Contraception board game report

Contents Page
Abstract 5

Declaration & Copyright Statement 7

The Author 8

Introduction 10

The Research Question 17

Aims & Objectives 18

The Contraception Boardgame 19

Literature Review 24

Methodology 33

Results 44

Discussion 55

Conclusion 60

References 61

Word Count = 13,054

1

List of Appendices Page
Appendix 1 – Letter from Ethical Review Committee 64

Appendix 2 – Statement Explaining The Game Sessions 67

Appendix 3 – YIP consent Form 68

2

List of Tables Page
Table 1 - Under-20 birth rates worldwide 10

Table 2 - Sex & Relationships Education Guidance 13

Table 3 - Feedback Relating to The Contraception Boardgame 16

Table 4 - Common Features of Successful Programmes 31

Table 5 - Focus Group & Interview Discussion Statements 36

Table 6 - The Constant Comparative Method 37

Table 7 - Development of Categories Overview 38

3

List of Figures Page
Figure 1 - Under-16 conception rate for England: 1998-2006 11

Figure 2 - Under-18 conception rate for England: 1998-2006 11

Figure 3 – Setting Up The Contraception Boardgame 20

Figure 4 - The Choices Panel 22

Figure 5 - Refinement of Categories 39

4

Abstract
Background
The UK is well documented as having high rates of teenage pregnancy &
sexually transmitted infections. Sex & Relationships Education (SRE) is central
to the Governments Teenage Pregnancy Strategy & there are now clear
guidelines relating to this. The Contraception Boardgame is an SRE teaching
resource that reflects the Governments SRE guidelines; the aim of this study is
to investigate how the this boardgame influences teenagers’ knowledge, skills &
behaviour towards sexual relationships.

Methods
A qualitative study was carried out involving teenage participants through the
Youth Inclusion Project (YIP) in Stalybridge. Multiple methods of data
collection were used to ensure sufficient evidence was collected from a group
who provided only limited verbal responses in interview situations but were
happy to engage in the less formal atmosphere of playing a boardgame.

Findings
Of the 16 young people involved in the study, most were quite well informed
about some but not all the contraceptive methods covered by the game. There
was a very positive response to the information about sexually transmitted
diseases with most of the participants identifying this as making the greatest
impact in terms of them practicing safe sex in future.

Interpretation
Evidence from this study supports SRE as an important part of any strategy to
reduce teenage pregnancy but emphasises the need for sessions to be
conducted by appropriately qualified & experienced individuals. In order to
encourage young people to practice safe sex, SRE content needs to be more
comprehensive & be delivered concurrently with information relating to STD’s &
their prevention. The study participants made positive comments about the
value of the game as an SRE resource but more research is required to

5

evaluate the game in a wider range of settings, with a greater number of
participants & with more typical facilitators.

6

Declaration
A portion of the work included in this dissertation has been submitted as part of
the Designing a Research Study unit of this qualification at this University but
has been rewritten for the dissertation. Most of the work included has not been
submitted in support of an application for another degree or qualification of this
or any other university or other institute of learning;

Copyright Statement
i. Copyright in text of this dissertation rests with the author. Copies (by any
process) either in full, or of extracts, may be made only in accordance with
instructions given by the author. Details may be obtained from the appropriate
Graduate Office. This page must form part of any such copies made. Further
copies (by any process) of copies made in accordance with such instructions
may not be made without the permission (in writing) of the author.

ii. The ownership of any intellectual property rights which may be described in
this dissertation is vested in the University of Manchester, subject to any prior
agreement to the contrary, and may not be made available for use by third
parties without the written permission of the University, which will prescribe the
terms and conditions of any such agreement.

iii. Further information on the conditions under which disclosures and
exploitation may take place is available from the Head of the School of
Medicine.

7

The Author
As 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’ was
repeated on a fairly regular basis, mainly because noone else wanted to do it. I
found the subject got easier the more I did it & I became desensitised to the
students’ difficult questions. I struggled, however, to find better ways of getting
through the topic in a more meaningful way. With a degree in Genetics &
Microbiology & a PGCE, I had no formal training or experience in sex education
as such, but felt like it was becoming my specialist subject.

I was impressed by my friend & colleague, Barbara Hastings-Asatourian, who
had 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 a
teaching resource for her sex ed lessons, a game that covers all the basic facts
but also gets teenagers to talk to each other about sexual health &
relationships. Through my own experience of talking about sex & relationships
with teenagers, I was aware that, despite the bravado, a lot of young people
found the topic uncomfortable in a formal teaching setting & my feeling was that
there were many questions that never got asked & many scenarios that were
never explored. A game seemed like a really good way of dealing with a
notoriously 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 to
see how educators would receive it but was also interested to know what
teenagers thought about it. Despite the quantity of research into teenage
pregnancy, there is not that much information about what teenagers in this
country actually think about the teenage pregnancy problem or the various
strategies, interventions & resources being used to try & help with this difficult

8

problem. I saw this project as an opportunity to add teenagers views to the
debate, at least in terms of this one resource.

9

Introduction
The UK is widely quoted as having the highest rate of teenage pregnancy in
17, 23, 25 23
Western 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, 18
around 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
23
in underprivileged areas although even the most prosperous areas in the UK
have higher rates of teenage pregnancy than the national rates for the
25
Netherlands and France . Those found to be at particularly high risk include,
individuals who have been in care, those who have truanted from school, those
that are from a large family or those that are themselves the children of teenage
mothers 23.
Table 1
Under-20 birth rates worldwide: 1998 (most recent comparable year) 8

KOREA GERMANY 2.9 13.1
JAPAN AUSTRIA 4.6 14.0
SWITZERLAND CZECH 5.5
16.4
REPUBLIC
NETHERLANDS 6.2 AUSTRALIA 18.4
SWEDEN 6.5 IRELAND 18.7
ITALY 6.6 POLAND 18.7
SPAIN 7.9 CANADA 20.2
DENMARK 8.1 PORTUGAL 21.2
FINLAND 9.2 ICELAND 24.7
FRANCE 9.3 HUNGARY 26.5
SLOVAK 26.9
LUXEMBOURG 9.7
REPUBLIC
BELGIUM 9.9 NEW ZEALAND 29.8
GREECE 11.8 UK 30.8
NORWAY 12.4 USA 52.1
Source: United Nations Childrens Fund, Innocenti Research Centre 2001
Rate per thousand females aged 15-19,

Although there was a rise in conceptions in the under 16 age group between
14
2004 & 2005 (Figure 1) , the under 16 conception rate for England in 2005
was 7.7 per 1000 girls which is 13.0% lower than the Teenage Pregnancy
Strategy’s 1998 baseline rate of 8.8 conceptions per 1000 (Figure 1) 14.

