Key informant perspectives on sexual health services for travelling young adults: a qualitative study

Background International travel has become increasingly popular among young adults. Young adults often engage in casual sexual relationships abroad, exhibit sexual risk behaviours and may thus be at risk of contracting sexually transmitted and blood-borne infections. Pre-travel interventions and consultations may mitigate this risk. At present, we know little about sexual health-related pre-travel interventions. The aim of this study was therefore to document key informants’ experiences, perceptions and recommendations in the context of sexual health of young adult travellers. Methods Key informants were professionals working in Ottawa, Canada travel clinics, travel organizations or sexual health clinics with a young adult clientele. This study used a qualitative approach and consisted of 13 in-person or Skype semi-structured interviews with key informants. Thematic content analysis was informed by a sexual health framework, with themes emerging both inductively and deductively. Results Sexual health was not common in pre-travel interventions described by key informants. Risk-assessment, and practical or purpose-driven pre-travel interventions were identified, resulting in risk mitigation strategies tailored to the destination region and/or mission/culture of the travel organization. Dissemination (e.g. limited time, lack of training) and uptake (e.g. young adults’ embarrassment, provider discomfort, financial constraints) barriers limited in-depth discussions of pre-travel interventions related to sexual health. Key informants acknowledged the importance of early sexual health education, and recommended ongoing, comprehensive sexual education for both youth and young adults. Conclusion The findings of this study suggest that more time and resources should be allocated to the topic of sexual health during pre-travel interventions with young adults. Professionals who guide and prepare young adults for travel must develop concomitant skills in sexual health promotion. Early, comprehensive sexual education is recommended to improve overall sexual health in young adults and mitigate risk behaviours during travel.

STBBI and unintended pregnancies [2][3][4] in youth and young adults may be caused by inconsistent condom use [5,6] high-risk behaviours such as drug and alcohol use, social media-related sexual encounters and multiple partners [7][8][9][10]. STBBI can contribute to many serious health complications such as reproductive cancers and infertility, and the presence of one or more symptomatic STBBI significantly increases the risk of HIV transmission [11][12][13].
Young adults are one of the most mobile generations in terms of international experiences [14]. In 2015, 23% of all international travellers were young adults (aged 15-29 according to the World Tourism Organization) [15]. Young adult travellers are more likely to spend long periods abroad, with purposeful travel -work, study, volunteer or language opportunities -steadily replacing leisure travel [15]. Motivations for international travel include interactions with local citizens and a desire for an immersive local, cultural experience [15]. Due to the COVID-19 pandemic, international travel is reduced significantly, including cross-border travel between Canada and the United States [16]. Vaccinations are gradually increasing Canadian international travel in 2021 [17], with normal travel volume anticipated post-pandemic.
The popularity of international travel has created a healthcare sector focused on the provision of travelrelated health information [18,19]. The field of travel medicine is predominantly preventative, ensuring predeparture review, counselling and management of destination-specific risks, itinerary-specific risks, and risks specific to the individual traveller-such as pre-existing conditions [20]. Pre-travel health consultations typically include individual risk assessment, medical history, health risk education and related mitigation strategies specific to the travel region, as well as relevant immunizations and medications for prophylaxis and selftreatment [21,22]. STBBI are among the communicable disease risks faced by travellers based on their destination or their planned activities [20]. It is difficult to quantify the impacts of travel on adverse sexual health outcomes due to the heterogeneity of travellers, trip characteristics and destination regions [23][24][25][26][27]. A systematic review estimated the prevalence of travel-associated casual sex as 20.4% with approximately 49.4% unprotected sexual encounters [27]. Risk factors for travel-acquired STBBI include casual sex, single status, alcohol or drug use, lack of travel advice, male, higher number of sexual partners and inconsistent condom use [23,27]. Although discussion of sexual risk behaviours in pre-travel consultations by health practitioners is a best practice [20,21,28,29] the quality and frequency of sexual health promotion is less well known.
Ottawa, Ontario is the bilingual (English, French) capital city of Canada, home to 934,243 residents including 125,840 young adults, aged 15-24 years [30]. Pre-pandemic Canadians were avid travellers, with 28.7 million international trips in 2010; 44.6% representing travel by Ontario residents [31]. Although the United States remains the most popular destination, Canadian travellers also include overseas backpackers, volunteers traveling to low-income countries, and immigrants returning in their country of origin to visit relatives [32]. Canadian Generation Z (age 18-23 y) travellers prioritize experiential travel that includes physical activity, exploration and inspiration [33]. Given the increased risk of adverse sexual health outcomes, including STBBI, unintended pregnancy, and sexual harassment/assault, among travelling young adults, travel health interventions can be considered an essential component of public health. This study aims to investigate the experiences, practices and recommendations of Ottawa-region professionals, employed in fields of travel medicine, sexual health or travel/tour agencies, within the context of young adult travellers' sexual health.

