The impact of discussing a sexual history in role-play simulation teaching on pre-clinical student attitudes towards people who submit for STI testing

Abstract

Sex, sexuality and sexual health beliefs are individual, impacting on physical and mental health. Sexual history taking is rarely taught in General Practice (GP). However, ‘sex’ is routinely relevant in this setting. Birmingham students practice discussing sexual history with a simulated-patient in GP. Simulated-patient inclusion in teaching/assessment is well-documented, but no study evaluating the impact of role play on attitudes to people who need STI testing was identified. We aimed to identify whether facilitated simulations featuring a sexual history scenario effected change in students’ attitudes towards people who need STI testing. A randomised-controlled-trial was used to compare attitudinal scores between students exposed to an STI role play and a control group who did not receive the role-play teaching until after data capture. There were no significant differences in attitude, either in negative or positive direction, observed between control and intervention groups. Ethnicity was a significant variable, with white-British students self-reporting more positive attitudes. Twenty five percent students admitted personal STI exposure. Again response varied significantly between ethnic groups (the white-British group reporting 4× the exposure). Females reported more positive attitudes than males, most marked in relation to ‘willingness to date’ someone who admitted to STI testing.

Introduction

Role play or improvised representation of a patient, carer/advocate (or colleague), is a well-established methodology. Historically documented as ‘simulation’ or ‘standardisation’ (Barrows & Abrahamson 1964), the technique gives learners the opportunity to experience, reflect on and receive critique about integrated aspects of performance (Skelton et al. 1997). These can include elements of communication and professionalism, concurrent with areas such as clinical reasoning and management.

Complex role plays feature in many undergraduate/postgraduate curricula (Hargie et al. 1998). For this study, the teaching was a clinical communication role-play workshop for Year 2 undergraduate medical students, set in General Practice (GP), and featuring two scenarios – one of which involved exploration of a patient's sexual history and sexual practices.

Scenario: The patient fears that s/he has contracted a sexually transmitted infection (STI) under the influence of alcohol, and is concealing this from a regular partner.

Although timetabled as ‘communication’, the scenario was designed to challenge students simultaneously in taking an appropriate history, communicating effectively and demonstrating ethical practice. This course has a 7-year history, receiving consistently positive evaluation. This research therefore does not evaluate the acceptability or effectiveness of this teaching. Instead, the opportunity has been taken to consider whether the undertaking of this particular session additionally impacts on the attitudes of students towards a ‘fictitious individual in the general student population who has had STI testing on three occasions’.

The development of appropriate professional attitudes is core in medical training (General Medical Council 2003). Arguably, in sensitive areas where embarrassment and stigmatisation (Brandt and Shumway Jones 1999; White and Morterson 2003) may present, the health professional needs to be particularly aware. While displayed attitudes relating to the role-played scenario are managed within the teaching, this study sought to look beyond that to see whether students’ more generic attitudes altered after learners had had the experiential learning.

Sexual health was considered an important area for reflection for its perceived sensitivity and its suspected under-emphasis in medical training. At Birmingham, students do not received explicit teaching on sexual history taking until their Genito-Urinary Medicine (GUM) rotation, and only in Year 5. By the time students receive this teaching, they will have had 4 years exposure to most aspects of community-based medicine, but not have been taught to talk about sex in a structured way.

Discussions with patients about sex and sexuality are clearly not limited to GUM. Elements of both impact on people's physical and mental health at many levels (Department of Health 2001), and have clinical importance in other areas (Torkko et al. 2000). GUM patients might expect to be asked intimate questions, whereas in a GP consultation asking the ‘out of the blue’ question about a person's sexual activity is important, but may be less expected (Matthews et al. 1997), and hence less well received.

While the literature features a great deal on sexual health, it weighs in favour of management (Skrine 1997), advice (Levy 1997) teaching methods (Schweickert & Heeran 1999; Leeper et al. 2007), evaluations (Wagner et al. 2006), skills development (Haist et al. 2004), etc., and often in secondary care contexts. Skelton and Matthews (2001) reported specifically on teaching the sexual history in (postgraduate) primary care, and while other periodic references exist (Wenrich et al. 1997), the work is not prolific. Temple-Smith et al. (1999) reported on attitudes to sexual history taking in GP, with focus on working practises. A national survey by FitzGerald et al. (2003) established that sexual history taking was undertaken in 17 UK Medical Schools, but assessed in six. In terms of using role play in this context, the literature remains sporadic. Occasional reports (Edinger et al. 2010) on the effectiveness of role play to, e.g. build confidence in this area exist, but do not report changes in attitudes over time, and sometimes feature sexual history as part of a wider context, e.g. as a single objective standardised clinical examination (OSCE) station (Wass et al. 2003). Interestingly, online transcripts for this report show the lowest OSCE grade being awarded for taking a sexual history from a young Muslim woman (Wass et al. 2009).

