Sexual and Reproductive Health Service Seeking Scale (SRHSSS): development, validity, and reliability

United Nations has reported that 1.2 billion young people, or 16% of the world's population, are between the ages of 15 and 24, and mentioned that the number of youth will increase by nearly 1.3 billion [1]. World Health Organization (WHO), defines "Adolescents" as 10–19 age range and "Youth" as 15–24 age range [2]. Many people have their first sexual and reproductive experiences in adolescence and young adulthood. Adolescents and young adults (AYAs), defined here as those aged 15–24 years, have these experiences during a critical time for psychological, social, cognitive, and physical development. During this stage of growth, AYAs create their own identity and establish autonomy, responsibility, and independence. At the same time, they are negotiating interpersonal relationships with peers, friends, parents, and guardians [3].

Individuals in young adulthood are sexually active, and open to different lives and behaviors in terms of thought and action. Young adults are more at risk than other age groups, especially due to the adverse effects of sexually transmitted diseases (STDs) such as HIV/AIDS, frequently changing sexual partners, engaging in early sexual acts, and early pregnancy [4, 5]. Many social problems such as age inequalities among heterosexual partners, gender differences in sexual behavior norms, early marriage for girls and the likelihood of sexual oppression also threaten the SRH of this age group [6]. Therefore, young adults are the best age group that could receive education and services to prevent adverse cases such as unwanted pregnancies and STDs [7].

Difficulties in accessing contraception and safe abortion, and the risk of contracting STDs, including HIV, are major challenges in young adults' lives. Studies by Lancet Commissions report that 25 million unsafe abortions are performed worldwide each year, more than 350 million men and women need treatment for one of four curable STDs, and approximately 2 million people are newly infected with HIV. In addition, one in three women has experienced intimate partner violence or non-partner sexual violence at some point in their lives. In the same study, it was reported that almost all of the 4.3 billion people of reproductive age worldwide would have inadequate SRH services during their lifetime [8].

On the other hand, there are still difficulties for young adults in accessing SRH services and exercising their SRH rights due to social and cultural reasons. Young adults try to solve their SRH problems by referring to unreliable sources on the internet instead of using counselling and treatment services provided by official institutions [9]. The reason for this, is stated as unpleasant or judgmental attitudes of healthcare professionals in a cross-sectional study conducted by Decker et al. in 2021 [10]. Health care providers do not recognize the needs of young people and welcome them, especially the unmarried. Thus, healthcare professionals may present an unsupportive and judgmental attitude towards young adults, thereby creating an obstacle to service procurement. The data on unintended pregnancy and abortion, violence against women, and STDs/HIV/AIDS are all restricted by the persistent taboos surrounding the subject of sexuality. In addition, in SRH services; Various political, economic and sociocultural factors can restrict the provision of information and services [11‐13].

In some societies around the world, sexuality is still described with expressions such as "secret, shameful, forbidden" and is seen as a taboo. Especially young people cannot access sufficient and accurate information about sexuality, sexual and reproductive health [14]. The majority of adolescents in school have inadequate SRH, necessitating their need for access to comprehensive sexual education, information and services. Providing these services is necessary to ensure that adolescents can access, understand, evaluate and apply good SRH information in their decision-making processes for their own health [15]. In their study, Jinping Lyu and his colleagues drew attention to the importance of the issue by reporting that especially female students in China behave conservatively in sexual attitudes and behaviors and that low levels of sexual knowledge contribute to risky behaviors among Chinese adolescents [14].

In recent years, new measurement tools have been developed to evaluate the empowerment of adolescents and young adults regarding sexual and reproductive health [3]. Additionally, measurement tools are being developed to assess young people's needs and problems [16].

Providing health and counseling services related to SRH in official institutions, will provide a reliable official resource that young people can refer to if they are faced with serious dangers such as gender inequality, early and unwanted pregnancies, HIV and other STDs [17‐19].

When the studies that have been done so far on receiving health services related to SRH with young adults are examined; Although the results of studies on the importance of young adults receiving services on SRH have been reported; There is no measurement tool that can evaluate the demand and need for service procurement from an official institution. Given the above-mentioned reasons, it is young adults who have the most difficulties in SRH and seek health services [20, 21]; It is important to determine the SRH services they need, and therefore the need for a valid and reliable measurement tool is inevitable.

Measuring the knowledge of a group also allows comparison with other groups and their progress over time. Changes in groups often represent results in knowledge, attitudes, or behavior. Thus, one of the greatest challenges when measuring the knowledge, attitudes, or behavior of a group may be measuring when these outcomes are most likely to be evident and are most meaningful. Problems such as unwanted pregnancies, increase in sexually transmitted diseases, sexual exploitation, violence, and adolescent marriages, especially in adolescence and youth periods. It is a risky period in some societies because of this and it is very important to receive reliable and healthy service from official institutions regarding sexual and reproductive health [22, 23].