Sample
Recognizing that young adult travel may include predeparture consultations with both travel organizers, and travel health providers, EG recruited travel health sector key informants to participate in semi-structured interviews through purposive sampling by email, phone or in person. To best capture an overview of the travel health sector, interviews with key informants convey, by proxy, the experiences, practices and culture within their respective organizations [34,35]. Inclusion criteria for key informants were as follows: professionals employed in the travel sector within the Ottawa region who routinely provided pre-travel health counselling and guidance to young adults, and were able to participate in the interview in English or French. Lack of English/French language proficiency, organizations which did not offer services in the Ottawa-region, and professions limited to travel/itinerary arrangements (e.g. travel agents) were exclusion criteria. Thirteen key informants from 11 different organizations, including travel-health clinics, sexual health clinics, young-adult-focused tour agencies and health-promotion groups, with no restriction on the type of organization/business (e.g. commercial, health, academic, non-governmental organization) were recruited. Given that key informants were drawn solely from organizations based in the Ottawa-region, and that there are limited such travel services which provide guidance and counselling related to health and wellness, this sample size was deemed adequate [36] to reflect a diverse breadth of local organizations and upon data analysis, saturation was achieved [37].

Data collection
The interview guide was informed by the World Health Organization's sexual health conceptual framework [38] which promotes sexual health as the holistic achievement of physical, emotional, mental and social well-being, framed by human rights, evidence-based and a sex-positive approach. Interview topics included: Key informants' (i) roles in travel interventions related to sexual health, (ii) perceptions of young adult Ottawa-region travellers' sexual health and experiences, (iii) practices and recommendations for travel-related sexual health promotion; (iv) challenges and barriers to sexual health promotion; and (v) demographics.

Data analysis
Interviews were audio-recorded, transcribed and analyzed in the original source language, with field notes confirming that thematic saturation was reached [39,40]. Translations of sample quotations from French-speaking participants appear in this article. Interview transcript data, coded using NVivo (Version 11.4.3 (2084)), were analyzed using both inductive [39,40] and deductive approaches; supported by the WHO sexual health framework [38] and the interview guide. EG analyzed the data iteratively and the research team reviewed and discussed the interpretation and qualitative content analysis [39] to fully develop our understanding of the data.

Ethics
All methods were performed in accordance with relevant medical ethics and research guidelines and regulations. All study protocols were reviewed and approved by Research Ethics Board at the University of Ottawa (File # H02- . EG conducted English and French interviews in person or via Skype, between April-November 2017, with seven English-and six French-speaking participants, each of whom provided written, informed consent to participate in the study.

Participant characteristics
Key informants included seven professionals working in a health-related organization (4 travel clinics, 3 sexual health clinics) and six employed by travel services ( Table 1). The majority of the key informants identified as female (n = 11) and had less than 10 years of experience in their current field of work (n = 8). Recognizing that mandates of healthcare (i.e. travel clinics, sexual health clinics) are distinct from travel services (i.e. organizations specializing in international cooperation, tourism, volunteering or student exchanges), our presentation of the findings notes major differences between these groups.

