Contraception board game report


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Contraception board game report

  1. 1. Contents PageAbstract 5Declaration & Copyright Statement 7The Author 8Introduction 10The Research Question 17Aims & Objectives 18The Contraception Boardgame 19Literature Review 24Methodology 33Results 44Discussion 55Conclusion 60References 61 Word Count = 13,054 1
  2. 2. List of Appendices PageAppendix 1 – Letter from Ethical Review Committee 64Appendix 2 – Statement Explaining The Game Sessions 67Appendix 3 – YIP consent Form 68 2
  3. 3. List of Tables PageTable 1 - Under-20 birth rates worldwide 10Table 2 - Sex & Relationships Education Guidance 13Table 3 - Feedback Relating to The Contraception Boardgame 16Table 4 - Common Features of Successful Programmes 31Table 5 - Focus Group & Interview Discussion Statements 36Table 6 - The Constant Comparative Method 37Table 7 - Development of Categories Overview 38 3
  4. 4. List of Figures PageFigure 1 - Under-16 conception rate for England: 1998-2006 11Figure 2 - Under-18 conception rate for England: 1998-2006 11Figure 3 – Setting Up The Contraception Boardgame 20Figure 4 - The Choices Panel 22Figure 5 - Refinement of Categories 39 4
  5. 5. AbstractBackgroundThe UK is well documented as having high rates of teenage pregnancy &sexually transmitted infections. Sex & Relationships Education (SRE) is centralto the Governments Teenage Pregnancy Strategy & there are now clearguidelines relating to this. The Contraception Boardgame is an SRE teachingresource that reflects the Governments SRE guidelines; the aim of this study isto investigate how the this boardgame influences teenagers’ knowledge, skills &behaviour towards sexual relationships.MethodsA qualitative study was carried out involving teenage participants through theYouth Inclusion Project (YIP) in Stalybridge. Multiple methods of datacollection were used to ensure sufficient evidence was collected from a groupwho provided only limited verbal responses in interview situations but werehappy to engage in the less formal atmosphere of playing a boardgame.FindingsOf the 16 young people involved in the study, most were quite well informedabout some but not all the contraceptive methods covered by the game. Therewas a very positive response to the information about sexually transmitteddiseases with most of the participants identifying this as making the greatestimpact in terms of them practicing safe sex in future.InterpretationEvidence from this study supports SRE as an important part of any strategy toreduce teenage pregnancy but emphasises the need for sessions to beconducted by appropriately qualified & experienced individuals. In order toencourage young people to practice safe sex, SRE content needs to be morecomprehensive & be delivered concurrently with information relating to STD’s &their prevention. The study participants made positive comments about thevalue of the game as an SRE resource but more research is required to 5
  6. 6. evaluate the game in a wider range of settings, with a greater number ofparticipants & with more typical facilitators. 6
  7. 7. DeclarationA portion of the work included in this dissertation has been submitted as part ofthe Designing a Research Study unit of this qualification at this University buthas been rewritten for the dissertation. Most of the work included has not beensubmitted in support of an application for another degree or qualification of thisor any other university or other institute of learning;Copyright Statementi. Copyright in text of this dissertation rests with the author. Copies (by anyprocess) either in full, or of extracts, may be made only in accordance withinstructions given by the author. Details may be obtained from the appropriateGraduate Office. This page must form part of any such copies made. Furthercopies (by any process) of copies made in accordance with such instructionsmay not be made without the permission (in writing) of the author.ii. The ownership of any intellectual property rights which may be described inthis dissertation is vested in the University of Manchester, subject to any prioragreement to the contrary, and may not be made available for use by thirdparties without the written permission of the University, which will prescribe theterms and conditions of any such agreement.iii. Further information on the conditions under which disclosures andexploitation may take place is available from the Head of the School ofMedicine. 7
  8. 8. The AuthorAs a student FE lecturer, my first experience of teaching ‘for real’ was to teach“Sex Education” to a group of teenagers at the Outreach Centre in Ashton-Under-Lyne. It is an experience that I will never forget! As a qualified lecturer,teaching biology & health related courses, the ‘sex education experience’ wasrepeated on a fairly regular basis, mainly because noone else wanted to do it. Ifound the subject got easier the more I did it & I became desensitised to thestudents’ difficult questions. I struggled, however, to find better ways of gettingthrough the topic in a more meaningful way. With a degree in Genetics &Microbiology & a PGCE, I had no formal training or experience in sex educationas such, but felt like it was becoming my specialist subject.I was impressed by my friend & colleague, Barbara Hastings-Asatourian, whohad similar experience to myself in terms of teaching but is trained &experienced in the area of sex education, having worked as a nurse, midwife &health visitor before entering the teaching profession. Barbara had designed ateaching resource for her sex ed lessons, a game that covers all the basic factsbut also gets teenagers to talk to each other about sexual health &relationships. Through my own experience of talking about sex & relationshipswith teenagers, I was aware that, despite the bravado, a lot of young peoplefound the topic uncomfortable in a formal teaching setting & my feeling was thatthere were many questions that never got asked & many scenarios that werenever explored. A game seemed like a really good way of dealing with anotoriously difficult subject area.When I started my MPHe in 2001, Barbara was well on the way with developing& marketing the Contraception boardgame commercially. I was interested tosee how educators would receive it but was also interested to know whatteenagers thought about it. Despite the quantity of research into teenagepregnancy, there is not that much information about what teenagers in thiscountry actually think about the teenage pregnancy problem or the variousstrategies, interventions & resources being used to try & help with this difficult 8
  9. 9. problem. I saw this project as an opportunity to add teenagers views to thedebate, at least in terms of this one resource. 9
  10. 10. IntroductionThe UK is widely quoted as having the highest rate of teenage pregnancy in 17, 23, 25 23Western Europe & is second only to the USA in the developed world(Table 1). In England there are nearly 90,000 teenage conceptions a year with 17, 18around 7,700 of these being to girls under 16 & 2,200 to girls under 14 .Within the UK, rates of teenage pregnancy vary widely, with much higher rates 23in underprivileged areas although even the most prosperous areas in the UKhave higher rates of teenage pregnancy than the national rates for the 25Netherlands and France . Those found to be at particularly high risk include,individuals who have been in care, those who have truanted from school, thosethat are from a large family or those that are themselves the children of teenagemothers 23.Table 1Under-20 birth rates worldwide: 1998 (most recent comparable year) 8KOREA GERMANY 2.9 13.1JAPAN AUSTRIA 4.6 14.0SWITZERLAND CZECH 5.5 16.4 REPUBLICNETHERLANDS 6.2 AUSTRALIA 18.4SWEDEN 6.5 IRELAND 18.7ITALY 6.6 POLAND 18.7SPAIN 7.9 CANADA 20.2DENMARK 8.1 PORTUGAL 21.2FINLAND 9.2 ICELAND 24.7FRANCE 9.3 HUNGARY 26.5 SLOVAK 26.9LUXEMBOURG 9.7 REPUBLICBELGIUM 9.9 NEW ZEALAND 29.8GREECE 11.8 UK 30.8NORWAY 12.4 USA 52.1Source: United Nations Childrens Fund, Innocenti Research Centre 2001Rate per thousand females aged 15-19,Although there was a rise in conceptions in the under 16 age group between 142004 & 2005 (Figure 1) , the under 16 conception rate for England in 2005was 7.7 per 1000 girls which is 13.0% lower than the Teenage PregnancyStrategy’s 1998 baseline rate of 8.8 conceptions per 1000 (Figure 1) 14. 10
  11. 11. The under 18 conception rate for England also shows a rise between 2001 &2002 but the provisional 2006 rate of 40.4 per 1000 represents an overalldecline of 13.3% since the 1998 baseline (Figure 2).Figure 1Under-16 conception rate for England: 1998-2006 14 10.0 9.0 Under-16 conception rate 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 1998 1999 2000 2001 2002 2003 2004 2005 2006p YearSource: Office for National Statistics and Teenage Pregnancy Unit, 2008Rate per thousand females aged 13-15, 2006 data are provisionalFigure 2Under-18 conception rate for England: 1998-2006 14 48.0 46.0 Under-18 conception rate 44.0 42.0 40.0 38.0 36.0 34.0 32.0 30.0 1998 1999 2000 2001 2002 2003 2004 2005 2006p YearSource: Office for National Statistics and Teenage Pregnancy Unit, 2008Rate per thousand females aged 15-17, 2006 data are provisional 11
  12. 12. Although the figures show that, overall, the teenage pregnancy rate is slowlydeclining, the UK rate is still high compared to other countries (Table 1). Inaddition, the change in rate of teenage pregnancy is not uniform across thewhole of the country, with some areas seeing much more of a decline comparedto others, for example Oldham MCD (-32.8%) & Bolton MCD (-4%) & otherareas actually seeing varying degrees of increase, for example, Manchester 15MCD (9.8%) & Tameside MCD (1.4%), between 1998 & 2006 . Although theeffects of the Teenage Pregnancy Strategy appear to be encouraging in some 15 25areas of the country, based on these figures & other recent evidence , itseems unlikely that the government target of halving teenage conceptions by2010 will be met.The National Strategy For Sexual Health And HIV was published by theDepartment of Health in July 2001 & aims to improve sexual health in England.Sexual health promotion aims to reduce the transmission of STD’s & the rate ofunintended pregnancy by raising awareness of sexual health issues, providinginformation & education, developing services, improving skills & capacitybuilding in individuals & communities. A range of settings in which sexualhealth promotion takes place have been identified & these include schools &informal youth settings, along with many others. Sex & RelationshipsEducation (SRE) in both formal & informal education, along with peer education& education within youth & community groups are identified as appropriatemethodologies for sexual health promotion 24. 24The Department of Health Effective Sexual Health Promotion toolkit providessome evidence for the effectiveness of interventions to reduce teenagepregnancy & STD’s. It recommends targeted, participatory, school &community based education programmes that improve skills as well asincreasing knowledge as some effective ways of reducing high-risk sexualbehaviour & unwanted pregnancy.The Teenage Pregnancy Strategy for England (1999) aims to halve the under18 conception rate by 2010 & provide support to teenage parents to reduce thelong-term risk of social exclusion. The four main areas covered by the strategy 12