10

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 overall
decline of 13.3% since the 1998 baseline (Figure 2).

Figure 1
Under-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
Year

Source: Office for National Statistics and Teenage Pregnancy Unit, 2008
Rate per thousand females aged 13-15, 2006 data are provisional

Figure 2
Under-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
Year

Source: Office for National Statistics and Teenage Pregnancy Unit, 2008
Rate per thousand females aged 15-17, 2006 data are provisional

11

Although the figures show that, overall, the teenage pregnancy rate is slowly
declining, the UK rate is still high compared to other countries (Table 1). In
addition, the change in rate of teenage pregnancy is not uniform across the
whole of the country, with some areas seeing much more of a decline compared
to others, for example Oldham MCD (-32.8%) & Bolton MCD (-4%) & other
areas actually seeing varying degrees of increase, for example, Manchester
15
MCD (9.8%) & Tameside MCD (1.4%), between 1998 & 2006 . Although the
effects of the Teenage Pregnancy Strategy appear to be encouraging in some
15 25
areas of the country, based on these figures & other recent evidence , it
seems unlikely that the government target of halving teenage conceptions by
2010 will be met.

The National Strategy For Sexual Health And HIV was published by the
Department 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 of
unintended pregnancy by raising awareness of sexual health issues, providing
information & education, developing services, improving skills & capacity
building in individuals & communities. A range of settings in which sexual
health promotion takes place have been identified & these include schools &
informal youth settings, along with many others. Sex & Relationships
Education (SRE) in both formal & informal education, along with peer education
& education within youth & community groups are identified as appropriate
methodologies for sexual health promotion 24.

24
The Department of Health Effective Sexual Health Promotion toolkit provides
some evidence for the effectiveness of interventions to reduce teenage
pregnancy & STD’s. It recommends targeted, participatory, school &
community based education programmes that improve skills as well as
increasing knowledge as some effective ways of reducing high-risk sexual
behaviour & unwanted pregnancy.

The Teenage Pregnancy Strategy for England (1999) aims to halve the under
18 conception rate by 2010 & provide support to teenage parents to reduce the
long-term risk of social exclusion. The four main areas covered by the strategy

12

are media awareness, joined up action at a national & local level to ensure all
relevant partners are involved, improvements to SRE & access to contraception
& sexual health services along with support for teenage parents to reduce their
long term risk of social exclusion 17.

17
Both the Teenage Pregnancy Report & the OFSTED Sex & Relationships
Education Report 2002 18 consider young peoples’ lack of knowledge about safe
sex, relationships & parenting as one reason why the teenage pregnancy rate is
so high. For this reason, Sex and Relationships Education (SRE) is central to
the Governments Teenage Pregnancy Strategy & there are now very clear
guidelines regarding this 16,18.

The guidelines in Table 2 are taken from the UK Government Sex &
16
Relationships Education Guidance & the Ofsted Sex & Relationships
Education Report 18.

Table 2
Sex & 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

The Department for Education & Employment (DfEE) Sex & Relationships
16
Education (SRE) Guidance 2000 goes on to state that the objective of sex
and relationship education is to help & support young people through their
physical, emotional and moral development & that a successful SRE
programme will help young people learn to respect themselves & others & move
with confidence from childhood through adolescence & into adulthood

The following summary of SRE requirements in the UK is taken from a Family
Planning 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

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
16,18
in line with the Governments Sex & Relationship Education Guidelines but
7
also in consultation with young people . It was first produced commercially by
Contraception Education in 2001 & since then, it has been purchased by
10
schools, youth groups, social services & other young peoples centres both in
the UK & various countries worldwide.

The following feedback (Table 3) relating to the Contraception game has been
7
collected by Contraception Education & is displayed on their website or
10
through a presentation made at Salford University by Barbara Hastings
Asatourian, who developed the game. Despite the weight of evidence
supporting SRE & clear Government guidelines relating to SRE in the UK, there
still seems to be differing opinions as to what is or is not appropriate or
effective.

15

Table 3
Feedback 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

The Research Question
Will playing the Contraception boardgame help or encourage teenagers to
practice safe sex in the future?

Safe sex is a broad term but for the purpose of this study, it involves an
individual having the knowledge & skills to practice or negotiate protected sex,
involving the use of an inclusive barrier, for example using a condom or
femidom, in order to reduce the risk of pregnancy & STD’s.

As a group identified as being at high risk of unwanted pregnancy & STD’s, the
views of teenagers, from low socioeconomic &/or educational backgrounds are
of particular interest.

Qualitative data will be collected from direct observation of groups of teenagers
playing the Contraception boardgame, from focus group discussions & from
individual interviews. Participants will be asked questions as to what, if
anything, they have learnt or gained from playing the game & whether they may
change their behaviour as a result.

17

The Aims & Objectives Of The Study
To investigate how the Contraception boardgame influences teenagers’
knowledge, skills & behaviour towards sexual relationships.

Knowledge
To investigate what has been learnt about contraceptive methods, how they
work & where they can be obtained.

To investigate what has been learnt about sexually transmitted diseases, how
they are transmitted & ways of avoiding them.

Skills
To investigate what has been learnt about the effective use of contraceptives.

To investigate what has been learnt about negotiating skills that could help
individuals avoid unwanted sex.

Behaviour
To investigate if playing the game will have any influence on future safe sexual
behaviour.

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 useful
evaluation of the Contraception game that will be of use for its further
development.

18

The Contraception Boardgame
The game comes with a comprehensive instruction booklet covering all the
information required to facilitate the game. The booklet covers all the different
contraceptive 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, the
facilitator’s role & some game management strategies. The following
information is taken from the Contraception information booklet 5 & gives some
background to the game. The booklet also highlights the crucial role played by
the facilitator in terms of the range of skills & the knowledge required to
successfully 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 floor
space. 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 are
placed under the card carousel around the condom demonstrator (3). Safe (4),
Risk (5) & question (6) cards are then positioned on the card carousel.