Pre-Travel interventions
In general, key informants described pre-travel interventions tailored to the mission of the tour agency or the destination region, with sexual health not considered a core component. Themes related to informants' pre-travel practices emerged as either risk-assessment approach and/or practical or purpose-driven interventions. Healthcare key informants typically used risk-assessment approaches to mitigate disease risk or potential health hazards (e.g. food, water, mosquitoes, etc.) associated with the destination region. Typical pretravel healthcare interventions included vaccinations, medications and general travel advice. When asked how young travellers' sexual health could be improved, a female travel nurse (EG01) said, "[…] we have to focus on vaccines and medications like malaria-we have to focus on the risks of illness, " following the guidelines and directives of the host organization. A travel services informant recognized the risk-assessment approach used by healthcare workers, and recalled that the nurses responsible for the pre-travel health module training emphasized risks related to diseases: Travel services participants reported that most humanitarian or volunteer opportunities are organized as group activities. Although practices varied across different host organizations, informants used practical or purpose-driven interventions tailored to the collective needs of the group. Travel services key informants noted little emphasis on sexual health in the pre-travel health discussions. Although sexual health was most often discussed in terms of casual sex, participants were cognizant that adverse sexual health outcomes could include harassment and assault. The risk-assessment approach was used to discuss travel-safety, which both health and travel services key informants discussed in terms of acceptability of sexual expression and risks of sexual assault.
"…we know how difficult it is for people to talk about.. um.. sex in general, sexual assault and harassment in particular, is even more taboo and difficult, so if we talk to them before them [

Barriers to sexual health promotion
Major themes related to key informants' pre-travel sexual health promotion were dissemination and uptake barriers. Dissemination barrier subthemes included; (1) limited time for discussion, (2) lack of suitable resources (i.e. Uptake barriers related to the accessibility of sexual health promotion itself by young travellers. Barriers to sexual health uptake by travellers were categorized as three subthemes: (1) young adults' embarrassment, (2) travel/healthcare professionals' discomfort, and (3) travellers' financial constraints. Both travel services and healthcare respondents described young travellers' discomfort with sexual health discussions, perceived shyness, apparent disinterest, or requests to change topic when sexual health was introduced.
"I think they're also very shy. People  A humanitarian travel organization key informant seemed ill at ease when discussing sexual health topics during the interview,

"I don't think it's [sexual health] a common topic. I don't know if it's because the organization might think that talking about it might encourage people… encourage [sexual] actions…For us, it's difficult… We are all together during fifteen days in the same environment…I don't think it's appropriate. " [translation] -female, travel services mission lead, EG13
Respondents also considered young travellers' financial limitations as barriers to their uptake of sexual health information, given the consultation fees required for some travel-health services.

Sexual behaviours and travel
An overarching theme which emerged across interview questions, was the recognition by both health and travel key informants that travel itself may cause young adults to engage in risky sexual behaviours. Key informants' perceptions of the impact of travel on sexual behaviours were summarized as the following subthemes: disinhibiting effects of alcohol, anonymity of travel, and exoticism of travel.
Travel-related increased alcohol intake was widely acknowledged as interlinked with casual sex.
"Well, I think we all know that alcohol and sex go to together ... When you're away, um you will drinkmost people will drink more…. where there's a lot of drinking involved, they'll absolutely be at a higher risk of sexually transmitted diseases and probably more frequent unplanned sex. "-female, travel nurse, EG01 "You know, students, when they travel abroad, they party. Often, they party a lot and they meet people and they are more vulnerable" [translation]-female, program director-travel services, EG02.
The anonymity of travel, being away from social networks at home, was recognized as a contributing factor to increased sexual activity abroad. A volunteering program officer explains: "You'll keep your anonymity and you will do more things…and this is the danger that we often witness. You  A healthcare professional considered that many young adults may return from travel and reflect on their travelrelated sexual behaviours with regret, health or safety concerns resulting in "post-travel anxiety".
"People will travel, come back and only then will the reality strikes.

Key informant recommendations
When asked to provide recommendations related to sexual health and travel, several themes emerged about key informants' general perceptions of young adults: early sexual health promotion and education is a determinant of adult sexual health and well-being; young adults exhibit a general lack of sexual health knowledge, and comprehensive sexual education targeted to youth and young adults is the recommended strategy to improve these knowledge gaps.