  13. 13. are media awareness, joined up action at a national & local level to ensure allrelevant partners are involved, improvements to SRE & access to contraception& sexual health services along with support for teenage parents to reduce theirlong term risk of social exclusion 17. 17Both the Teenage Pregnancy Report & the OFSTED Sex & RelationshipsEducation Report 2002 18 consider young peoples’ lack of knowledge about safesex, relationships & parenting as one reason why the teenage pregnancy rate isso high. For this reason, Sex and Relationships Education (SRE) is central tothe Governments Teenage Pregnancy Strategy & there are now very clearguidelines regarding this 16,18.The guidelines in Table 2 are taken from the UK Government Sex & 16Relationships Education Guidance & the Ofsted Sex & RelationshipsEducation Report 18.Table 2Sex & Relationships Education Guidance SRE in secondary schools should prepare young people for an adult life in which they can: Develop positive values and a moral framework that will guide their decisions, judgements and behaviour Be aware of their sexuality and understand human sexuality Understand the arguments for delaying sexual activity Understand the reasons for having protected sex Understand the consequences of their actions and behave responsibly within relationships Have the confidence and self-esteem to value themselves and others, & to have respect for individual conscience and the skills to judge what kind of relationships they want Communicate effectively Have sufficient information and skills to protect themselves and, where they have one, their partner, from unintended and unwanted conceptions, & sexually transmitted infections, including HIV Avoid being exploited or exploiting others Avoid being pressurised into having unwanted or unprotected sex Get confidential sexual health advice, support and, if necessary, treatment Know how the law applies to sexual relationships. 13
  14. 14. The Department for Education & Employment (DfEE) Sex & Relationships 16Education (SRE) Guidance 2000 goes on to state that the objective of sexand relationship education is to help & support young people through theirphysical, emotional and moral development & that a successful SREprogramme will help young people learn to respect themselves & others & movewith confidence from childhood through adolescence & into adulthoodThe following summary of SRE requirements in the UK is taken from a FamilyPlanning Association report on young people’s views of sex and relationships 11. “In England the mandatory elements of SRE in schools are primarily contained within the National Curriculum Science Order, which covers human biology & reproduction. In addition, secondary schools are required to provide an SRE programme that includes, as a minimum, information about HIV/AIDS & sexually transmitted infections. Beyond this, each school is free to determine its own SRE policy, for which direction is given in guidance issued by the Department for Education and Employment (DfEE), now known as the Department for Children, Schools & Families (DCSF). Under the Education Act 2002, all maintained schools in Wales must provide a Basic Curriculum in addition to the National Curriculum for Wales. This includes a requirement to provide SRE in all maintained secondary schools & for all young people of secondary school age in maintained special schools. In September 2003, personal & social education (PSE) was added to the Basic Curriculum for all maintained primary & secondary schools. In Scotland, there is no statutory requirement to teach SRE in schools. The Scottish Executive’s policy is to encourage schools to provide SRE within a comprehensive programme of personal, social & health education & religious & moral education”. In Northern Ireland in September 2007, a new learning area was introduced called Personal 14
  15. 15. Development and Mutual Understanding (PDMU) in primary schools, and this develops into Learning for Life and Work (LLW) in post-primary schools6. The key concepts of personal development are self- awareness, personal health and relationships, supplemented with home and family life and independent living in home economics. Consequently RSE is now a statutory component of personal development and home economics as well as the science curriculum.”The Contraception Board Game is an interactive teaching resource, developed 16,18in line with the Governments Sex & Relationship Education Guidelines but 7also in consultation with young people . It was first produced commercially byContraception Education in 2001 & since then, it has been purchased by 10schools, youth groups, social services & other young peoples centres both inthe UK & various countries worldwide.The following feedback (Table 3) relating to the Contraception game has been 7collected by Contraception Education & is displayed on their website or 10through a presentation made at Salford University by Barbara HastingsAsatourian, who developed the game. Despite the weight of evidencesupporting SRE & clear Government guidelines relating to SRE in the UK, therestill seems to be differing opinions as to what is or is not appropriate oreffective. 15
  16. 16. Table 3Feedback Relating to The Contraception Boardgame 7,10 Feedback from young people who have played the game: "Fun to play and very informative" "It gave a lot of information and involved everybody" "Interesting because it was full of information and had a lot of things to do" “Don’t like board games – boring” “Needs more on personal relationships” Feedback from teachers who have used the game: “ …very well received indeed by the students in year 10 & 11….Our local health visitors have been much impressed by them. The game is far & away the best material I have ever used with young people” “The general consensus..praise, at last a fun, relaxed & INTERESTING tool for teaching PSD” “I was horrified to see reference to “methods of contraception ranging from abstinence to abortion” – whilst I agree that the issue of abortion needs to be discussed in SRE, to present it as a method of contraception is totally unacceptable.” Feedback from various opponents of the game: “I was saddened to see your boardgame which will not help our youngsters at all as it promotes the same “safe sex” myth which has dismally failed for the past 30 years resulting in this countries depressive state of high teen pregnancy & abortion rates & spiralling STI’s” “This game is just corrupting. The idea is for children to work their way around a board, using counters in the shape of different contraceptives. In any other setting an adult who asked children to play a game like this would be arrested.” 16
  17. 17. The Research QuestionWill playing the Contraception boardgame help or encourage teenagers topractice safe sex in the future?Safe sex is a broad term but for the purpose of this study, it involves anindividual having the knowledge & skills to practice or negotiate protected sex,involving the use of an inclusive barrier, for example using a condom orfemidom, in order to reduce the risk of pregnancy & STD’s.As a group identified as being at high risk of unwanted pregnancy & STD’s, theviews of teenagers, from low socioeconomic &/or educational backgrounds areof particular interest.Qualitative data will be collected from direct observation of groups of teenagersplaying the Contraception boardgame, from focus group discussions & fromindividual interviews. Participants will be asked questions as to what, ifanything, they have learnt or gained from playing the game & whether they maychange their behaviour as a result. 17
  18. 18. The Aims & Objectives Of The StudyTo investigate how the Contraception boardgame influences teenagers’knowledge, skills & behaviour towards sexual relationships.KnowledgeTo investigate what has been learnt about contraceptive methods, how theywork & where they can be obtained.To investigate what has been learnt about sexually transmitted diseases, howthey are transmitted & ways of avoiding them.SkillsTo investigate what has been learnt about the effective use of contraceptives.To investigate what has been learnt about negotiating skills that could helpindividuals avoid unwanted sex.BehaviourTo investigate if playing the game will have any influence on future safe sexualbehaviour.The vision for the research is to provide more evidence to guide policy &practice for the implementation of SRE with teenagers from low socioeconomic&/or educational backgrounds. I am also hoping that this will be a usefulevaluation of the Contraception game that will be of use for its furtherdevelopment. 18
  19. 19. The Contraception BoardgameThe game comes with a comprehensive instruction booklet covering all theinformation required to facilitate the game. The booklet covers all the differentcontraceptive methods, how they work as well as the advantages &disadvantages of each. It also provides answers & guidance for the question &discussion cards, along with instructions on how to play the game, thefacilitator’s role & some game management strategies. The followinginformation is taken from the Contraception information booklet 5 & gives somebackground to the game. The booklet also highlights the crucial role played bythe facilitator in terms of the range of skills & the knowledge required tosuccessfully manage the game.Setting up the Game (see Figure 3)The board consists of 7 hexagons (1) & is opened out onto a large table or floorspace. Up to 6 people can play. Each player chooses one of the hexagons &sits next to it.The card carousel (2) is placed in the central hexagon. Several condoms areplaced under the card carousel around the condom demonstrator (3). Safe (4),Risk (5) & question (6) cards are then positioned on the card carousel. 19