This is an all too brief representation of a diverse work range, but comparison of pre- and post attitudes in the simulated sexual history context in a UK undergraduate sample was not sourced. A further feature in the project presented here is that that teaching was core, so not an explicitly designed ‘attitudinal’ intervention. The results of our comparison of questionnaire data from students who have and have not been exposed to the teaching session therefore provide additional outcomes for the teacher. It should be noted that the aim of our research was to invite students to consider how they felt about an individual who admits to multiple STI testing, rather than to invite them to consider how they felt about his/her sexual practices. The distinction is subtle, but important.

Table

Practice points

An RCT role-play intervention had neither a negative or positive impact on student attitudes towards STI testing. Students perceive themselves to have better attitudes then the general population. Student ethnicity is a significant variable in relation to this topic. Female respondents regard willingness to be tested as a more positive attribute in a future partner than males.

Methodology

Format and participants

A randomised controlled trial (RCT) design was utilised. For teaching purposes, the population of Year 2 MBChB1 (n = 387) students is routinely randomly allocated into 22 smaller cohorts for logistic and educational purposes. We used this existing class allocation, and further randomised the 22 groups to receive either the intervention (role-play session before data capture) or control (role-play session after data capture).

The curriculum requirement to offer teaching parity and the inclusion of content in a summative examination meant that all students had to experience the same role play. Comparing the attitudes of those who ‘had’ and ‘had not’ attended was therefore not an option. Instead, the members of the control group were presented with the study questionnaire before the role-play teaching, while the intervention group completed it after teaching. Both control and intervention groups comprised a total of 11 smaller groups, each further divided into two to reduce class numbers to 8–9 for the role plays.

Students had written notification that data collection forms were anonymous, that participation was not compulsory, that the study aimed to determine thoughts about STI testing, and that candid, spontaneous answers would most useful. Any student present for the timetabled teaching was eligible for participation. No explicit connection was made between the role-play session and the questionnaire. (n.b. Teaching evaluation does not require regional ethical approval. However, care is taken to minimise ‘research saturation’. Proposals are approved by senior personnel, and a benefit to educational development must be demonstrated.)

Questionnaire

The questionnaire measured personal stigma and social distance as well as perceived stigma (perceptions of the attitudes of others) towards a fictitious individual ‘John’, whose circumstances were presented as a written vignette. ‘John’ is a student who comfortably admits to having had STI tests ‘for peace of mind’ (including Chlamydia and HIV) – Appendix 2. Students were invited to rate: (1) their own comfort levels in interacting with ‘John’ in different circumstances and (2) how comfortable they thought others might be under those conditions.

The 25 statements presented in Appendix 3 (9 each for personal and perceived stigma, and 7 for social distance) included respondents’ thoughts on ‘John’ as a romantic prospect for them or a family member, a politician, a colleague, a neighbour and so on. Statements also invited respondents to consider John's self-control, weakness/strength, reliability, etc., and whether they themselves might confess to having had STI testing. Finally, students were invited to provide their gender and ethnicity, and indicate whether they had any personal experience of STIs (where personal experience was defined as occurring within themselves or close friends and family).

Attitudinal scales used were similar to those adopted previously (Roberts et al. 2008), and adapted from established work (Griffiths et al. 2004) The social distance score was modified from the Social Distance Scale (Link et al. 1987).

To score responses, each statement was assigned a numeric according to the student's agreement level, 0 representing a positive attitude and 4 representing a high level of aversion/negativity. This arrangement gave a possible total score between 0 and 36 for each of their own views and their perceived views of others, with higher scores indicating greater negativity of attitude. Social distance scores, 0–21, were similarly calculated with higher scores indicating greater aversion/social distance.

Intervention

The STI scenario used in the role-play workshop is detailed in Appendix 1.