Discussion
We report here that sexual health is generally omitted, discussed superficially, or considered an awkward, uncomfortable topic by Ottawa-region key informants. Respondents recognized that the anonymity and exoticism of travel, along with use of disinhibiting substances like alcohol and drugs increased travel-associated sexual behaviours among young adults. Healthcare key informants prioritized risk-assessment driven interventions, emphasized infectious diseases other than STBBI, prophylactic vaccinations and general health and safety; whereas travel services participants relied on practical or purpose-driven interventions tailored to the immediate needs and activities of the travellers. Key informants identified barriers to the dissemination of sexual health promotion but also perceived that uptake of such messaging was impeded by provider/young adult discomfort and embarrassment with the subject. A 2016 systematic review identified that less than half of travellers from high income countries received pretravel sexual health interventions [23]. Previous studies report that sexual health risks are rarely discussed in pre-travel consultation in travel clinics [41,42], consistent with our findings. Although pre-travel sexual health promotion is a recommended best practice for travel medicine [20], evaluation of the benefits of these interventions is complicated by inconsistent, non-standard programmes, heterogeneity of both providers and travellers and trip destinations [27,32]. Whereas some studies conclude that pre-travel sexual health promotion can be effective in reducing adverse outcomes [23,42], other studies consider that such pre-travel sexual health interventions may successfully increase sexual health knowledge and risk perception without necessarily reducing risk behaviours [43,44],

Reported barriers to sexual health promotion
Reported uptake barriers of sexual health promotion during pre-travel consultations include format and perceived relevance of the sexual health travel-related promotion [24,25]. In our study, travel and health professionals articulated discomfort, lack of training and confidence associated with sexuality discussions as barriers. This is consistent with implementation barriers for sexual education by teachers [45,46], and clinical sexual histories/ counselling by medical students [47,48], and nurses [49,50]. Training and continuing education are strategies to enable sexual educators, including health professionals, become more assertive and confident with sexuality discussions [46,49]. Attitudes related to perceived discomfort and embarrassment of clients, students, patients, and in our study, young travellers, often reflect gaps in understanding of the importance of sexual promotion to the target audience, insufficient training or other barriers including lack of time or privacy [46,49]. Training by itself, however, cannot abrogate policies, protocols or organization cultures which do not support open, inclusive sexual health promotion [45]. Best practices for sexual health promotion should ensure a judgment-free Page 8 of 11 Gareau and Phillips BMC Health Services Research (2022) 22:145 dialogue that is sex-positive [38,46,51], tailored and relevant to the audience, and is evidence-based [1,38,52]. Although sexual health promotion may provide comprehensive discussion about risk reduction, and safe sex, broader issues related to sexualities, sexual rights and gender equity are often omitted [53]. Inflexible personal beliefs about sexualities may bias sexual health promotion, contribute to missed opportunities for needed referrals, information and counsel, and lead to incorrect sexual health risk assessments [47]. Therefore, an essential starting point for inclusive, sex-positive sexual health promotion is relevant training and personal reflection for providers, so that they are able to meaningfully discuss these issues with trust, respect and dignity. A cis-heteronormative lens of sexuality does not meaningfully reflect diverse sexual identities in Canada [46], such that the needs of minority groups may go unaddressed with respect to sexual health and travel. Travel key informants discussed sexual harassment, risk of sexual assault and cultural/legal acceptability of homosexuality and non-binary sexual identity expression abroad, however these topics received less emphasis compared with standard pre-travel consultation topics (e.g. food and water safety, medication, culture shock). Key informants framed gender-based violence along with legality of sexual expression abroad as human-resource or safety topics, rather than part of the broader dialogue about sexual health. Responsibility for sexual violence always rests with the perpetrator, however risk behaviours such as travel destination, excessive intoxication, accommodation, nightlife activities, and solo travel, are associated with assaults on young women and gay and bisexual men [54,55], Tourism-sector workers face considerable sexual harassment, such that young adult travellers may also represent potential perpetrators [56]. It was unclear the intent of established abstinence policies and no-sex contracts for travellers described by Ottawa-travel services informants. These policies may serve to reduce risk of sexual assault, and possible legal repercussions of casual sex abroad, and may also be intended to safeguard the reputation of participating travel organizations by minimizing problematic sexual behaviours of travellers abroad. Key informants acknowledged that these abstinence contracts were difficult to monitor and enforce.