The purpose of the study is to develop a valid and reliable measurement tool that can be used to determine the knowledge and attitudes of young adults about SRH and the barriers for accessing services, and to evaluate the attitudes and needs of young adults to receive SRH services.

This study was designed with a methodological study to develop a valid and reliable measurement tool in order to determine the knowledge and attitudes of young adults and the barriers for accessing SRH services, and also to evaluate the attitudes and needs of young adults to receive these services (Fig. 1).

In this chapter; The descriptive features of the participants and the findings regarding the validity and reliability of the “SRHSSS” were presented.

In this study, a valid and reliable measurement tool was developed to measure SRH service seeking, and the features of this tool were explained.

In the exploratory factor analysis conducted to examine the construct validity of SRHSSS, a four-factor structure was obtained that explained 89.45% of the total variance. The factor loadings of the scale items were found to vary between 0.78–0.97. Büyüköztürk states that a factor load value of 0.45 and above is a good criterion for selection, since the factor load values of the items are higher than 0.45, which means that these components collectively measure an idea, structure and factor. In addition, it is advised that there should be a minimum 0.10 difference between the highest load value of an item in the factors and the highest load value after this value.' According to the explanation in the form, it was possible to select items measuring the same construct in this study. The load difference between the factors of an item is higher than 0.10. This shows that this study achieved a good factorization. The investigation conducted to ascertain if the sample size was adequate for factor analysis revealed that the sample size was adequate because the KMO value was above 0.60. Büyüköztürk (2021) also stated that “If there is a cluster of items that are highly correlated with a factor, this finding means that those items together measure a concept-structure-factor. Regardless of sign, a load value of 0.66 and above is considered high; The range of loads between 0.30 and 0.59 is known as the medium magnitude range and is taken into account in subtracting the variable” (Table 1) [25].

In this study, the internal consistency coefficient for the whole of SRHSSS and its sub-dimensions was found to be 0.90 and above. According to Tavşancıl, one of the approaches used to determine the reliability or consistency of the measurements is the re-test method. The same measurement tool is applied to the same group after a certain period of time and the relationship between the measurements is found. This reliability coefficient is also called the continuity or stability coefficient and determines the extent to which the measurement tool measures the permanent characteristics of the individual.' In this study, the re-test method was used to evaluate the reliability of SRHSSS and at a high-level positive relationship was found (r = 0.713, p < 0.001). Tavşancıl stated, “To determine that a scale is invariant over time, the calculated correlation coefficient should be positive and high, and this limit is at least 0.70 for scales.” In this study, it can be said that SRHSSS has a high level of reliability and resolutely measures the service-seeking status of young adults [26].

For determining the total score discrimination of SRHSSS items, item-total correlations were investigated and 27% lower–upper group comparisons were made. According to Büyüköztürk, ‘Item-total correlation, which demonstrates how each item in a measuring instrument displays comparable behaviors, explains the link between the scores gained from the test items and the overall score of the test. The item-total correlation should be strong and positive in this situation. Items with a score of 0.30 or above are seen to have enough representation power of the scale when interpreting the item-total correlation.' In this study, it was found that the overall item-total correlations in the SRHSSS ranged between 0.41–0.77 and the 't' values were significant (p < 0.001). As a result, it is possible to say that the SRHSSS items illustrate similar behaviors, distinguish the participants in terms of SRH service-seeking situations, and thus have a high internal consistency [25].

In a study which is conducted with adolescents and young adults, a scale has been developed which has 23 questions and seven subscales. All subdimensions had good internal consistency reliability (Cronbach’s alpha scores > 0.7) and all items had rotated factor loadings > 0.5. Additionally, it is indicated that additional measures are necessary for this group because of their unique circumstances and life stage, which typically involve frequent changes in sexual partners and parental involvement in decision-making [3]. In another study by Cleland (2001), researchers designed a measurement tool to document knowledge, beliefs, behaviors, and outcomes and also to assess young people’s needs and problems in the field of SRH [16].

The implementation of SRHSSS in young adults or in different age groups will be able to measure the service-seeking of individuals in this regard, and accordingly, it will enable studies to facilitate access to health services. It is thought that SRHSSS has sufficient validity and reliability to be used in researches in the field of SRH.

Since SRH is an important issue for young adults, it is necessary to understand the thoughts, attitudes and perceptions of this age group on the subject. The SRHSSS is a scale with sufficient validity and reliability to identify and evaluate young adults' thoughts, attitudes, and perceived barriers to accessing services regarding SRH.