Statistical analysis

Data were managed in Microsoft Access; where multiple data points were missing, cases were excluded from analysis within each domain. Data were imputed in cases where only a single question was not answered (imputed value being the mean of the other responses). Comparisons were made between groups for each of the outcome variables: (1) personal stigma, (2) social distance and (3) perceived stigma. Two-sample t-tests were employed for comparisons. In addition, differences were considered in light of respondents’ ethnicity, gender and experience of STIs or someone with an STI or other serious infection. Multiple regression models were developed for each score, to assess the effect of intervention group while adjusting for potential confounders. The relationships between the three outcomes were examined using partial correlations adjusting for all other variables of interest.

Results

Baseline data

A total of 299 respondents, comprising 188 females, 102 males and 9 gender unrecorded. Respondent age range was 19–26 (27% 19; 45% 20; 15% 21 and 13% 22–26 years). Ethnic mix was 61% white British, 34% other (national census categories) with 5% unrecorded.2 Control group and intervention group distribution was 175 : 124. Two tutors failed to distribute questionnaires to intervention group classes, hence the imbalance. Groups were similarly comprised in respect to gender, ethnicity and age.

STI experience

Twenty six percent respondents reported having had personal experience (including self, friend and family member) of an STI; 71% did not have personal experience; and 3% did not answer this question. Similar figures were found for experience of another serious infection, with 22% positive response. STI experience was more prevalent in females compared to males however this difference was not significant at the 5% level (females 29.8%, males 20%, χ² = 3.22, p = 0.07). Experience by ethnic group differed significantly with 35.6% of the white British population having experience compared to 9.7% of the combined other group (χ² = 21.25, p < 0.001).

Results for intervention and control group comparison

There were no significant differences between the intervention and the control group, suggesting no impact of the role play on general attitude. This was true of the scores for students’ own views, their perception of the views of others and the social distance scores (Table 1).

Table 1.  Between group differences in stigma and social distance scores

Category	Intervention group mean	SD	Control group mean	SD	Need t-statistic, p-value (two-tailed)
Own view	12.35	4.82	11.70	3.76	1.24, 0.215
Others’ view^a	20.26	5.00	21.26	4.63	1.77, 0.077
Social distance^b	5.53	4.70	5.57	4.08	0.13, 0.900

Notes: ^an = 122 intervention; 174 control; ^bn = 120 intervention; 173 control.

Results for age, ethnicity and gender

There was little variance in age, and no significant differences in scores between age groups. Comparison of the dichotomous ethnic groups however demonstrated significantly more positive reported attitudes in the group who classed themselves as white British, compared to the other ethnic groups. Comparisons for ‘own attitudes’, for example were 11.29 versus 12.63, t = 2.45, p = 0.015. Difference was particularly notable for ‘social distance’ scores, with the scores of the group that were not white British at 7.80 almost doubling those of the white British group at 4.06 (t = 7.8, p < 0.001). Interestingly, all groups held in common the belief that their own opinions were significantly more positive than those of others in the general population (perceived attitudes of others). The mean score for students’ own opinion across all students was 11.93, compared to a mean score of 20.85 for the opinion of others (t = 29.1, p < 0.001). Between group differences were also observed for gender, with male respondents overall reporting more negative attitudes and greater social distance than females (Table 2).

Table 2.  Comparison of male and female attitudinal scores

Gender	Own attitude score	Social distance score
Male	13.30	7.38
Female	11.15	4.48
Between gender means (95% confidence interval)	2.16 (1.18–3.13)	2.90 (1.90–3.91)
T-statistic, p-value	4.34, p < 0.0001	5.41, p < 0.0001

When data were scrutinised much of the difference for scores appeared to relate to views held about dating the character in the vignette. Of the 20% females reported definite willingness to date the character who had had STI testing, compared to 4% of males. Similarly, 22% of males indicated that they would definitely not date the character in the vignette compared to 11% of their female counterparts. Again ethnic differences were observed. Of the 20 females unwilling to date someone who had had an STI test, 14 were from the non-white British group.