STBBI
Healthcare key informants identified that the topic of vaccines, especially hepatitis B vaccine, was used as a mechanism to briefly introduce sexual health, mainly HIV and STBBI, in pre-travel interventions. Emphasis on travel STBBI risk reduction is essential, as globalization and travel have facilitated STBBI dispersion and impacted surveillance and treatment [23,27,32,44].
Indeed, travellers who engage in sexual relationships abroad are exposed to new and different sexual networks [21] especially when travelling to STBBI hot-spots [57]. Travel-related sexual networks can facilitate the introduction of new drug-resistant STBBI in the home country, including drug-resistant strains of N. gonorrhoea [21,27,44], as well as other blood-borne pathogens [27,32] like the Zika virus [58,59]. As young travellers, particularly men, are at higher risk to engage in casual sexual relationship abroad [21,26,27], it is important that pretravel consultations address the issue of STBBI and safe sex abroad [21,60].

Recommendations
Our findings indicate that Ottawa-region travel and health key informants provide only limited sexual health pre-travel interventions. Most international health organizations identify sexual health is as an essential pre-travel intervention (e.g. CDC [21], International Society of Travel Medicine (ISTM) [29], Committee to Advise on Tropical Medicine and Travel [CATMAT] [28]). Further, travellers should be encouraged to follow up with posttravel interventions, including sexual health assessments. It is evident that Ottawa-region travel services prioritize pre-travel preparations, rather than post-travel followup or referrals. Health key informants were more likely to manage post-travel incidents, however there did not appear to be a systematic scheduling of post-travel followup appointments. Post-travel interventions to improve follow-up could include automated reminders issued from travel organizers, airlines or public health agencies.
More research is needed to identify the best practices in terms of pre-travel health interventions and sexual health information uptake by young travellers [61]. Young adults perceive health hazards, such as unprotected sex, as less risky, compared with older adults [62]. Dialogues about sensitive topics such as sexual health with adolescents and young adults may create discomfort for both provider and patient [63], consistent with the views expressed by our key informants. For providers, sexual health training, youth/ young adult-targeted sexual health guidelines, and sexual risk assessment decision aids, such as the touch-screen-administered measure Sexual Risk Behavior Inventory (SRBI) for primary care patients [64], may help instill confidence and ability. Engagement of adolescents/young adults in such discussions requires establishment of trust and emotional comfort initiated by informal conversation [63]. Our health key informants seemed to realize this, however, they described very little time to establish patient rapport, with consultation time restricted to priority travel vaccinations. Once trust and rapport are established, provider-guided interventions that are sex-positive, individually-tailored could include condom negotiation, safer, alternative non-penetrative sexual practices such as mutual masturbation [43,65]. Digital mechanisms to deliver sexual health information and recommendations should be used to complement classic provider-interventions. Use of digital apps such as GGD Op reis [66], MyTravelHealth [67] or CDC's app TravWell [68] and travel SMS/text messages with sexual health promotion [69] may better serve this young adult demographic. Although we recommend modernization and diversification of pre-travel sexual health promotion platforms, these mechanisms should complement face-to-face provider consultations which can best provide individualized counsel and provision of evidence-based advice, prophylaxis/mitigation immunizations and medications [70].

Limitations
This qualitative study is not meant to be generalizable or representative of the experiences and practices of all key informants working in travel clinics, sexual health clinics and travel organizations. Several organizations declined our invitation to participate in the study; citing lack of coverage of sexual health topics or discomfort with the topic. This suggests a sampling bias, as the key informants who agreed to participate did address sexual health to some extent or were comfortable discussing this topic.

Conclusion
The findings from our study highlight that Ottawa-region health or travel key informants omit or neglect sexual health in pre-travel interventions. We recommend that youth-focused travel organizations emphasize within pre-travel consultations for comprehensive sexual health discussions that recognize the intersectionality of sexual identities, race/ethnicity, gender, age and citizenship. Both travel and health key informants should consider established and emerging sexual risk assessment decision aids to facilitate sensitive discussions and use of digital technologies for efficient, cost-effective sexual health promotion at the population level.