19

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 resource
centre cards (14) are then placed on the holders.

Figure 3
Setting Up The Contraception Boardgame

20

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 contraceptive
board 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 Game

The objective of the game is to gather up one card from each of the resource
centres. 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 either
clockwise or anticlockwise direction from their start position. Players start from
the Safe place on the nearest hexagon to them.

Players will land on one of 4 types of space – Safe, Risk, Question or Wait
Here. Players will pick up the Safe, Risk or Question card, read its information
or instruction, complete a task or activity, or discuss the issue raised.

21

The card activities & discussion takes time, as it is here where most of the
sharing of information & learning takes place.

Figure 4
The 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 be
made about the nature of sexual activities between willing partners.

The choices panel is incorporated into the game, when opportunities for
discussion arise from the statements & scenarios on the Safe & Risk cards.
Players are asked to consider & discuss the most appropriate choice & read it
out to their peers.

Play moves on to the next person when the card activity has finished.

22

Players who land on the Wait Here space will pick up a resource centre card on
their next turn.

In theory, the game finishes when the first person has gathered all six cards.

The Facilitators Role
Facilitators 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 planning
expertise, youth & community workers or peer educators.

Some preparation for the role of facilitator is essential. How much will depend
on the individuals background.

The level facilitator involvement with the game (whether the facilitator is
integrated into the group as a player or acts as a separate resource) will depend
on:
• 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 players

The Contraception Game Facilitators Notes also contain information & guidance
relating 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

Literature Review
There is a large amount of literature available relating to teenage pregnancy
both in the UK & worldwide. The literature covers a wide range of issues &
includes evaluations of interventions to reduce teenage pregnancy along with
suggested good practice, as well as various statistics relating to teenage
pregnancy. There is not, however, any literature specifically relating to the use
of 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 information

The 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 are
about sexual health, contraception & the underlying reasons why they may or
12
may not become pregnant. One study found that young women were not
poorly educated about contraception, the barriers to them using contraception
consistently were indifference to pregnancy & the belief that they could not or
21
would not become pregnant. Another study , however, found that girls had
only sketchy knowledge regarding contraception & did not recognise when their
information was incomplete or wrong.

Many young people are highly critical of SRE in schools & have difficulty
11
communicating about issues relating to sex & relationships but the Teenage
13
Pregnancy Strategy Evaluation Annual Report Synthesis No 1 (2001) states
that nearly 9 out of 10 parents, and as many young people, believe SRE “helps

24

make people more responsible about sex” 13. UK Government SRE guidance
16
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 SRE
programme, developed by the Department of Child Health at the University of
Exeter. It aims to: increase tolerance, respect & understanding; enhance
knowledge of risks & counteract myths; provide effective skills to those who
wish to resist unwelcome pressure; & improve effective contraceptive use
among teenagers who are already sexually active. In 2003, 135 schools
(across 16 LEAs) were participating in the APAUSE programme. An evaluation
9
of the programme showed that APAUSE was highly valued for the
involvement of peer educators & health professionals. Where it worked well,
the peer education element was considered to be very powerful & the
combination of the health professionals’ expertise & the teachers’ classroom
skills in co-teaching sessions was considered a real advantage. When asked
about the most helpful aspects of the programme, the involvement of health
professionals 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 had
a more mature & responsible attitude towards sex than students in comparison
schools. The 2003 Year 11 data showed that there was a small but significant
difference in reported sexual activity with APAUSE students being less likely to
be sexually active than comparison students. There were also tentative links
between APAUSE and the reported use of contraception & students who
reported having been taught about assertiveness skills were less likely to have
had unprotected sex. The majority of interviewees & survey respondents gave
positive feedback about the programme & data from the programme provided
evidence of a positive impact on young people’s knowledge and attitudes 9.

Another aspect to the APAUSE evaluation was to assess to what extent it
conformed to recommended good practice in SRE, in particular that

25

recommended by the DfES. On the whole, the evaluation showed that the
programme did, or mostly did, conform to the guidelines & as already stated
was, on the whole, well received & was starting to show some positive effects.
One of the major positives about the programme was the involvement of health
professionals alongside teachers & the key role played by peer educators. The
success of these elements though, was very directly dependant on how well
prepared the sessions were & the training of the individuals involved, poorly
prepared sessions presented by individuals with insufficient training were, not
surprisingly, 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.” 20

but acknowledges that
“further work is needed to ensure that young people are well informed
about sexual matters including contraception.” 20

Despite a positive association between the total number of school SRE lessons
received & a reduced likelihood of pregnancy, many young people still feel that
SRE is received too late.
“The status, & thereby the quality, of SRE could be improved by making
high quality PSHE mandatory within the National Curriculum” 20

This would bring England in line with other European countries that have had
much lower rates of teenage pregnancy. 20

This evaluation of the UK teenage pregnancy strategy recognizes that:
“Changing sexual attitudes and behaviour is a challenging task that takes
time.” 20

But, goes on to say that

26

“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

26
A systematic review of traditional primary prevention strategies , such as sex
education and contraceptive services, reports that none of the strategies
evaluated were effective in reducing the number of pregnancies among young
women. It suggests that adolescent sexual behaviour is not well understood &
the idea that simply increasing young peoples knowledge of contraception can
solve the teenage pregnancy problem is misguided. Although knowledge &
understanding about sex & access to good sexual health and contraceptive
services may be important, there is no evidence to suggest that they are
sufficient on their own. In contrast to this, a report produced by the Family
11
Planning Association states that “evidence consistently shows that high
quality SRE can lead to young people starting to have sex later & helps to
reduce teenage pregnancy rates & the rate of sexually transmitted infections”.
It does go on to say, however, that the SRE provided in schools is variable in
content & quality & that young people feel it is too little, too late & too biological.

11
The Family planning Association report also identifies the power of peer
group pressure & misconceptions about the sexual behaviour of peers as
factors 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”. 11

So, although improvements in sex education generally would help, teenage
pregnancy is clearly not just an educational issue, it is also a matter of social
norms & expectations & is more complex 26.