  20. 20. Six plastic resource centre card holders: A&E (7), Pharmacy (8), Doctor (9),Family Planning / Young Person Clinic (10), Condom Machine (11) & GUM (12)are positioned on the circles (13) around the carousel. The matching resourcecentre cards (14) are then placed on the holders.Figure 3Setting Up The Contraception Boardgame 20
  21. 21. Each player takes a players card holder (15) & places it by the nearest hexagon(16) to where they are sitting. Players then choose a miniature contraceptiveboard piece (17) & place it on the “safe” space (18) in their nearest hexagon.Players are now ready to start playing the game.Rules of the GameThe objective of the game is to gather up one card from each of the resourcecentres. These cards have been designed to be taken away & to be kept /used by the players for future information.The player with the highest score of the dice goes first.The order of play follows in a clockwise direction for the remaining 5 players.Players throw dice & can move their contraceptives around the board in eitherclockwise or anticlockwise direction from their start position. Players start fromthe Safe place on the nearest hexagon to them.Players will land on one of 4 types of space – Safe, Risk, Question or WaitHere. Players will pick up the Safe, Risk or Question card, read its informationor instruction, complete a task or activity, or discuss the issue raised. 21
  22. 22. The card activities & discussion takes time, as it is here where most of thesharing of information & learning takes place.Figure 4The Choices Panel CHOICES 1. I can openly express myself without fear or embarrassment. 2. I can say “yes” or “no” for myself, without pressure from anyone. 3. I can make my own mistakes & learn for myself. 4. I do not depend on the approval of others. 5. I am responsible for myself & my own actions. 6. I am no greater or lesser person than anyone. 7. I can ask for outside help without fear or ridicule. 8. I can choose to keep private things to myself.The choices panel (Figure 4) outlines an individuals rights to be respected,treated as an equal partner & to be free to choose any activity for themselves.There are clear choices about how individuals express sexuality & choices to bemade about the nature of sexual activities between willing partners.The choices panel is incorporated into the game, when opportunities fordiscussion arise from the statements & scenarios on the Safe & Risk cards.Players are asked to consider & discuss the most appropriate choice & read itout to their peers.Play moves on to the next person when the card activity has finished. 22
  23. 23. Players who land on the Wait Here space will pick up a resource centre card ontheir next turn.In theory, the game finishes when the first person has gathered all six cards.The Facilitators RoleFacilitators for the Contraception game will come from a variety of education,health or social care settings. They may be fully qualified professionals,teachers, nurses & midwives with community, school health or family planningexpertise, youth & community workers or peer educators.Some preparation for the role of facilitator is essential. How much will dependon the individuals background.The level facilitator involvement with the game (whether the facilitator isintegrated into the group as a player or acts as a separate resource) will dependon: • The relationship of the facilitator with the group (& possibly parents / carers) • Wishes of the group • Literacy skills of the group members • Setting of the session (recreational or formal) • Facilitator / player ratio • Fine motor & visual skills of the playersThe Contraception Game Facilitators Notes also contain information & guidancerelating to: • Using the board graphics • Pregnancy, safe sex & sexually transmitted diseases. • Methods of contraception work & how they work • Answers / discussion for the question cards. 23
  24. 24. Literature ReviewThere is a large amount of literature available relating to teenage pregnancyboth in the UK & worldwide. The literature covers a wide range of issues &includes evaluations of interventions to reduce teenage pregnancy along withsuggested good practice, as well as various statistics relating to teenagepregnancy. There is not, however, any literature specifically relating to the useof boardgames in SRE.The literature review for this study involved a search of the following databases: • TRIP & Medline to ensure a thorough search of the available evidence • Web of Science to search a more diverse range of evidence • Google to search for any other credible sources of informationThe concepts of interest for the search were: • Teenage pregnancy statistics. • Interventions to reduce teenage pregnancy & evidence for their effectiveness • General information relating to sex & relationships education & its effectiveness.There is conflicting evidence relating to how well informed young people areabout sexual health, contraception & the underlying reasons why they may or 12may not become pregnant. One study found that young women were notpoorly educated about contraception, the barriers to them using contraceptionconsistently were indifference to pregnancy & the belief that they could not or 21would not become pregnant. Another study , however, found that girls hadonly sketchy knowledge regarding contraception & did not recognise when theirinformation was incomplete or wrong.Many young people are highly critical of SRE in schools & have difficulty 11communicating about issues relating to sex & relationships but the Teenage 13Pregnancy Strategy Evaluation Annual Report Synthesis No 1 (2001) statesthat nearly 9 out of 10 parents, and as many young people, believe SRE “helps 24
  25. 25. make people more responsible about sex” 13. UK Government SRE guidance16 identifies sex & relationship education as lifelong learning about physical,moral & emotional development. It includes attitudes & values, personal &social skills, knowledge & understanding as key elements.APAUSE (Added Power and Understanding in Sex Education) is a SREprogramme, developed by the Department of Child Health at the University ofExeter. It aims to: increase tolerance, respect & understanding; enhanceknowledge of risks & counteract myths; provide effective skills to those whowish to resist unwelcome pressure; & improve effective contraceptive useamong teenagers who are already sexually active. In 2003, 135 schools(across 16 LEAs) were participating in the APAUSE programme. An evaluation 9of the programme showed that APAUSE was highly valued for theinvolvement of peer educators & health professionals. Where it worked well,the peer education element was considered to be very powerful & thecombination of the health professionals’ expertise & the teachers’ classroomskills in co-teaching sessions was considered a real advantage. When askedabout the most helpful aspects of the programme, the involvement of healthprofessionals was the most frequent response 9.The APAUSE programme was found to have a positive effect on students’knowledge of contraception and STD’s & those involved in the programme hada more mature & responsible attitude towards sex than students in comparisonschools. The 2003 Year 11 data showed that there was a small but significantdifference in reported sexual activity with APAUSE students being less likely tobe sexually active than comparison students. There were also tentative linksbetween APAUSE and the reported use of contraception & students whoreported having been taught about assertiveness skills were less likely to havehad unprotected sex. The majority of interviewees & survey respondents gavepositive feedback about the programme & data from the programme providedevidence of a positive impact on young people’s knowledge and attitudes 9.Another aspect to the APAUSE evaluation was to assess to what extent itconformed to recommended good practice in SRE, in particular that 25
  26. 26. recommended by the DfES. On the whole, the evaluation showed that theprogramme did, or mostly did, conform to the guidelines & as already statedwas, on the whole, well received & was starting to show some positive effects.One of the major positives about the programme was the involvement of healthprofessionals alongside teachers & the key role played by peer educators. Thesuccess of these elements though, was very directly dependant on how wellprepared the sessions were & the training of the individuals involved, poorlyprepared sessions presented by individuals with insufficient training were, notsurprisingly, poorly received 9.The 2005 Teenage Pregnancy Strategy Evaluation Report Summary 20 “affirms the importance of school SRE as a source of learning about sex for young people, including those from deprived areas.” 20but acknowledges that “further work is needed to ensure that young people are well informed about sexual matters including contraception.” 20Despite a positive association between the total number of school SRE lessonsreceived & a reduced likelihood of pregnancy, many young people still feel thatSRE is received too late. “The status, & thereby the quality, of SRE could be improved by making high quality PSHE mandatory within the National Curriculum” 20This would bring England in line with other European countries that have hadmuch lower rates of teenage pregnancy. 20This evaluation of the UK teenage pregnancy strategy recognizes that: “Changing sexual attitudes and behaviour is a challenging task that takes time.” 20But, goes on to say that 26
