perceptions and experiences with sexuality and sexual reproductive health. This approach further enhanced the participants’ engagement and facilitated a deeper understanding of their unique perspectives within their community context.

The duration of the interview was estimated to be around 45–60 minutes. To prevent any potential distractions that could arise from note-taking during the interview, all discussions were recorded with the participants’ consent. Furthermore, field notes and memos were taken to document the researcher’s observations, and emotions regarding the environmental context and non-verbal expressions of the adolescents that may not have been adequately captured in the recorded audios [28]. Those field notes guided the research team members to remember those impressions during data analysis and interpretations.

Data management and analysis

The collected data were transcribed verbatim by the research team member. Since the research team members were proficiency in both used languages, this allowed them to translate all collected data from Kinyarwanda to English language. Dedoose software was used to manage and organize transcribed data to enhance the process of data analysis.

Inductive thematic analysis by Braun and Clarke [29] was followed to analyze and generate themes from collected transcripts. The authors implemented a six-step process of inductive thematic analysis, which involved familiarization, coding, generation of themes, reviewing of themes, defining and naming themes, and writing up. By utilizing thematic analysis methods, the research team was able to gain insights into the perspectives of adolescent boys and girls regarding the challenges affecting their sexual and reproductive health during adolescence.

Measures undertaken to ensure quality of data

In order to establish the rigor of this study, four specific criteria were carefully considered: credibility, dependability, transferability, and confirmability. To ensure credibility, the researchers remained committed to accurately representing the perceptions of adolescents regarding their sexual and reproductive health changes. This was achieved by purposefully selecting participants who met specific criteria and were able to provide valuable insights into their physiological changes. The researchers engaged in extensive discussions to reach a consensus on the interpretation of the findings derived from the participants’ interviews. This collaborative approach ensured that the outcomes were reliable and trustworthy.

To address the issue of dependability, the researchers developed an interview guide that was consistently followed in a sequential manner across all participants. This systematic approach allowed the research team to assess whether conducting the same study in the same context and with the same participants would yield consistent findings. By adhering to a standardized procedure, the researchers were able to establish the dependability of the study’s results. In order to enhance the transferability of the study, a comprehensive description of the research methods was provided. This detailed account enables future researchers to replicate the study in different settings and environments. By sharing the methodology, other researchers can employ the same methods and compare their findings, thereby contributing to the overall understanding of the phenomena being studied.

Theme 1: Young adolescents’ awareness of strategies to prevent STIs and unwanted pregnancies

This overarching theme encompasses two distinct sub-themes: the recognition among young adolescents of the importance of condoms in protecting against STIs and unintended pregnancies, as well as young adolescents’ understanding of the adverse consequences associated with engaging in risky sexual behaviors.

Subtheme 1: A condom can prevent unplanned pregnancies and sexually transmitted infections, but we lack parental and practical guide on how to use it. The majority of participants reported that parental guidance and consistent reminders are necessary for both boys and girls on the significance of using condoms during sexual intercourse. They emphasized that some of the teenage girls often become pregnant due to limited knowledge about condom use.

“You know for most of us boys, we don’t even mind much about using condoms. But if parents should provide education to girls about condom use and even buy some for their daughters just in case, I think the cases of unintended pregnancies we see here would decrease.” (Male participant 3, Kayonza FGD)

Subtheme 2: Young adolescents are aware of the negative outcomes poorly managed sexuality during adolescence. All participating adolescents were aware of the consequences they can face if they mismanage their adolescence. Adolescent males possess knowledge regarding the potential consequences of engaging in unprotected sexual intercourse, such as the possibility of impregnating their female counterparts. Additionally, they are cognizant of the various risks associated with unprotected sex, including the transmission of sexually transmitted infections, notably HIV/AIDS. Moreover, they are well-informed about the emotional and psychological burdens that teenage pregnancy imposes on both young males and females, as well as the social stigma attached to HIV infection, which can contribute to feelings of depression and contemplation of self-harm.

“Unprotected sex carries a risk for boys as well because we too can get HIV. Another consequence is when you have sex with a woman older than you, she may transmit sexually transmitted infections to you. When you learn that you have those infections or HIV, you can become depressed to the point that you indulge in abusing drug substances thinking that we are getting relief. However, the end result would be harming our health and also leading to suicidal ideas. Another issue is to manage the pressure of assuming family and parental responsibilities at young age which affect your future health.” (Male participant 5, Mukarange FGD).