27

A meta-analysis to assess the effectiveness of primary prevention strategies for
30
adolescent pregnancy included data from community & school based
programmes along with clinic & non-clinic based programmes. It concluded that
prevention programmes have no effect on the sexual activity of adolescents
although some programmes can increase the use of contraceptives & so, to
some extent, can reduce pregnancy rates. The authors state that further
research is required to identify the most effective community based
programmes, to explore ways of teaching responsible sexual behaviour to
young men & to examine the effectiveness of various approaches for the
younger age group.

A systematic synthesis of research evidence relating to teenage pregnancy &
25
social exclusion categorised the factors affecting teenage pregnancy as
individual factors, including knowledge, self-esteem & age at first intercourse,
family factors, including communication, family structure, history of mother or
sister being pregnant as a teenager & children in care, educational factors,
including provision of sex education, truancy & lack of qualifications, community
factors, including social norms relating to sexual activity, peer & media
influences & finally, social factors, including childhood poverty, employment
prospects & housing. Not surprisingly, the relationship between these factors
is complex, with previous reviews of the effects of sex education & sexual
health promotion having shown mixed results.

25
This review showed that interventions that aimed to reduce unintended
teenage pregnancy by attempting to improve young people’s education,
training, employment & career prospects, or financial circumstances fell into two
categories, early childhood interventions aimed at preschool & primary school
aged children & youth development programmes aimed at improving social &
academic development among young people aged 11 to 18. All the studies
worked with young people defined as being at ‘high risk’ of experiencing
teenage pregnancy or other problem behaviours. Meta analysis of the study
findings showed that both categories of intervention could reduce teenage
11
pregnancy rates. There is other research that also supports effective SRE

28

being initiated early, before adolescents have established patterns of sexual
behaviour.

25
Studies included in the review that reported on the views & experiences of
young 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 were
identified across all the studies, with a dislike of school & unhappiness, rather
than poverty, being key aspects of young parents’ lives. The desire for loving
& secure relationships meant that some women wanted to start a family as soon
as possible with a baby providing the opportunity for them to give & receive love
& affection. Not all teenage mothers, however, had grown up unhappy, some
had positive experiences of family life themselves & had planned their
pregnancy, while others had wanted to have babies young & were looking
forward to still being young when their children were older.

25
The 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 who
became parents later in life expected, from a young age, to go to university & to
travel.

27
These results were corroborated by another study that also showed young
people from socioeconomically disadvantaged & advantaged backgrounds have
different attitudes towards adolescent pregnancy & contraception. Young
women from disadvantaged backgrounds thought that the ideal age for starting
a family was 17-25 years, whereas women from advantaged backgrounds
wanted to wait until their late 20’s or early 30’s to start a family. The study also
found that contraceptive use was influenced by how women felt about their
relationship particularly with young women from disadvantaged backgrounds,
who were setting contraception aside in relationships they perceived to be
stable & long term.

29

Socioeconomic background again appears to affect participants experience &
perspective, with study participants from young mothers groups, having become
sexually active at a young age, feeling that sex education was provided too late
& did not explain enough about contraception or the emotional aspects of
sexual relationships or pregnancy. They felt they were poorly informed about
contraception & health & had used contraception ineffectively. Young women
from advantaged backgrounds, however, were generally better informed & more
likely to use emergency contraception in high risk situations, rather than those
from disadvantaged groups who tended to just ” wait & see” 27.

In contrast to other studies that report a recent increase in under 16
25
conceptions , the 2005 Teenage Pregnancy Strategy Evaluation Report
Summary states that during the first four years of the Strategy, conception rates
for women in England aged under 18 have fallen. There was a 9% fall in under
18 conceptions by 2002, compared with the 1998 baseline for the strategy &
20
with a higher rate of decline being seen in deprived areas . This report also
makes a strong link between social deprivation, low educational achievement &
high rates of teenage pregnancy & identifies the “underlying socio-economic
determinants of teenage pregnancy” as being in need of further attention 20.

In the USA, comprehensive sex education curricula, aiming to improve
contraceptive use & modify high-risk behaviours associated with pregnancy &
STD’s, present abstinence as the most effective method of prevention (although
there is no evidence that abstinence only programmes reduce rates of
28
intercourse or pregnancy ) but also discuss contraception as an appropriate
strategy for individuals who are sexually active. These types of programmes
28
have been shown to significantly improve their desired outcomes .
Successful programmes were found to vary in their approach but had some
important common features (see Table 4).

30

Table 4
Common Features of Successful Programmes
Successful 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 behaviours
29
identified some similar common features of programmes that effectively
delayed the onset of intercourse, increased the use of condoms or
contraception & reduced sexual risk behaviours in adolescents. As well as
focusing on reducing high-risk behaviours that may lead to unintended
pregnancy or contraction of an STD, these programmes also provided accurate
information about the risks of unprotected sex & suggested strategies for
avoiding this. The programmes considered social or media influences on
sexual behaviours, gave clear and appropriate values to strengthen individual &
group norms against unprotected sex & provided models for & opportunity to
practice 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
28
information on responsible sexual behaviour . There is a suggested model
for talking to teenagers about responsible sexual behaviour that involves
engaging adolescents in confidential, open & non-judgemental discussions,
independent of caregivers, about sexual behaviours & concerns. Adolescents
should be asked & advised about contraception & the prevention of STD’s as
well 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 may
improve the adherence of the subject to a chosen contraceptive plan.

31

Physicians are also advised to educate all sexually active adolescents about
emergency contraception, emphasising that this is an emergency option & that
it offers no protection against STD’s.

28
A review of pregnancy prevention strategies for adolescents in the USA
recommends that prevention of pregnancy & prevention of sexually transmitted
diseases should be linked when counselling sexually active teenagers; it also
recommends that condom use should be encouraged in all sexually active
teenagers, regardless of whether another contraceptive method is used.

Regarding the position in the UK, the Family Planning Association firmly believe
that currently, young peoples opinions are missing from the sex & relationships
debate & 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”. 11

The literature highlights that there are some differences of opinion & grey areas
regarding which interventions are effective & what the wider measures are that
need 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 for
more research in this area & teenagers’ views on a range of relevant issues
need to be considered.