  27. 27. “Experience from other European countries, where teenage pregnancy has fallen steadily since the 1970s, reminds us that behaviour change over the long term is an achievable goal.” 20 26A systematic review of traditional primary prevention strategies , such as sexeducation and contraceptive services, reports that none of the strategiesevaluated were effective in reducing the number of pregnancies among youngwomen. It suggests that adolescent sexual behaviour is not well understood &the idea that simply increasing young peoples knowledge of contraception cansolve the teenage pregnancy problem is misguided. Although knowledge &understanding about sex & access to good sexual health and contraceptiveservices may be important, there is no evidence to suggest that they aresufficient on their own. In contrast to this, a report produced by the Family 11Planning Association states that “evidence consistently shows that highquality SRE can lead to young people starting to have sex later & helps toreduce teenage pregnancy rates & the rate of sexually transmitted infections”.It does go on to say, however, that the SRE provided in schools is variable incontent & quality & that young people feel it is too little, too late & too biological. 11The Family planning Association report also identifies the power of peergroup pressure & misconceptions about the sexual behaviour of peers asfactors that influence teenage sexual behaviour. “There are huge pressures to conform to a societal norm & the need to conform is particularly strong during adolescence. Young people often experience pressure to become sexually active & also have misconceptions about the sexual behaviour of their peers – many believe that their peers are more experienced at a younger age than is actually the case”. 11So, although improvements in sex education generally would help, teenagepregnancy is clearly not just an educational issue, it is also a matter of socialnorms & expectations & is more complex 26. 27
  28. 28. A meta-analysis to assess the effectiveness of primary prevention strategies for 30adolescent pregnancy included data from community & school basedprogrammes along with clinic & non-clinic based programmes. It concluded thatprevention programmes have no effect on the sexual activity of adolescentsalthough some programmes can increase the use of contraceptives & so, tosome extent, can reduce pregnancy rates. The authors state that furtherresearch is required to identify the most effective community basedprogrammes, to explore ways of teaching responsible sexual behaviour toyoung men & to examine the effectiveness of various approaches for theyounger age group.A systematic synthesis of research evidence relating to teenage pregnancy & 25social exclusion categorised the factors affecting teenage pregnancy asindividual factors, including knowledge, self-esteem & age at first intercourse,family factors, including communication, family structure, history of mother orsister being pregnant as a teenager & children in care, educational factors,including provision of sex education, truancy & lack of qualifications, communityfactors, including social norms relating to sexual activity, peer & mediainfluences & finally, social factors, including childhood poverty, employmentprospects & housing. Not surprisingly, the relationship between these factorsis complex, with previous reviews of the effects of sex education & sexualhealth promotion having shown mixed results. 25This review showed that interventions that aimed to reduce unintendedteenage pregnancy by attempting to improve young people’s education,training, employment & career prospects, or financial circumstances fell into twocategories, early childhood interventions aimed at preschool & primary schoolaged children & youth development programmes aimed at improving social &academic development among young people aged 11 to 18. All the studiesworked with young people defined as being at ‘high risk’ of experiencingteenage pregnancy or other problem behaviours. Meta analysis of the studyfindings showed that both categories of intervention could reduce teenage 11pregnancy rates. There is other research that also supports effective SRE 28
  29. 29. being initiated early, before adolescents have established patterns of sexualbehaviour. 25Studies included in the review that reported on the views & experiences ofyoung people on the role of education, training, employment, careers, &financial circumstances in unintended teenage pregnancy included participants,mainly women, from a wide variety of backgrounds. Common themes wereidentified across all the studies, with a dislike of school & unhappiness, ratherthan poverty, being key aspects of young parents’ lives. The desire for loving& secure relationships meant that some women wanted to start a family as soonas possible with a baby providing the opportunity for them to give & receive love& affection. Not all teenage mothers, however, had grown up unhappy, somehad positive experiences of family life themselves & had planned theirpregnancy, while others had wanted to have babies young & were lookingforward to still being young when their children were older. 25The same review also found different aspirations among teenage mothers &women who became mothers later in life. Teenage mothers had, on the whole,wanted to leave school as soon as possible & get a job while those whobecame parents later in life expected, from a young age, to go to university & totravel. 27These results were corroborated by another study that also showed youngpeople from socioeconomically disadvantaged & advantaged backgrounds havedifferent attitudes towards adolescent pregnancy & contraception. Youngwomen from disadvantaged backgrounds thought that the ideal age for startinga family was 17-25 years, whereas women from advantaged backgroundswanted to wait until their late 20’s or early 30’s to start a family. The study alsofound that contraceptive use was influenced by how women felt about theirrelationship particularly with young women from disadvantaged backgrounds,who were setting contraception aside in relationships they perceived to bestable & long term. 29
  30. 30. Socioeconomic background again appears to affect participants experience &perspective, with study participants from young mothers groups, having becomesexually active at a young age, feeling that sex education was provided too late& did not explain enough about contraception or the emotional aspects ofsexual relationships or pregnancy. They felt they were poorly informed aboutcontraception & health & had used contraception ineffectively. Young womenfrom advantaged backgrounds, however, were generally better informed & morelikely to use emergency contraception in high risk situations, rather than thosefrom disadvantaged groups who tended to just ” wait & see” 27.In contrast to other studies that report a recent increase in under 16 25conceptions , the 2005 Teenage Pregnancy Strategy Evaluation ReportSummary states that during the first four years of the Strategy, conception ratesfor women in England aged under 18 have fallen. There was a 9% fall in under18 conceptions by 2002, compared with the 1998 baseline for the strategy & 20with a higher rate of decline being seen in deprived areas . This report alsomakes a strong link between social deprivation, low educational achievement &high rates of teenage pregnancy & identifies the “underlying socio-economicdeterminants of teenage pregnancy” as being in need of further attention 20.In the USA, comprehensive sex education curricula, aiming to improvecontraceptive use & modify high-risk behaviours associated with pregnancy &STD’s, present abstinence as the most effective method of prevention (althoughthere is no evidence that abstinence only programmes reduce rates of 28intercourse or pregnancy ) but also discuss contraception as an appropriatestrategy for individuals who are sexually active. These types of programmes 28have been shown to significantly improve their desired outcomes .Successful programmes were found to vary in their approach but had someimportant common features (see Table 4). 30
  31. 31. Table 4Common Features of Successful ProgrammesSuccessful Programmes:• Focussed on reducing high-risk behaviours• Presented accurate, age appropriate & culturally sensitive information about the risks associated with unprotected sexual activity, use of contraceptives, strategies for preventing pregnancy & STD’s.• Actively involved all participants & allowed adequate time for interactive exchange.• Taught the communication skills necessary to avoid the social pressures that may influence sexual activity.• Applied theoretical models that have been proved effective for changing high-risk behaviours.Another review of school-based programs to reduce high risk sexual behaviours29 identified some similar common features of programmes that effectivelydelayed the onset of intercourse, increased the use of condoms orcontraception & reduced sexual risk behaviours in adolescents. As well asfocusing on reducing high-risk behaviours that may lead to unintendedpregnancy or contraction of an STD, these programmes also provided accurateinformation about the risks of unprotected sex & suggested strategies foravoiding this. The programmes considered social or media influences onsexual behaviours, gave clear and appropriate values to strengthen individual &group norms against unprotected sex & provided models for & opportunity topractice communication and negotiation skills 29.Physicians in the USA are recommended to engage young people in open, non-judgemental & confidential discussions that should include complete & accurate 28information on responsible sexual behaviour . There is a suggested modelfor talking to teenagers about responsible sexual behaviour that involvesengaging adolescents in confidential, open & non-judgemental discussions,independent of caregivers, about sexual behaviours & concerns. Adolescentsshould be asked & advised about contraception & the prevention of STD’s aswell as about their relationship with their parents & about their views on dating &sexual activity. Discussing common misconceptions, possible side effects &benefits of various contraceptives in simple, age-appropriate terms mayimprove the adherence of the subject to a chosen contraceptive plan. 31