The anguish and dilemma faced by young boys intensify when they contract HIV from a girlfriend or a trusted female figure, such as a close relative.

“You feel heartbroken, and it is not even easy to report such cases to the police because of the misconception that reporting such cases would be an embarrassment for the extended family. So, because of sorrow and flashbacks on how you have fallen in that mistake of sleeping with her and get HIV, you can end up infecting others intentionally as a way of revenge.” (Male participant 8, Kayonza FGD).

The issue of assuming pregnancy and parental responsibilities at a young age was a topic of concern among most adolescent boys. During discussions, participants highlighted various challenges associated with this situation, including the lack of preparedness to become parents while still relying on their own parents for support. Additionally, it was noted that impregnating girls while attending school could result in both the young boy and girl dropping out of their education, which was an undesirable consequence. The viewpoints of young girls aligned with those of their male peers. They believed that if boys impregnate young girls, they may be compelled to enter into early parenthood and take on the responsibilities of being a parent.

“It happens that a young boy does unprotected sex out of exploration and curiosity and then impregnate the young girl… When it happens, the young boys’ parents instead of supporting him, tell him to assume the parenting and family care responsibilities while still very young. That’s when you see the young boy dropping out school to assume family responsibilities.” (Male participant 3, Kiziguro FGD)

Adolescent girls who fail to navigate their teenage years effectively may encounter a range of adverse outcomes, such as unintended pregnancies, heightened vulnerability to sexually transmitted infections (including HIV), substance misuse, and engagement in sex work. In light of these circumstances, young boys reiterated that teenage pregnancy impacts young girls in various ways, such as familial rejection, the onset of depression leading to contemplation of suicidal thoughts, and resorting to secretive abortions, as evidenced by the following quotations.

“Most of the time when girls become pregnant, they keep it secret because some parents do not want to hear their daughters being pregnant. Others may find it shameful to bear and raise that baby in the future. As a result of hiding the pregnancy, some young girls may decide to have clandestine abortion of course which is threatening because she may die. If she does not die, still her reproductive system mainly her womb can be destroyed.” (Female participant 8, Kayonza FGD).

“There are some girls who become pregnant and keep it a secret. They hide that from anyone, even from their parents. During their pregnancy, they do not take care of themselves, and they may not eat properly. On the day of delivery, such girls don’t go to the health facilities and may risk dying giving birth or their babies may die in the process.” (Female participant 5, Kiziguro FGD).

Female participants reported that the occurrence of unplanned pregnancies and the subsequent actions they take to avoid the responsibilities of parenting without any form of support. These actions often involve attempting secretive abortions.

“You know not all our families are rich, so when you get pregnant and you don’t get support from your parents and the baby’s father support, surely you suffer quite a lot when upbringing the baby as a single mother.” (Female participant 1, Mulinga FGD).

The impact of unplanned pregnancy on the lives of female participants was vividly expressed, especially during the process of childbirth.

“Teen pregnancy for some young girls can result into caesarean during the time of delivery which is a risk itself. A girl may also have prolapsed uterus during delivery, and this may result into infertility later.” (Female participant 7, Mulinga FGD).

Female participants also reported that young girls who do not receive sufficient support may also experience depression, discontinue their education, and face the harsh reality of extreme poverty.

“My elder sister has so far got two kids and she has dropped out of school. Now, she is depressed and whenever we try to find her a job, she doesn’t want to work.” (Female participant 7, Mukarange FGD).

“One of my classmates got pregnant and she suffered a lot. Her parents were very poor and were even finding it difficult to find money for renting. After giving birth, she was obliged to leave her parents and lead a life of her own. It was heartbreaking seeing her because at times she might not obtain food and you know when you have a baby, you need sufficient food so that you can breastfeed the baby. She was starving and it was also difficult for her to get clothes for herself and the baby.” (Female participant 5, Kiziguro FGD).

Theme 2: Barriers affecting young people’s sexual and reproductive health during adolescence

The second theme encompasses three separate sub-themes, namely: a) Insufficient engagement of parents in educating their young adolescents about sexual and reproductive health, b) misconceptions surrounding sexuality during adolescence, and c) inadequate knowledge regarding the menstrual cycle.