32

Methodology
19
Qualitative research methods provide insight into individuals opinions , so are
an appropriate way of investigating if, how or why using the Contraception
Boardgame as a sex & relationships education tool, could influence the
knowledge, skills & behaviour of teenagers. Qualitative methods will also
allow current knowledge, skills & sexual behaviour to be investigated.

2,4,6
Purposeful or discriminate sampling was used to deliberately select
subjects who were relevant to the research question, rather than a random or
representative sample. Youth Inclusion Programmes (YIP’s) operate in 114 of
the most deprived neighbourhoods in England and Wales. They target young
people in a neighbourhood who are considered to be at high risk of offending
but are also open to other young people in the area. Young people on the YIP
are identified through various agencies, including the police, family services,
schools & anti-social behaviour teams. The programme gives young people
somewhere safe to go where they can learn new skills, take part in group
23
activities & get educational support along with careers guidance . I
approached the Youth Inclusion Programme in Tameside & explained the
nature of my project. I offered to run a series of sex & relationships education
sessions, using the Contraception Boardgame at their drop in centre in
Stalybridge. I asked if they had any time available on the programme for this
kind of activity & if they had any young people who would be interested in, or
would benefit from, playing the Contraception boardgame & then talking about
what 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 the
project; he felt that there were a number of young people involved with the YIP
in Stalybridge who would benefit from this kind of activity.

After considering the time available for the study & investigating the availability
of study groups through Tameside YIP, a sample of about 18 young people
aged 16-18 was identified. Initially I arranged to run three game sessions with a
maximum of 6 teenagers per session. It was not, however, possible to say for
definite how many would actually attend each session until we were actually

33

there. For this kind of study, the sample size is ultimately determined by the
data collected; data analysis done concurrently with data collection identifies the
2,6
point at which theme saturation (no new or conflicting data is produced)
occurs. If more data was required for this study, there was the possibility of
arranging additional game sessions with other young peoples groups linked to
the YIP in Tameside.

The study design involved the use of multiple methods of data collection to
allow corroboration between sources. This method of data collection is
referred 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 relying
exclusively on the ability of subjects to express themselves verbally; we actually
watched them play the game & saw what happened first hand rather than just
asking them about it afterwards. Interviewing was preferred to written
evaluation of the game to ensure that the writing & comprehension skills of the
participants were not a barrier to some individuals providing evidence.

Ethical approval for the project was sought through Tameside & Glossop Local
Research Committee. The proposal was considered by the Chair, who advised
that the project did not need to be subject to an ethical review (appendix 1), but
advised that I seek management approval for the project from my host
organisation. As well as obtaining approval from the YIP co-ordinator, all the
YIP participants had completed, either themselves if over 18 or by a parent if
under 18, a general consent form (Appendix 3) to cover all activities covered by
the YIP & the use of photography. Although the project had been explained to
the participants by their YIP co-ordinator, a statement was read out by the game

34

facilitator at the start of each session to ensure that all the participants involved
fully understood the nature & purpose of the game sessions (appendix 2).

The confidentiality of the study data was ensured by the discrete use & secure
storage of all recorded information relating to the study. All the video & audio
tapes were stored in a lockable office desk & were deleted once transcription
was complete. The process of transcribing both the video & audio recordings
was carried out in private, away from public view or using headphones. All
contributions to the project have been anonymised both in the session
transcripts & this report.

Phase 1 – Observation of The Game Sessions
This involved the systematic noting & recording of events, behaviours & objects
in the setting used for each study group 1. Due to the fact that there were only
two members of the research team & one of these was involved as the game
facilitator, each game session was recorded, on video, so that detailed, non-
judgmental descriptions of events, as the group played the game, could be
written up later. The video camera was positioned in the room in order to be as
unobtrusive as possible. The cameraperson was a passive observer & did not
participate in the game session at all. Having a video recording of each session
meant it was possible to write a very accurate & complete description of the
game 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 & were
recorded (audio only). The same six statements (Table 5) were discussed with
each group. The audio recordings were transcribed, word for word, after each
session.

35

Table 5
Focus Group & Interview Discussion Statements

Statement 1
Playing Contraception has given me the confidence to talk about sex &
relationships

Statement 2
Playing Contraception has not increased my knowledge of contraceptive
methods & how to get them

Statement 3
Playing Contraception has given me the knowledge & skills needed to avoid
unwanted sex.

Statement 4
Playing Contraception has not made me more likely to practice safe sex

Statement 5
Playing Contraception has given me the knowledge & skills needed to negotiate
safe sex

Statement 6
Playing Contraception has not increased my knowledge of sexually transmitted
diseases or how to avoid catching them

Focus groups provide breadth of information, which coupled with individual
interviews, allow verification of & clarification of any interpretations or
conclusions drawn from observations 1. Compared to individual interviews,
focus groups are socially orientated & therefore more natural & comfortable for
the participants 1. They are however, more difficult to control & require a skilled
facilitator to avoid digression 1. The role of the focus group facilitator was to
create a supportive environment & provide statements or open questions to
encourage discussion as well as the expression of opinions 1.

Phase 3 - In Depth Interview
The interviews were carried out in a semi-structured manner between one
interviewer & one participant in a private location, away from the rest of the
group. 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

discussion. As with the focus groups, these sessions were recorded (audio
only) & transcribed, word for word, after the session. The aim of the interviews
was to explore a few general topics, identified through the discussion
statements, but to allow the participant to structure the response.

The most appropriate way of analysing the data collected from the three phases
12
would be to identify themes . The Constant Comparative Method for
Analysing Qualitative Data combines inductive category coding with a
simultaneous comparison of all units of meaning obtained (Table 6). As each
new unit of meaning is selected for analysis it is compared to all other units of
meaning & subsequently grouped (categorised & coded) with similar units of
meaning. If there are no similar units of meaning, a new category is formed.
In this process there is room for continuous refinement; initial categories are
changed, merged or omitted; new categories are generated; & new
relationships can be discovered 22.

Table 6
The Constant Comparative Method for Analysing Qualitative Data
Step 1
Inductive category coding & simultaneous comparing of units of meaning across
categories.

Step 2
Refinement of categories

Step 3
Exploration of relationships & patterns across categories.