  32. 32. Physicians are also advised to educate all sexually active adolescents aboutemergency contraception, emphasising that this is an emergency option & thatit offers no protection against STD’s. 28A review of pregnancy prevention strategies for adolescents in the USArecommends that prevention of pregnancy & prevention of sexually transmitteddiseases should be linked when counselling sexually active teenagers; it alsorecommends that condom use should be encouraged in all sexually activeteenagers, regardless of whether another contraceptive method is used.Regarding the position in the UK, the Family Planning Association firmly believethat currently, young peoples opinions are missing from the sex & relationshipsdebate & conclude from their own research 11 that: “In order to develop a responsible & considered approach to sex & relationships, young people want & need more & better information, advice & guidance. Clearly, focusing on scare stories & the negative aspects of sex is a real turn-off, & doesn’t equip young people with either the skills or the knowledge to negotiate relationships in the real world. Collectively, parents, schools & wider society need to stop being afraid of talking about sex & relationships & start being honest with young people”. 11The literature highlights that there are some differences of opinion & grey areasregarding which interventions are effective & what the wider measures are thatneed to be taken in order to reduce the rate of teenage pregnancy in the UK.There does, however, seem to be some consensus that there is a need formore research in this area & teenagers’ views on a range of relevant issuesneed to be considered. 32
  33. 33. Methodology 19Qualitative research methods provide insight into individuals opinions , so arean appropriate way of investigating if, how or why using the ContraceptionBoardgame as a sex & relationships education tool, could influence theknowledge, skills & behaviour of teenagers. Qualitative methods will alsoallow current knowledge, skills & sexual behaviour to be investigated. 2,4,6Purposeful or discriminate sampling was used to deliberately selectsubjects who were relevant to the research question, rather than a random orrepresentative sample. Youth Inclusion Programmes (YIP’s) operate in 114 ofthe most deprived neighbourhoods in England and Wales. They target youngpeople in a neighbourhood who are considered to be at high risk of offendingbut are also open to other young people in the area. Young people on the YIPare identified through various agencies, including the police, family services,schools & anti-social behaviour teams. The programme gives young peoplesomewhere safe to go where they can learn new skills, take part in group 23activities & get educational support along with careers guidance . Iapproached the Youth Inclusion Programme in Tameside & explained thenature of my project. I offered to run a series of sex & relationships educationsessions, using the Contraception Boardgame at their drop in centre inStalybridge. I asked if they had any time available on the programme for thiskind of activity & if they had any young people who would be interested in, orwould benefit from, playing the Contraception boardgame & then talking aboutwhat they thought about the game, either as a group or one to one or both.The YIP co-ordinator was very helpful & extremely enthusiastic about theproject; he felt that there were a number of young people involved with the YIPin Stalybridge who would benefit from this kind of activity.After considering the time available for the study & investigating the availabilityof study groups through Tameside YIP, a sample of about 18 young peopleaged 16-18 was identified. Initially I arranged to run three game sessions with amaximum of 6 teenagers per session. It was not, however, possible to say fordefinite how many would actually attend each session until we were actually 33
  34. 34. there. For this kind of study, the sample size is ultimately determined by thedata collected; data analysis done concurrently with data collection identifies the 2,6point at which theme saturation (no new or conflicting data is produced)occurs. If more data was required for this study, there was the possibility ofarranging additional game sessions with other young peoples groups linked tothe YIP in Tameside.The study design involved the use of multiple methods of data collection toallow corroboration between sources. This method of data collection isreferred to as triangulation of data 3. Data was collected by: 1. Direct observation of groups playing the game for approximately 1 hour in their setting, 2. Group interviews (focus groups) lasting 30-40 minutes immediately following the game session 3. Semi-structured interviews with individuals from each group, immediately following the focus group session & lasting approximately 10 minutes.The use of observation to collect data meant that we were not relyingexclusively on the ability of subjects to express themselves verbally; we actuallywatched them play the game & saw what happened first hand rather than justasking them about it afterwards. Interviewing was preferred to writtenevaluation of the game to ensure that the writing & comprehension skills of theparticipants were not a barrier to some individuals providing evidence.Ethical approval for the project was sought through Tameside & Glossop LocalResearch Committee. The proposal was considered by the Chair, who advisedthat the project did not need to be subject to an ethical review (appendix 1), butadvised that I seek management approval for the project from my hostorganisation. As well as obtaining approval from the YIP co-ordinator, all theYIP participants had completed, either themselves if over 18 or by a parent ifunder 18, a general consent form (Appendix 3) to cover all activities covered bythe YIP & the use of photography. Although the project had been explained tothe participants by their YIP co-ordinator, a statement was read out by the game 34
  35. 35. facilitator at the start of each session to ensure that all the participants involvedfully understood the nature & purpose of the game sessions (appendix 2).The confidentiality of the study data was ensured by the discrete use & securestorage of all recorded information relating to the study. All the video & audiotapes were stored in a lockable office desk & were deleted once transcriptionwas complete. The process of transcribing both the video & audio recordingswas carried out in private, away from public view or using headphones. Allcontributions to the project have been anonymised both in the sessiontranscripts & this report.Phase 1 – Observation of The Game SessionsThis involved the systematic noting & recording of events, behaviours & objectsin the setting used for each study group 1. Due to the fact that there were onlytwo members of the research team & one of these was involved as the gamefacilitator, each game session was recorded, on video, so that detailed, non-judgmental descriptions of events, as the group played the game, could bewritten up later. The video camera was positioned in the room in order to be asunobtrusive as possible. The cameraperson was a passive observer & did notparticipate in the game session at all. Having a video recording of each sessionmeant it was possible to write a very accurate & complete description of thegame session after the event.The observation phase of the study provides: Verbal evidence of factual knowledge, opinions, attitudes, behaviour & skills in relation to sexual health. Visual evidence of attitudes through body language & group dynamics & also skills through demonstrations & role-play.Phase 2 - Group Interviews (Focus Groups)Focus group discussions followed on directly after each game session & wererecorded (audio only). The same six statements (Table 5) were discussed witheach group. The audio recordings were transcribed, word for word, after eachsession. 35
  36. 36. Table 5Focus Group & Interview Discussion StatementsStatement 1Playing Contraception has given me the confidence to talk about sex &relationshipsStatement 2Playing Contraception has not increased my knowledge of contraceptivemethods & how to get themStatement 3Playing Contraception has given me the knowledge & skills needed to avoidunwanted sex.Statement 4Playing Contraception has not made me more likely to practice safe sexStatement 5Playing Contraception has given me the knowledge & skills needed to negotiatesafe sexStatement 6Playing Contraception has not increased my knowledge of sexually transmitteddiseases or how to avoid catching themFocus groups provide breadth of information, which coupled with individualinterviews, allow verification of & clarification of any interpretations orconclusions drawn from observations 1. Compared to individual interviews,focus groups are socially orientated & therefore more natural & comfortable forthe participants 1. They are however, more difficult to control & require a skilledfacilitator to avoid digression 1. The role of the focus group facilitator was tocreate a supportive environment & provide statements or open questions toencourage discussion as well as the expression of opinions 1.Phase 3 - In Depth InterviewThe interviews were carried out in a semi-structured manner between oneinterviewer & one participant in a private location, away from the rest of thegroup. The interview structure was provided by using the same 6 statements(Table 5) as for the focus groups but interview subjects were allowed to &encouraged, where possible to elaborate on particular themes or aspects of the 36
  37. 37. discussion. As with the focus groups, these sessions were recorded (audioonly) & transcribed, word for word, after the session. The aim of the interviewswas to explore a few general topics, identified through the discussionstatements, but to allow the participant to structure the response.The most appropriate way of analysing the data collected from the three phases 12would be to identify themes . The Constant Comparative Method forAnalysing Qualitative Data combines inductive category coding with asimultaneous comparison of all units of meaning obtained (Table 6). As eachnew unit of meaning is selected for analysis it is compared to all other units ofmeaning & subsequently grouped (categorised & coded) with similar units ofmeaning. If there are no similar units of meaning, a new category is formed.In this process there is room for continuous refinement; initial categories arechanged, merged or omitted; new categories are generated; & newrelationships can be discovered 22.Table 6The Constant Comparative Method for Analysing Qualitative DataStep 1Inductive category coding & simultaneous comparing of units of meaning acrosscategories.Step 2Refinement of categoriesStep 3Exploration of relationships & patterns across categories.Step 4Integration of data yielding an understanding of people & settings being studied. 22Before it could be analysed, the data from each phase of the research needed 1,4to be accurately transcribed. In order to become very familiar with the datait was necessary to watch the video recordings of the game sessions, listen totapes of the group & individual interviews & read the data transcripts severaltimes. Transcribed data from different groups & individuals were given aparticular colour text. The coloured transcripts were then printed out, readthrough & physically ‘cut up’ in order to allocate sections of text to a category. 37