Subtheme 1: Limited parental involvement in their young adolescents’ sexual and reproductive health education. The lack of parental guidance regarding sexual and reproductive matters has been identified by the majority of participants as a significant challenge for young boys and girls in the Eastern province of Rwanda. Participants reported that this absence of parental voice contributes to the various risks that adolescents in the region face. The main barriers to parental involvement reported by participants include conflicts within families and a lack of understanding about sexuality issues. The participants also emphasized that conflicts within families have a detrimental impact on their sexual and reproductive health.

“When there is conflict within a family, the parents do not educate their children about sexual and reproductive health. Since a young child has no one to provide her with information or even warn her about certain bad behaviours, he/she takes decisions themselves. For us girls, that’s when we will end up sleeping with boys and get unintended pregnancies.” (Female participant 9, Kiziguro FGD).

Female participants reported that when parents are absent, especially in the case of young girls, they may leave their families in search of informal employment opportunities in their local communities or urban areas. Unfortunately, this search for employment can expose these young girls to the risk of sexual exploitation. Additionally, they noted that parents often neglect the informational needs of young boys regarding sexual and reproductive health. They mentioned that parents still consider these topics as taboo and lack the necessary knowledge to provide guidance to their children.

“The challenge is that some young people see the pubertal changes and we fear to inform our parents. When we tell them about the changes we saw, they end up retorting that it is not time for us to know such obscene things because they are still children. Oftentimes, when parents answer you like that you keep quiet and anticipate to get information elsewhere”. (Female participant 3, Kayonza FGD).

The participants also highlighted the lack of attention from parents towards their sexual and reproductive health, especially boys, as a contributing factor to the rise in unintended teenage pregnancies within their community’s health as highlighted in quotes below.

“There are some parents who even fear their teen children because perhaps they do not know where to start the conversation around for example sexuality concerns.” (Female participant 6, Mulinga FGD).

Another female participant corroborated the fact that parents shy away from discussing topics related to sexuality and reproductive health with their children.

“When you have hostile mother, she doesn’t give you time to discuss about reproductive health issues. You know some of our parents do not even ask us if we have seen our periods or even about life in general because they take that as normal things. Whether we do sex or do not, they don’t care.” (Female participant 6, Kayonza FGD).

Subtheme 2: Misconception surrounding sexuality during adolescence. Although a significant number of participants reported strategies to navigate the various changes taking place during adolescence, some of them noted that some girls may misinterpret the presence of acne for example as a reason to engage in sexual activities. Male participants reported that young male adolescents often may receive inaccurate information about circumcision from their peers or the general public, which could potentially lead them to engage in unprotected sex.

“Outside here there is a misconception that when recovering from the circumcision wound, you should seek a girl to sleep with in order to reduce the sores where the out skin of the male sex has been removed.” (Male participant 7, Mukarange FGD).

Other male participants expressed that some of their peers give them wrong information about sexuality during adolescence.

“You know, your friends can tell you if you do sex, you will feel relieved from stress. They tend to only focus on the good things you will benefit from and do not tell you about the negative side. Most of the time, if you don’t accept what they are doing, they call you naïve or a coward.” (Male participant 8, Munyiginya FGD).

Social media, as an alternative information source, has the potential to mislead young individuals. It is concerning that some young people may exploit these platforms to search for explicit content, including sexuality-related information and pornography.

“One day I gave my smartphone to my cousin. She opened YouTube to search for something using my internet bundle. You know what, at the end of the day, when I checked the search history, I was surprised to see that she was search videos around sexuality from Rwanda.” (Female participant 4, Kayonza FGD).

Subtheme 3: Lack of adequate information on menstrual cycle. In response to inquiries regarding the possibility of a girl becoming pregnant, a majority of young boys and girls expressed a lack of adequate knowledge on the matter. Upon further probing, a small number of participants provided varied responses, indicating the necessity for enhanced education on the human reproductive cycle. Some female participants who attempted to answer unanimously suggested that a girl can conceive within a range of one to eight days following her menstrual bleeding and four days preceding her periods. Male participants on the other hand stated that a boy could potentially impregnate a girl at any time, regardless of her monthly cycle.