Step 4
Integration of data yielding an understanding of people & settings being studied.

22

Before it could be analysed, the data from each phase of the research needed
1,4
to be accurately transcribed. In order to become very familiar with the data
it was necessary to watch the video recordings of the game sessions, listen to
tapes of the group & individual interviews & read the data transcripts several
times. Transcribed data from different groups & individuals were given a
particular colour text. The coloured transcripts were then printed out, read
through & physically ‘cut up’ in order to allocate sections of text to a category.

37

The categories were spread out across a table, with all the sections of text
visible. Similar sections of text were arranged next to each other; arranging the
text in this way made it possible to see when a sub theme was developing
within a category. Initial interpretation of the data starts once coding is
underway; these ideas are then explored through the data as the analysis
progresses 1.

Development of Categories (Table 7)
The initial categories were developed through familiarity with the data. It
became apparent that most of the observations, behaviour & responses within
the transcripts related to the participants knowledge (category 1), skills
(category 2) or behaviour (category 3) in relation to various aspects of the
game. There were a few areas of the text that did not come under these broad
headings but they could initially be described as miscellaneous (category 4).

Table 7
Development 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 required

Working initially with these four categories (Knowledge, Skills, Behaviour, Misc),
it very quickly became possible to subdivide each of these (see Figure 5).

38

Knowledge was subdivided into knowledge relating to:
• Contraceptive methods
• Sexually transmitted diseases
• Sexual health services

Skills was subdivided into:
• Negotiating skills
• Ability to play the game

Behaviour was subdivided into:
• Behaviour relating to practicing safe sex
• Behaviour relating to playing the game

By subdividing the initial categories, it was possible to fit some of the
miscellaneous responses into one of the already defined categories. Another
category was also formed from the remaining miscellaneous responses, where
the responses had a similar theme. The new category related to attitudes to
playing the game.

Further consideration of the sections of text allocated to each category allowed
a more specific category title to be developed. For example, ‘Negotiating Skills’
became ’Talking About Sex & Dealing With Pressure To Have Unwanted Or
Unsafe Sex’

A definition (rules for inclusion) of the information included in each category was
also developed & the responses within each category were then checked
against the definition & reassigned if necessary. As a result of this, two further
categories were added, where it became apparent that the several responses
addressed specific areas.

• Knowledge relating to Contraceptive methods was divided into:
• Knowledge relating to different methods of contraception & how to use them
effectively.

40

• 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:

Behaviour
1. I am more / less likely to practice safe sex

Rule For Inclusion
Subjects indicate through observation, discussion or responses to questions
that their likelihood of practicing safe sex either had or had not changed as a
result of playing the game.

2. Willingness to play the game.

Rule For Inclusion
Observations that relate to the subjects’ willingness to participate in the game &
how the game facilitator manages this.

Knowledge
1. Knowledge relating to different methods of contraception & how to use
them effectively

Rule For Inclusion
that they have gained, or already had, knowledge or skills relating to the
effective use of various contraceptive methods.

41

2. Knowledge relating to how & where different contraceptives can be
obtained.

Rule For Inclusion
that they have gained, or already had, knowledge relating to how & where they
can obtain various contraceptives.

3. Knowledge relating to Sexually transmitted diseases & how they are
transmitted.

Rule For Inclusion
that they have gained, or already had, knowledge, about various sexually
transmitted diseases & how they are transmitted.

4. Knowledge relating to how to protect against sexually transmitted
diseases.

Rule For Inclusion
that they have gained, or already had, knowledge about how to avoid catching
STD’s.

5. Knowledge about different sexual health services

Rule For Inclusion
that they have gained, or already had, knowledge about what different sexual
health services do & how they can access or locate them.

42

Skills
1. Talking about sex & dealing with pressure to have unwanted or unsafe
sex.

Rule For Inclusion
Subjects indicate through observation, discussion or responses to questions,
that they have gained, or already had, knowledge or skills that could help them
talk about sex & / or have thought about how they could deal with various
situations involving sex.

2. Ability to play the game.

Rule For Inclusion
Observations that relate to the subjects’ ability to participate in the game & the
involvement of the game facilitator..

Attitudes
1. Playing Contraception was a good / bad learning experience.

Rule For Inclusion
Subjects expressed an opinion relating to whether playing contraception was /
wasn’t an effective way to learn about sexual health & relationships.

Miscellaneous
Rule For Inclusion
Subjects expressed an opinion or made a comment that does not fit into any
other category.

43

Results
The Role of the Facilitator
The game facilitator played an essential part in the success & management of
each of the game sessions. One group were able to play the game with
minimal 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 & providing
information & explanations relating to the different questions or tasks required
by the game.

“Barbara involved in each turn, guiding discussion, asking questions &
ensuring that all three players are involved.”

The facilitator’s role reduced as the game progressed & subjects became more
confident 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.”

“Game now moving much quicker, each player confident with what to do
for their turn”

44

Most of the participants were willing to play the game, however, two groups had
one disruptive or disinterested subject.

“One member of the group is trying to disrupt but others are all on task.”

“Girl ‘A’ is texting & not engaged in the game.”

The game facilitator attempted to accommodate these individuals & keep them
involved in the game.

“’A’ decides to ’sort of’ play, Barbara says she’ll do all ‘action’ if required.”

“’A’ prepared to contribute to impersonal or factual but not personal
discussions e.g. negotiation etc.”

Once the game had been going for some time, the apparently disinterested
subject 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 2

After 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.”

The facilitator was unable to engage the disruptive subject so he was asked to
sit out of the session.

45

“Disruptive boy sits out; group now working much better, everyone
playing looks involved / interested”

Apart from these two, all three groups had a comfortable atmosphere with all
remaining subjects contributing to the game.

“Atmosphere still relaxed, some jokes mixed in with serious discussion
but tone is ‘on task’ & constructive”

Knowledge & Attitudes Towards Contraception
All of the game sessions involved discussion about the different contraceptive
methods available with subjects asking questions & wanting explanations about
methods 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 game
facilitator explaining how these work, along with how they are used & fitted.
There was discussion about the risks of using a diaphragm that does not fit
properly & two subjects said that they had learnt about using spermicide cream
with the diaphragm to provide better protection against pregnancy.