  38. 38. The categories were spread out across a table, with all the sections of textvisible. Similar sections of text were arranged next to each other; arranging thetext in this way made it possible to see when a sub theme was developingwithin a category. Initial interpretation of the data starts once coding isunderway; these ideas are then explored through the data as the analysisprogresses 1.Development of Categories (Table 7)The initial categories were developed through familiarity with the data. Itbecame apparent that most of the observations, behaviour & responses withinthe transcripts related to the participants knowledge (category 1), skills(category 2) or behaviour (category 3) in relation to various aspects of thegame. There were a few areas of the text that did not come under these broadheadings but they could initially be described as miscellaneous (category 4).Table 7Development of Categories Overview The initial categories were developed through familiarity with the data Refinement of categories Refinement of category title Development of rules for inclusion of data Further refinement of categories where requiredWorking initially with these four categories (Knowledge, Skills, Behaviour, Misc),it very quickly became possible to subdivide each of these (see Figure 5). 38
  39. 39. 39
  40. 40. Knowledge was subdivided into knowledge relating to: • Contraceptive methods • Sexually transmitted diseases • Sexual health servicesSkills was subdivided into: • Negotiating skills • Ability to play the gameBehaviour was subdivided into: • Behaviour relating to practicing safe sex • Behaviour relating to playing the gameBy subdividing the initial categories, it was possible to fit some of themiscellaneous responses into one of the already defined categories. Anothercategory was also formed from the remaining miscellaneous responses, wherethe responses had a similar theme. The new category related to attitudes toplaying the game.Further consideration of the sections of text allocated to each category alloweda more specific category title to be developed. For example, ‘Negotiating Skills’became ’Talking About Sex & Dealing With Pressure To Have Unwanted OrUnsafe Sex’A definition (rules for inclusion) of the information included in each category wasalso developed & the responses within each category were then checkedagainst the definition & reassigned if necessary. As a result of this, two furthercategories were added, where it became apparent that the several responsesaddressed specific areas.• Knowledge relating to Contraceptive methods was divided into:• Knowledge relating to different methods of contraception & how to use them effectively. 40
  41. 41. • Knowledge relating to how & where different contraceptives can be obtained.• Knowledge relating to Sexually transmitted diseases was divided into:• Knowledge relating to sexually transmitted diseases & how they are transmitted.• Knowledge relating to how to protect against sexually transmitted diseases.The final categories developed were as follows:Behaviour1. I am more / less likely to practice safe sexRule For InclusionSubjects indicate through observation, discussion or responses to questionsthat their likelihood of practicing safe sex either had or had not changed as aresult of playing the game.2. Willingness to play the game.Rule For InclusionObservations that relate to the subjects’ willingness to participate in the game &how the game facilitator manages this.Knowledge1. Knowledge relating to different methods of contraception & how to usethem effectivelyRule For InclusionSubjects indicate through observation, discussion or responses to questionsthat they have gained, or already had, knowledge or skills relating to theeffective use of various contraceptive methods. 41
  42. 42. 2. Knowledge relating to how & where different contraceptives can beobtained.Rule For InclusionSubjects indicate through observation, discussion or responses to questionsthat they have gained, or already had, knowledge relating to how & where theycan obtain various contraceptives.3. Knowledge relating to Sexually transmitted diseases & how they aretransmitted.Rule For InclusionSubjects indicate through observation, discussion or responses to questionsthat they have gained, or already had, knowledge, about various sexuallytransmitted diseases & how they are transmitted.4. Knowledge relating to how to protect against sexually transmitteddiseases.Rule For InclusionSubjects indicate through observation, discussion or responses to questionsthat they have gained, or already had, knowledge about how to avoid catchingSTD’s.5. Knowledge about different sexual health servicesRule For InclusionSubjects indicate through observation, discussion or responses to questionsthat they have gained, or already had, knowledge about what different sexualhealth services do & how they can access or locate them. 42
  43. 43. Skills1. Talking about sex & dealing with pressure to have unwanted or unsafesex.Rule For InclusionSubjects indicate through observation, discussion or responses to questions,that they have gained, or already had, knowledge or skills that could help themtalk about sex & / or have thought about how they could deal with varioussituations involving sex.2. Ability to play the game.Rule For InclusionObservations that relate to the subjects’ ability to participate in the game & theinvolvement of the game facilitator..Attitudes1. Playing Contraception was a good / bad learning experience.Rule For InclusionSubjects expressed an opinion relating to whether playing contraception was /wasn’t an effective way to learn about sexual health & relationships.MiscellaneousRule For InclusionSubjects expressed an opinion or made a comment that does not fit into anyother category. 43
  44. 44. ResultsThe Role of the FacilitatorThe game facilitator played an essential part in the success & management ofeach of the game sessions. One group were able to play the game withminimal assistance but in the other two groups the facilitator was very involved,initially, to guide each subject through their turn. “Boy B not sure what to do so Barbara talks him through his turn.” (Observation group 2) “Barbara talks him through his turn, what to do & the knowledge / information required to complete that task” (Observation Group 1)She was also involved in prompting & guiding group discussion & providinginformation & explanations relating to the different questions or tasks requiredby the game. “Barbara involved in each turn, guiding discussion, asking questions & ensuring that all three players are involved.” (Observation group 1)The facilitator’s role reduced as the game progressed & subjects became moreconfident in terms of what to do & the information they needed to give. “Everyone now comfortable to be involved, all contributing to discussion with much less prompting from Barbara. All topics / situations come up again, all players quickly provide answers.” (Observation group 1) “Game now moving much quicker, each player confident with what to do for their turn” (Observation Group 1) 44
  45. 45. Most of the participants were willing to play the game, however, two groups hadone disruptive or disinterested subject. “One member of the group is trying to disrupt but others are all on task.” (Observation group 3) “Girl ‘A’ is texting & not engaged in the game.” (Observation group 2)The game facilitator attempted to accommodate these individuals & keep theminvolved in the game. “’A’ decides to ’sort of’ play, Barbara says she’ll do all ‘action’ if required.” (Observation group 2) “’A’ prepared to contribute to impersonal or factual but not personal discussions e.g. negotiation etc.” (Observation group 2)Once the game had been going for some time, the apparently disinterestedsubject decided to join in properly. “‘A’ happy to join in, everyone joins in discussion about card (to do with whose responsibility contraception is, boy or girl). All valid / constructive comments.” Observation group 2After a few more turns, however, this participant decides to sit out again &eventually leaves completely. “Girl A says she’s not playing now, Barbara says she can observe no problem.” (Observation group 2)The facilitator was unable to engage the disruptive subject so he was asked tosit out of the session. 45
  46. 46. “Disruptive boy sits out; group now working much better, everyone playing looks involved / interested” (Observation group 3)Apart from these two, all three groups had a comfortable atmosphere with allremaining subjects contributing to the game. “Atmosphere still relaxed, some jokes mixed in with serious discussion but tone is ‘on task’ & constructive” (Observation group 2)Knowledge & Attitudes Towards ContraceptionAll of the game sessions involved discussion about the different contraceptivemethods available with subjects asking questions & wanting explanations aboutmethods that they had not seen before or heard about.Two subjects indicated that they had not heard of Intra Uterine Device (IUD)before; the game facilitator explained how these work & how they are fitted.There was a similar discussion about the diaphragm, again, with the gamefacilitator explaining how these work, along with how they are used & fitted.There was discussion about the risks of using a diaphragm that does not fitproperly & two subjects said that they had learnt about using spermicide creamwith the diaphragm to provide better protection against pregnancy. “Next turn about diaphragm, this time player able to explain all details.” (Observation Group 3)The use of spermicide creams & pessarries stimulated further discussion, withthe game facilitator explaining how these work & are used with other barriermethods of contraception to increase their effectiveness; three subjectsidentified spermicides as being something new that they had learnt about. “Spermicide, I didn’t even know there was a thing called that” (Interview 1) 46