Pairwise comparisons of the three outcomes showed that Personal stigma scores and Social distance scores were the most closely related (partial correlation = 0.47). Results of multiple regression analyses are presented in Table 3. Role-play intervention was not found to have an effect on any of the scores when adjusting for ethnicity, sex, previous STI or other infection experience. A negative relationship was found between perceived stigma and intervention group, but this effect was not significant (p = 0.12). Levels of personal stigma were found to increase significantly with being male (t = 3.71, p = 0.003) and marginally reduced with experience of other infection (t = 1.92, p = 0.06). Similar relationships with gender were also found with perception of stigma and social distance scores. Evidence of lower social distance score was found for the white ethnic group (t = 5.94, p < 0.0001) and having experience of STIs (t = 3.14, p = 0.002) or other infections (t = 2.98, p = 0.003). For all variables demonstrating statistical significance, the actual effect size was relatively small. A 2.2 unit change in social distance associated with being in the white British group; all other unit changes were smaller in size.

Table 3.  Multiple regression analyses to explain variance in attitudinal scores

Model	Variable	Parameter estimate	Standard error	t-value	p
Personal stigma score
Intercept		11.93	0.51	23.34	<0.0001
Group (intervention)		0.42	0.48	0.89	0.38
Ethnic category (white)		−0.71	0.52	1.36	0.17
Gender (male)		1.85	0.50	3.71	0.0003
STI experience		−0.95	0.57	1.66	0.10
Experience of other infections		−1.12	0.58	1.92	0.06
Perceived stigma score
Intercept		21.22	0.64	33.26	<0.0001
Group (intervention)		−0.91	0.59	1.55	0.12
Ethnic category (white)		−0.11	0.65	0.17	0.87
Gender (male)		1.16	0.62	1.87	0.06
STI experience		−0.21	0.71	0.29	0.77
Experience of other infections		−1.10	0.72	1.53	0.12
Social distance score
Intercept		7.19	0.47	15.46	<0.0001
Group (intervention)		0.14	0.43	0.32	0.75
Ethnic category (white)		−2.18	0.47	5.94	<0.0001
Gender (male)		2.08	0.45	4.59	<0.0001
STI experience		−1.64	0.52	3.14	0.002
Experience of other infections		−1.58	0.53	2.98	0.003

Discussion

Univariate and multivariable analyses showed no significant difference in attitudinal scores (respondents’ own, perceived others’ and social distance) between the intervention and control groups. There was therefore no evidence that students’ own attitudes became either more or less negative as a result of exposure to a single, intensive role-play workshop, although the perception of attitudes held by others may have been impacted upon by the role-play experience in a negative direction.

The teaching aim was to encourage students to reflect on integrated aspects of managing a complex problem, with a focus on improving communication. To that end, the lack of change in either direction on this study does not conflict with the teaching aims, and confirms no negative impact of the teaching methods.

The intention was to discover if this type of exposure had broader implications for the way students view individuals who have had STI testing. Arguably, more difference might have been observed if the questionnaire scenario had been closer to the role-played scenario, but under those circumstances, it would have been difficult to determine whether any changes were attitudinal, or attributable to improved knowledge about the circumstances of the role played ‘character’. The expansion of the area to include a fictitious ‘peer’ was felt to be a more reasonable measure of broader attitudes.

While we might reasonably expect to consider students’ attitudes in relation to the patient they are working with in the classroom, it appears (as we might anticipate) that deeper and more generic changes take time and work. This requirement is a moot point for educators. Noteworthy, perhaps, is that student attitudes did not become more negative after the role play. This outcome was considered, given that the role-played character (in contrast to the more responsible character in the written vignette) seeks collusion in an attempt to deceive and ‘blind-treat’ his/her partner. Any negative views of this request (Lee/Leigh – Appendix 1) did not transfer to judgements about ‘John’ (Appendix 2)

The result for age – no difference – was unsurprising give the lack of contrast. Regarding ethnicity, the differences resist evidenced explanation, but a tentative suggestion is cultural variance, upbringing and personal exposure (or not) to individuals in these circumstances. The data upheld that the white British group admitted more exposure to STIs than their peers from other groups. This suggests a relationship between attitude and personal experience, the latter perhaps making students more favourably disposed towards individuals with similar experience to themselves. The sample is reasonably diverse, but a larger group would establish relationships between personal experience and attitude more robustly.