“Next turn about diaphragm, this time player able to explain all details.”

The use of spermicide creams & pessarries stimulated further discussion, with
the game facilitator explaining how these work & are used with other barrier
methods of contraception to increase their effectiveness; three subjects
identified 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

There was discussion of withdrawal as method of contraception, again, with the
game facilitator explaining how this works & why it is a very unreliable method
to use.

All the game sessions involved subjects using the condom demonstrator.
Initially, the game facilitator was involved in ‘talking subjects through’ the
demonstrations but as the game progressed, the other subjects, rather than the
facilitator, provided feedback on the demonstrations. There was only one
subject who would not participate in the demonstration but this subject was
happy 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.”

There was discussion about the femidom & how it is used; one subject said that
they had not seen a femidom before. In one group, this discussion progressed
onto what could be done if partners could not agree about which contraceptive
method 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 several
others said that although they had heard the term they didn’t know much about
it. 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

Interviewer: “What about the others”
Subject: “The women’s condoms”
(Focus Group 3)

Eight subjects said that they had increased their knowledge of the different
contraceptive 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 discussion
regarding which were prescription & non-prescription, along with the different
places, medical & non-medical, where contraceptives could be obtained.
Subjects were particularly interested where contraceptives could be obtained in
the local area.

There was a discussion about where condoms could be obtained; where they
could get contraceptives without having to ask someone face to face was of
particular interest. Four subjects said that they had not known that they could
get contraceptives without going to the Doctor; they did not realise that they
could get contraceptives in shops & supermarkets.

“I knew you could get them from the pharmacy but I didn’t think about
shops”
(Interview 6)

48

“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 get
contraceptives generally. One subject said that they already knew about all the
different places that contraceptives could be obtained.

Knowledge & Attitudes Concerning Sexually Transmitted Diseases
There was a lot of interest in the subject of sexually transmitted diseases, how
they were passed between individuals & how they could protect themselves
from becoming infected. One subject indicated that they had learnt that some
diseases could be transmitted through other types of sexual contact, not just
intercourse, & depending on the disease, could be contracted through lesions &
cuts on different parts of the body. The game facilitator explained about dental
dams & finger cots & how they can protect against transmission of STD’s; none
of the game participants had heard of these before. Two subjects indicated
that they already had some knowledge of STD’s & how they are transmitted but
went 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 & one
subject 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

Reflecting on some of the information they had covered earlier in the game
helped to dispel some myths about which contraceptive methods do & don’t
protect against STD’s. Three subjects indicated they had found out that some
methods of contraception that they thought were protective against STD’s
actually 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 of
protecting against STD’s with several subjects saying that they had not realised
that some contraceptives could protect them against STD’s as well as
pregnancy.

“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 future
contraceptive use. Some subjects said that they would now think about
protecting themselves from disease as well as preventing unwanted pregnancy
in sexual relationships. One subject indicated that they would now consider
using a condom to protect themselves against diseases whereas previously
they would not have been prepared to use one. Another subject said that they
had learnt that practicing safe sex reduced the chance of getting an STD &
wasn’t just about preventing unwanted pregnancy.

50

Regarding the different sexual health services available, playing the game lead
to some discussion about Genito Urinary Medicine (GUM) clinics & sexual
health clinics. The game facilitator explained what GUM clinics do & one
subject asked about GUM clinics in the local area. One subject indicated that
they already knew about sexual health clinics.

“Next turn about GUM clinics – Barbara explains what happens here”

In terms of behaviour, two subjects indicated that they already practice safe
sex, although one of these subjects went on to say that if they were in a
situation where no barrier contraception was available, they would have sex as
long 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 of
them practicing safe sex & of these seven, five said that learning about sexually
transmitted diseases was the reason why they were going to change their
behaviour.

“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)

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Attitudes towards Sex & Relationships
Playing the game lead to discussion about how to deal with pressure to have
unwanted 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”

Several subjects said that playing the game would help them to avoid unwanted
sex in the future. They commented that gaining knowledge would help them in
this situation; either using knowledge of STD’s as their argument not to have
unwanted or unsafe sex or through improved confidence in recognising
incorrect advice from others. One subject specifically said that the game had
given them more things they could talk about & things they could actually say to
help 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 dealing
with unwanted sex & that the game had really made them think about what they
would 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 to
talk about sex & relationships with their partner or close friends. There were
two subjects, however, that said they were already confident to talk about sex &
relationships & the game had made no difference. Regarding how they would
deal with pressure to have unwanted or unsafe sex, several subjects said that
they would have no problem dealing with this, as they would ‘just say no’.

52

“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 knowledge
from the game that would help them talk about why they didn’t want to have
sex; they said knowledge of STD’s was something they could really use in this
situation.

“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 it
easier to say ‘no’ as they would be more confident they knew what they were
talking about.

Overall the game was positively reviewed in terms of its value as an SRE
resource.

“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 would
come across in life so it was good to think some of these through in advance
rather 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 better
than a taught session. Even though one subject had found playing the game

53

boring, they said that they had learnt something from it & that it was better than
the Sex Ed they had done at school.

54

Discussion
This study suggests that young people are quite well informed about some
contraceptive methods (condoms & the pill) but not others (femidoms,
contraceptive implants & injections, IUD’s the cap & use of spermicide) & that
they are not aware that some contraceptives are widely available through
supermarkets & the high street. The young people involved were not well
informed about STD’s; they recognised a few names of diseases & associated
them with having had sex but did not know specific information about the
causes or transmission of particular diseases. They were not aware that some
barrier methods of contraception could protect them from disease as well as
unwanted pregnancy; they only associated condom use with prevention of
pregnancy. None of them were familiar with dental dams & finger cots & were
not aware that STD’s could be transmitted without actually having sexual
intercourse. Most of the participants had heard of emergency contraception
but didn’t know much about how to use it or where it is available. This study
27
supports other evidence that suggests emergency contraception is not widely
used within this socio-economic group but suggests that lack of knowledge
about emergency contraception, rather than apathy is the reason for this.
Playing the game had a positive effect on the participants’ knowledge of
different contraceptive methods, how to use them effectively, where different
contraceptives could be obtained & which methods would protect them against
disease. Participants indicated that ‘knowledge is power’ & their increased
knowledge gave them confidence & would help them to negotiate safe sex or
avoid unwanted sex in the future.