“When we were in class if I remember well, they taught us that a girl may not be pregnant within the four days after having periods, but she can get pregnant four days before she sees her periods. They also told us that you can even get pregnant during periods if they do sex.” (Female participant 6, Mukarange FGD).

Theme 3: Informational needs for young people during adolescence

Participants highlighted a number of informational needs to leverage their sexual and reproductive health. Participants underlined that young girls are more vulnerable during adolescence due to the potential consequences of early unintended pregnancies, which can hinder their future prospects. In order to address this vulnerability, participants underscored the importance of providing comprehensive education on sexuality and reproductive health, including information on preventing unplanned pregnancies and sexually transmitted infections.

“For me, I think that a young girl needs to know that anytime she does sex, she may become pregnant which in turn can affect her future. Therefore, young girls need to know that, and one way is to empower them with information that can enable them to resist risky sexual behaviours.” (Female participant 2, Kiziguro FGD).

Additionally, they suggested that young girls should also be educated on the proper use of condoms, benefits of using them as a means of protection when abstinence is not an option and saying no to any romantic relationships luring them to unprotected sexual intercourses. The female participants corroborated their male counterparts’ viewpoints. Female participants stressed the importance of parents providing constant information and material support to protect them from sexual exploitation.

“…. a young girl should be advised by her parents on being cautious. I say this because during adolescence, we are vulnerable because we can be misled by men who might need to exploit us sexually. So, when we don’t have sufficient support, we can end up being lured by their fake gifts and then get pregnant or even get sexually transmitted infections.” (Female participant 4, Munyiginya FGD).

Furthermore, several female participants emphasized the importance of providing young girls with education on effective reporting of incidents of sexual violence committed against them.

“During adolescence, some girls may be lured into trusting men particularly those who give them lift or other material things. Such men may one day demand to be paid back through sleeping with them. If a young girl refuses, such men can rape her. In case this incident happens, a young girl needs to be aware of the reporting processes and be empowered to inform her parents for timely interventions.” (Female participant 8, Kiziguro FGD).

All participants have expressed that one of the primary informational requirements to prevent teen pregnancy is obtaining knowledge about the menstrual cycle.

“Honestly, even though we studied reproductive system in class, we do not really have information about a woman’s monthly cycle. Particularly, we don’t know which period of the cycle a girl can be pregnant if you sleep with her.” (Male participant 9, Kayonza FDG).

Female participants further emphasized the need to equally educate young boys about sexual and reproductive health matters, highlighting that these topics should not be exclusive to girls.

“You know, when they mention reproductive health, some of the young boys will interpret it as a girl’s thing, you know conception and menstruation things like that. They often don’t feel concerned. Therefore, to limit such attitudes boys too need to be educated about sexual and reproductive health. This can be a protective thing for us girls because informed young boys can protect us.” (Female participant 1, Munyiginya FGD).

Strengths and limitations

One of the main strengths of our study lies in the fact that the sample consisted of young adolescent boys and girls who were in a favorable position to provide comprehensive information regarding the phenomenon under investigation. However, it is important to acknowledge that this study does have certain limitations. Firstly, our sample only included young adolescents who were attending school, specifically from six secondary schools. As a result, the transferability of the findings may be restricted to this particular population, and therefore, the perspectives expressed by the participants may not be representative of all young individuals in the Eastern Province of Rwanda, including those who are not enrolled in school. This omission of young people who were not attending basic secondary education schools means that their experiences were not accounted for in our study. Additionally, we did not employ triangulation in our data collection methods, such as conducting individual interviews. Consequently, it is possible that some participants may have chosen to conceal their personal experiences with sexuality and the barriers they faced in terms of sexual and reproductive health during adolescence. This limitation resulted in some young individuals discussing general barriers that young people encounter, without providing specific context based on their own experiences.

The primary emphasis of the current study was on unintended pregnancy and its consequences, as well as sexually transmitted infections, including HIV/AIDS. Other essential components of sexual and reproductive health, such as life skills, sexual and reproductive health rights, responsibility, and the promotion of assertiveness among young adolescents, were not addressed. Consequently, further research should explore these aspects of sexual and reproductive health in order to develop a holistic sexual and reproductive education program that will empower young individuals in the Eastern Province of Rwanda to avoid unwanted pregnancies and STIs, including HIV/AIDS.