The finding that all the ethnic groups agreed that their own attitudes were more positive than those of others suggests something interesting about student ‘medics’ as a cultural group. These results suggest that they regard themselves as tolerant. An obvious question is whether their agreement that they hold more positive attitudes that the general public is rooted in a degree of self-righteousness or a particular perception about the prejudices of unnamed others. Of course, we might consider that bright students know how to ‘respond appropriately’, and that the educational itself setting could influence the integrity of the response, but such risk is inherent in questionnaire research. It is equally possible that this result reflects their level of education, access to information, genuine suitability to be doctors of the future and so on. Indeed, these results may replicate in a larger study of, say, health professionals and the general public – a project for the future perhaps?

It is worth commenting on the finding that females reported more positive attitudes, especially with regard to dating. We might present a number of explanations from social medicine, based on data about gender differences, but without further study theories are speculative. It is interesting though to consider that previous testing history appears to be less of a barrier to females, who perhaps perceive it as a positive screening process? Considering differences between ethnic groups (fewer white-British students saying ‘no’ to the date) other factors such as social/cultural attitudes towards dating (and what dating comprises) in the first place would need to be considered. The issues are complex.

Attitudes are, by reputation, considered difficult to evaluate. However, giving consideration to attitudinal teaching and assessment is a challenge that must be met by educators. Attitudinal change for learners comes from within, and may be a lengthy process as they encounter, and reflect on the complex circumstances they will encounter individually and in teams in professional life. Managing the sexual history is one such complex area, and one which (in our view) merits a more central position on the medical education stage.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Notes

Notes

1. The medical degree Bachelor of Medicine Bachelor of Surgery.

2. Previous study at Birmingham suggests that unrecorded ethnicity is likely to be in cases where disclosure is perceived as particularly sensitive.

Appendix 1

Role play scenario from the study workshop (summary of role player notes)

You are Lee/Leigh Robertson. A month ago you went out with work friends to celebrate a colleague's promotion. It was a great evening, but you consumed far too much alcohol. Later you ended up ‘getting off with’ with a member of the opposite sex you met in a nightclub. Subsequently you went home with them, and spent the night. You feel pretty bad about this now: e.g. “You must think I’m awful … ”, “I’ve let myself down, I can’t believe I did that with him/her … .” Your memory of the night, and the person, is vague. In the aftermath you feel a bit ‘dirty’.

If you are asked:

• You had sex twice, oral and vaginal both times.

• You did not use a condom.

• If you are a female you are on the pill.

• You have a long-term partner who is not aware of this one-night stand, which you now feel guilty about.

You have heard people talking about an infection called Chlamydia, which allegedly ‘causes infertility in women’. You are becoming increasingly worried that you may have caught it and transmitted it to your partner. You hope that you haven’t caught it and would like the GP to reassure you – “You don’t think I’ve got it do you, it was only one night?” (You are less concerned about other infections, as you’ve had no symptoms. You are not explicitly worried about HIV/AIDS, both of which you associate with excessive promiscuity and drug abuse.)

You’d be too embarrassed to go to a GUM clinic. Can’t the doctor just give you some antibiotics for yourself, and some that you could discreetly slip into your partner's food? You don’t want to tell your partner about your lapse, as they would definitely finish with you.

Appendix 2

Written vignette used as the focus for the pre- and post role play attitudinal questionnaire

John is 21, is in his last year of a geography degree and lives in a shared student house. He is not in a serious relationship at the moment, having recently broken up with a regular girlfriend from home. John has always been open about his health with his friends. Recently, during a night in with his housemates John refused alcohol, explaining that he was taking a course of antibiotics, provided by his GP, for Chlamydia. He explained that he’d heard that someone he’d had a previous sexual relationship with had tested positive, so he’d requested a test “to be on the safe side”.

When the conversation opened up John also openly revealed that in the past he’d had 2 HIV tests (both negative) he seemed surprised that his friends had never requested similar tests or treatments.

Appendix 3

Questionnaire

Attitudes to STI Study (AMIS)

Researchers within the Department of Primary Care and General Practice are undertaking research to determine the opinions that people hold about individuals with sexually transmitted infections living in the community.

We would appreciate it if you would take 5 minutes to complete this questionnaire and hand it in at your small group tutorial.

The questionnaire is totally anonymous and cannot be traced back to you. We therefore ask that you be as honest as you can and consider the questions carefully rather than just indicating what you believe to be a politically correct response.

If you have any questions about this research please contact Connie Wiskin in the Department of Primary Care on the number below.

C. Wiskin

Department of Primary Care & General Practice

The Medical School

The University of Birmingham

Edgbaston

Birmingham B15 2TT

Telephone [phone]