12, 21
Previous studies have produced conflicting evidence as to whether young
people were or were not well informed about sexual health & contraception so
the evidence provided here provides some clarification. There was a very
positive response to the information about STD’s with most study participants
identifying learning about sexually transmitted diseases & their prevention as
making the greatest impact in terms of the likelihood of them practicing safe sex
in 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

preventing pregnancy, which has lead to a change in attitude towards
28
contraception. There is other evidence that also recommends linking
pregnancy prevention & prevention of STD’s & that condom use should be
encouraged 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, the
facilitator 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 as
they became more familiar with the game format. It is essential that the
facilitator has the skills & knowledge to both answer questions & guide
discussion but also, crucially, be able to relate to the group & have the people
management skills required to create an appropriate atmosphere in which the
game can be played effectively. The study participants made positive
comments about the value of the game as an SRE resource, they liked the
relaxed approach, the way that ‘real life’ situations & dilemmas were
incorporated & that they could discuss solutions to problems amongst
themselves rather than being ‘taught’.

The game facilitator involved in the game sessions for this study had all the
necessary attributes along with an interest in sexual health, enthusiasm for this
game & experience of working with groups of young people. It would be
interesting to see whether the game could work as well in a more typical SRE
setting with perhaps a less knowledgeable facilitator who lacks the experience
& motivation in this area. The game comes with extensive facilitator notes that
provide the necessary knowledge to support the game. Although there is
guidance regarding the role of the facilitator & some ground rules for managing
the game, it is obviously very difficult for a booklet to provide the facilitator with
group management skills or attitude. Evidence from other interventions
suggests that, not surprisingly, SRE goes well when educators are well
prepared & specifically trained but can go equally badly when they are not 9.

The decision to collect data through observation as well as group & individual
interviews worked well. Relying solely on conventional interviewing would have

56

provided very little information regarding the knowledge, skills & behaviour of
many of the study subjects. The groups were, on the whole, comfortable with
the informal & relaxed atmosphere of playing the game & responded well to the
game facilitator who was able to involve, & therefore, extract responses from
nearly all the participants.

Good atmosphere – everyone listening/contributing

No prompting needed to get everyone involved

Despite the efforts of the interviewers, the atmosphere was different during the
interviews & the groups or individuals involved did not respond as well. There
were a few subjects who were happy to talk & give opinions but they tended to
dominate any discussion. More commonly, it was the interviewer that made a
statement to try & summarise the little that had been said & the subjects either
agreed 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 the
study.

Limitations

Regarding the overall design of the study, the collection of data through one to
one interviews was not as productive as anticipated. The intention was that in
the interviews, subjects would expand on issues raised in the focus groups &
have the opportunity to provide information that they may not feel comfortable
giving in a group situation. In reality, most of the interview subjects had very

57

little to say, forcing the interviewer to come up with summary statements that
they could then either say yes or no to. The focus groups lead to some
discussion but the interviews provided very little information. On reflection,
asking different questions in the individual interviews, or providing subjects with
different dilemmas to comment on, rather than just going through the focus
group statements again, could have inspired them to talk more; as it was, their
attitude was very much that they’d already told us what they thought so why
were we asking them again.

In terms of the methodology, the themes & categories for this study were
developed & constructed by a single researcher; analyst constructed typologies
are subjective & impose the researchers meaning on the data 1. Ideally, two
researchers would develop the categories independently & the final list would
be formed by consensus. Theme saturation in the data occurred very quickly &
the message appeared to be very clear; this was, however, a very small study
with only 3 game sessions being observed & a total of 16 participants involved
(13 boys & 3 girls). Although participants were identified as male or female
through the observation of the game session, responses from the focus group
sessions & interviews were not identified in this way; the aim of the study was to
investigate 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 in
a sexual health services secret shopping project & most of them had covered
sex & relationships education to some extent at school or as part of other youth
development or support groups. These activities may have influenced their
attitudes, opinions & knowledge prior to taking part in the Contraception game
sessions.

To encourage accurate & honest information from participants, we assured
them that all the data collected would be confidential & presented anonymously
in the final report. To try & create a productive atmosphere we emphasised the
importance of their contribution & our gratitude for them taking the time to
participate. Reluctant participants were recorded in the data so any failure to
4
obtain information was included . Because of limited resources & the time
available, it was not possible to invite the participants from the study to verify

58

that the transcripts for the game sessions, focus groups & interviews were an
accurate account of what actually happened & accurately reflected their points
of view, so again, the researchers interpretation could have been imposed on
the data.

We did manage, to some extent, to standardise the time spent on each focus
group & individual interview, as only a set amount of time was available for the
sessions. Although the game was played for a set length of time, the progress
of each game session & the number of turns each player had varied according
to how much discussion took place & how long particular tasks or scenarios
lasted. All of the discussion statements were covered in each of the focus
group & 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 as
time, verbal expressiveness or repetitiveness may affect how often a
phenomenon is observed & therefore how significant it appears to be through
manifest analysis 4.

59

Conclusion
11, 13, 17, 18, 20, 25,
This study adds to other evidence that supports SRE as an
important part of any strategy to reduce teenage pregnancy but emphasises the
need for sessions to be conducted by individuals who have the necessary
knowledge, skills & experience. More evaluation of SRE needs to be carried
out to ensure that programme aims & the needs of the young people involved
are being met & that educators have the necessary knowledge & skills to deliver
SRE programmes effectively. In order to encourage young people to practice
safe sex, SRE content needs to be comprehensive regarding contraceptive
methods & how they can be obtained; this needs to be delivered concurrently
with information relating to STD’s & their prevention.

Participants in this study mostly responded positively to the game & it’s value as
an SRE resource & did, on the whole, gain knowledge & skills that may
encourage or enable them to practice safer sex in the future. More research is
required, however, to evaluate the game in a wider range of settings, with a
greater number of participants & with more typical facilitators. A larger study
may also be able to further assess & make comparisons between male &
female participants responses to the game; young men, in particular, have been
identified 30 as a group in need of further investigation regarding effective sexual
health interventions.

60

Contraception board game report

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