  47. 47. There was discussion of withdrawal as method of contraception, again, with thegame facilitator explaining how this works & why it is a very unreliable methodto use.All the game sessions involved subjects using the condom demonstrator.Initially, the game facilitator was involved in ‘talking subjects through’ thedemonstrations but as the game progressed, the other subjects, rather than thefacilitator, provided feedback on the demonstrations. There was only onesubject who would not participate in the demonstration but this subject washappy to contribute feedback while others were demonstrating. “B gets condom demonstrator, good, knew what to do. Barbara asks about what makes condom burst – everyone gives answers.” (Observation Group 2)There was discussion about the femidom & how it is used; one subject said thatthey had not seen a femidom before. In one group, this discussion progressedonto what could be done if partners could not agree about which contraceptivemethod to use & the possibility of using more than one method of contraception,for example, using a femidom & something else.One subject said they already new about emergency contraception but severalothers said that although they had heard the term they didn’t know much aboutit. The game facilitator explained about the morning after pill & how it is used. “Next turn about emergency contraception, group have heard of it but don’t know much about how it works” (observation group 3)Six subjects had not heard about contraceptive injections or implants. Interviewer: “Are there any methods of contraception that you didn’t know about before?” Subject: “The injection thing” 47
  48. 48. Interviewer: “What about the others” Subject: “The women’s condoms” (Focus Group 3)Eight subjects said that they had increased their knowledge of the differentcontraceptive methods available. “I’ve learnt that there’s more contraception than I realised” (Interview 1) “The board pieces are all different contraceptives. It shows you all the different types you can get” (Focus Group 2) “I can tell my partner that there’s other methods than just taking the pill. Most girls don’t like taking the pill. There’s Femidoms, there’s loads of different methods she could try.” (Focus Group 2)Discussion of the contraceptives available lead onto further discussionregarding which were prescription & non-prescription, along with the differentplaces, medical & non-medical, where contraceptives could be obtained.Subjects were particularly interested where contraceptives could be obtained inthe local area.There was a discussion about where condoms could be obtained; where theycould get contraceptives without having to ask someone face to face was ofparticular interest. Four subjects said that they had not known that they couldget contraceptives without going to the Doctor; they did not realise that theycould get contraceptives in shops & supermarkets. “I knew you could get them from the pharmacy but I didn’t think about shops” (Interview 6) 48
  49. 49. “I didn’t know you could get it from Boots. I knew you could get it from the Doctors but I didn’t know about named shops like Boots.” (Interview 4)One subject indicated that they had learnt about where to get femidoms from, &three subjects indicated that they had learnt more about where to getcontraceptives generally. One subject said that they already knew about all thedifferent places that contraceptives could be obtained.Knowledge & Attitudes Concerning Sexually Transmitted DiseasesThere was a lot of interest in the subject of sexually transmitted diseases, howthey were passed between individuals & how they could protect themselvesfrom becoming infected. One subject indicated that they had learnt that somediseases could be transmitted through other types of sexual contact, not justintercourse, & depending on the disease, could be contracted through lesions &cuts on different parts of the body. The game facilitator explained about dentaldams & finger cots & how they can protect against transmission of STD’s; noneof the game participants had heard of these before. Two subjects indicatedthat they already had some knowledge of STD’s & how they are transmitted butwent onto say that they had learnt more through playing the game. Interviewer: “So have you learnt anything about STD’s today?” Subject: “Err, yeah but we already knew about some because we looked in some books.” ( Interview 6)Three subjects indicated that they had learnt a lot about STD’s generally & onesubject said specifically that they had learnt about how to avoid catching STD’s. “I didn’t even know about half of them” (Interview 3) “I’ve learnt most about this” (Interview 6) 49
  50. 50. Reflecting on some of the information they had covered earlier in the gamehelped to dispel some myths about which contraceptive methods do & don’tprotect against STD’s. Three subjects indicated they had found out that somemethods of contraception that they thought were protective against STD’sactually were not. Interviewer: “Has the game made you more aware of different diseases & how you catch them?” Subject: “Yeah, like some stuff doesn’t work” Interviewer: “OK, so it’s made you aware that some methods of contraception doesn’t protect you against disease?” Subject: “Yeah” (interview 2)Barrier methods of contraception were identified as an effective way ofprotecting against STD’s with several subjects saying that they had not realisedthat some contraceptives could protect them against STD’s as well aspregnancy. “I didn’t know a condom could stop all those diseases” (Interview 4) “If I bought a condom, I just thought it would stop her getting pregnant but it could stop you getting a disease as well. I’d not though of that before.” (Focus Group 3)This topic of discussion lead to some interesting comments regarding futurecontraceptive use. Some subjects said that they would now think aboutprotecting themselves from disease as well as preventing unwanted pregnancyin sexual relationships. One subject indicated that they would now considerusing a condom to protect themselves against diseases whereas previouslythey would not have been prepared to use one. Another subject said that theyhad learnt that practicing safe sex reduced the chance of getting an STD &wasn’t just about preventing unwanted pregnancy. 50
  51. 51. Regarding the different sexual health services available, playing the game leadto some discussion about Genito Urinary Medicine (GUM) clinics & sexualhealth clinics. The game facilitator explained what GUM clinics do & onesubject asked about GUM clinics in the local area. One subject indicated thatthey already knew about sexual health clinics.“Next turn about GUM clinics – Barbara explains what happens here”(Observation Group 2)In terms of behaviour, two subjects indicated that they already practice safesex, although one of these subjects went on to say that if they were in asituation where no barrier contraception was available, they would have sex aslong as some form of contraception was available to protect against pregnancy. Interviewer “So you’d have unsafe sex then if you didn’t have an alternative?” Subject: “Yes” Interviewer “So there’s nothing about the game then that would stop you in that situation?” Subject: “No” (Interview 2)Seven subjects indicated that playing the game had increased the likelihood ofthem practicing safe sex & of these seven, five said that learning about sexuallytransmitted diseases was the reason why they were going to change theirbehaviour. “You can get STD’s, I didn’t even think about it” (Interview 4) “Yeah, diseases, you don’t want a disease do you?” (Focus Group 3) 51
  52. 52. Attitudes towards Sex & RelationshipsPlaying the game lead to discussion about how to deal with pressure to haveunwanted sex in various situations. “It’s made me more aware how pressure can get to you” (Focus Group 2) “Good discussion between boys about scenario – what to do if partner wanted to do something you didn’t like” (Observation Group 2)Several subjects said that playing the game would help them to avoid unwantedsex in the future. They commented that gaining knowledge would help them inthis situation; either using knowledge of STD’s as their argument not to haveunwanted or unsafe sex or through improved confidence in recognisingincorrect advice from others. One subject specifically said that the game hadgiven them more things they could talk about & things they could actually say tohelp them deal with unwanted or unsafe sex. “It just like, helps you, gives you things you can talk through.” (interview 1)Other comments were that they had learnt some more subtle ways of dealingwith unwanted sex & that the game had really made them think about what theywould say or do in that situation. “It makes you relate to how you would really handle it, how you would answer in that situation yourself.” (Focus group 2)Several subjects said that playing the game had given them more confidence totalk about sex & relationships with their partner or close friends. There weretwo subjects, however, that said they were already confident to talk about sex &relationships & the game had made no difference. Regarding how they woulddeal with pressure to have unwanted or unsafe sex, several subjects said thatthey would have no problem dealing with this, as they would ‘just say no’. 52
  53. 53. “Well it’s not really that hard to say no if you don’t want to is it” (Interview 3)One of these subjects, however, went on to say that they had gained knowledgefrom the game that would help them talk about why they didn’t want to havesex; they said knowledge of STD’s was something they could really use in thissituation. “I know more things so I could talk about it more” (Interview 5)Another of these subjects went on to say that gaining knowledge would make iteasier to say ‘no’ as they would be more confident they knew what they weretalking about.Overall the game was positively reviewed in terms of its value as an SREresource. “You feel more relaxed, if you play it as a game it opens you up more, it’s just easier.” (Focus Group 2) “It’s like you’re learning without knowing your learning, you think you’re playing, you’re taking in all the time” (Focus Group 2)One subject said that the Contraception game covered issues that they wouldcome across in life so it was good to think some of these through in advancerather than ‘learning the hard way’. “Better learning it now in something that we’ve enjoyed like a game than doing it later on & learning by the risks & regretting it” (Focus Group 2)Generally, it was felt that the game would be useful in school Sex Ed lessons &that the peer group discussion of issues relating to sexual health was betterthan a taught session. Even though one subject had found playing the game 53
  54. 54. boring, they said that they had learnt something from it & that it was better thanthe Sex Ed they had done at school. 54
  55. 55. DiscussionThis study suggests that young people are quite well informed about somecontraceptive methods (condoms & the pill) but not others (femidoms,contraceptive implants & injections, IUD’s the cap & use of spermicide) & thatthey are not aware that some contraceptives are widely available throughsupermarkets & the high street. The young people involved were not wellinformed about STD’s; they recognised a few names of diseases & associatedthem with having had sex but did not know specific information about thecauses or transmission of particular diseases. They were not aware that somebarrier methods of contraception could protect them from disease as well asunwanted pregnancy; they only associated condom use with prevention ofpregnancy. None of them were familiar with dental dams & finger cots & werenot aware that STD’s could be transmitted without actually having sexualintercourse. Most of the participants had heard of emergency contraceptionbut didn’t know much about how to use it or where it is available. This study 27supports other evidence that suggests emergency contraception is not widelyused within this socio-economic group but suggests that lack of knowledgeabout emergency contraception, rather than apathy is the reason for this.Playing the game had a positive effect on the participants’ knowledge ofdifferent contraceptive methods, how to use them effectively, where differentcontraceptives could be obtained & which methods would protect them againstdisease. Participants indicated that ‘knowledge is power’ & their increasedknowledge gave them confidence & would help them to negotiate safe sex oravoid unwanted sex in the future. 12, 21Previous studies have produced conflicting evidence as to whether youngpeople were or were not well informed about sexual health & contraception sothe evidence provided here provides some clarification. There was a verypositive response to the information about STD’s with most study participantsidentifying learning about sexually transmitted diseases & their prevention asmaking the greatest impact in terms of the likelihood of them practicing safe sexin future. Learning more about STD’s has given them a different perspective,with the need to protect themselves against disease being more influential than 55
  56. 56. preventing pregnancy, which has lead to a change in attitude towards 28contraception. There is other evidence that also recommends linkingpregnancy prevention & prevention of STD’s & that condom use should beencouraged for all sexually active young people.Regarding the success of the game sessions, in terms of participant’s ability &willingness to play the game, the role of the game facilitator is key. Initially, thefacilitator was very involved in each player’s turn & in all aspects of the game,the role reduced as the game progressed & players became more confident asthey became more familiar with the game format. It is essential that thefacilitator has the skills & knowledge to both answer questions & guidediscussion but also, crucially, be able to relate to the group & have the peoplemanagement skills required to create an appropriate atmosphere in which thegame can be played effectively. The study participants made positivecomments about the value of the game as an SRE resource, they liked therelaxed approach, the way that ‘real life’ situations & dilemmas wereincorporated & that they could discuss solutions to problems amongstthemselves rather than being ‘taught’.The game facilitator involved in the game sessions for this study had all thenecessary attributes along with an interest in sexual health, enthusiasm for thisgame & experience of working with groups of young people. It would beinteresting to see whether the game could work as well in a more typical SREsetting with perhaps a less knowledgeable facilitator who lacks the experience& motivation in this area. The game comes with extensive facilitator notes thatprovide the necessary knowledge to support the game. Although there isguidance regarding the role of the facilitator & some ground rules for managingthe game, it is obviously very difficult for a booklet to provide the facilitator withgroup management skills or attitude. Evidence from other interventionssuggests that, not surprisingly, SRE goes well when educators are wellprepared & specifically trained but can go equally badly when they are not 9.The decision to collect data through observation as well as group & individualinterviews worked well. Relying solely on conventional interviewing would have 56
  57. 57. provided very little information regarding the knowledge, skills & behaviour ofmany of the study subjects. The groups were, on the whole, comfortable withthe informal & relaxed atmosphere of playing the game & responded well to thegame facilitator who was able to involve, & therefore, extract responses fromnearly all the participants. Good atmosphere – everyone listening/contributing (Observation group 2) No prompting needed to get everyone involved (Observation group 2)Despite the efforts of the interviewers, the atmosphere was different during theinterviews & the groups or individuals involved did not respond as well. Therewere a few subjects who were happy to talk & give opinions but they tended todominate any discussion. More commonly, it was the interviewer that made astatement to try & summarise the little that had been said & the subjects eitheragreed or disagreed with this. Interviewer “So the diseases side of things has made you more interested in safer sex for yourself, is that what you are saying?” Subject “yeah” (Focus group 3)The majority of the information collected was from the observation stage of thestudy.LimitationsRegarding the overall design of the study, the collection of data through one toone interviews was not as productive as anticipated. The intention was that inthe interviews, subjects would expand on issues raised in the focus groups &have the opportunity to provide information that they may not feel comfortablegiving in a group situation. In reality, most of the interview subjects had very 57
  58. 58. little to say, forcing the interviewer to come up with summary statements thatthey could then either say yes or no to. The focus groups lead to somediscussion but the interviews provided very little information. On reflection,asking different questions in the individual interviews, or providing subjects withdifferent dilemmas to comment on, rather than just going through the focusgroup statements again, could have inspired them to talk more; as it was, theirattitude was very much that they’d already told us what they thought so whywere we asking them again.In terms of the methodology, the themes & categories for this study weredeveloped & constructed by a single researcher; analyst constructed typologiesare subjective & impose the researchers meaning on the data 1. Ideally, tworesearchers would develop the categories independently & the final list wouldbe formed by consensus. Theme saturation in the data occurred very quickly &the message appeared to be very clear; this was, however, a very small studywith only 3 game sessions being observed & a total of 16 participants involved(13 boys & 3 girls). Although participants were identified as male or femalethrough the observation of the game session, responses from the focus groupsessions & interviews were not identified in this way; the aim of the study was toinvestigate the views of young people & did not include a comparison of male &female responses. Some (but not all) of the participants had also taken part ina sexual health services secret shopping project & most of them had coveredsex & relationships education to some extent at school or as part of other youthdevelopment or support groups. These activities may have influenced theirattitudes, opinions & knowledge prior to taking part in the Contraception gamesessions.To encourage accurate & honest information from participants, we assuredthem that all the data collected would be confidential & presented anonymouslyin the final report. To try & create a productive atmosphere we emphasised theimportance of their contribution & our gratitude for them taking the time toparticipate. Reluctant participants were recorded in the data so any failure to 4obtain information was included . Because of limited resources & the timeavailable, it was not possible to invite the participants from the study to verify 58
  59. 59. that the transcripts for the game sessions, focus groups & interviews were anaccurate account of what actually happened & accurately reflected their pointsof view, so again, the researchers interpretation could have been imposed onthe data.We did manage, to some extent, to standardise the time spent on each focusgroup & individual interview, as only a set amount of time was available for thesessions. Although the game was played for a set length of time, the progressof each game session & the number of turns each player had varied accordingto how much discussion took place & how long particular tasks or scenarioslasted. All of the discussion statements were covered in each of the focusgroup & interview sessions but a set amount of time was not spent on each;some groups or individuals were more forthcoming with information generally &all had more or less to say on some subjects than others. Factors such astime, verbal expressiveness or repetitiveness may affect how often aphenomenon is observed & therefore how significant it appears to be throughmanifest analysis 4. 59