Introduction

Sexual health is one of the most important aspects of family and community health, affecting people of all ages at all stages of life (1). Various studies have highlighted the importance of promoting knowledge and skills about sexual education and counseling in medical students and medical staff including midwives (2-5).

The World Health Organization considers midwives to play a substantial role in evaluating and improving sexual health and providing counseling for families (6). However, when dealing with patients requiring sexual counseling, most physicians and midwives lack the skills or self-confidence to assess, diagnose, and treat sexual problems (3, 7).

Previous studies have demonstrated a close relationship between self-efficacy and an individual's performance in service provision. Since the introduction of the concept of self-efficacy in 1977 by the Canadian psychologist, Bandura, extensive research has been performed in fields of medicine, nursing, sports, and education with regard to this concept. According to Bandura, self-efficacy is the feeling of adequacy, efficiency, and competence in coping with life. In fact, meeting and maintaining the performance criteria enhance self-efficacy, while failure to meet or maintain these criteria can have debilitating effects (8).

In the realm of education, self-efficacy refers to students' beliefs regarding their ability to perform the assigned tasks. Students with high self-efficacy show more interest, effort, and endurance in fulfilling their responsibilities and are confident in their abilities (9, 10). Researchers believe that self-efficacy plays an important role in applying professional knowledge and skills (11). In fact, self-efficacy plays a mediating role between knowledge and practice (8). This role accentuates the need for novel and active educational methods, which can expand and improve students’ clinical decision-making abilities, continuous and self-centered learning, and their self-efficacy.

Workshops and standardized patient (SP)-based training are among active methods which can eliminate the gap between education and practice and contribute to effective learning. Workshops are compressed, short-term training programs, with the aim to transfer knowledge and improve practical skills in particular subjects with participation of a limited number of individuals.

The aim of workshops is not merely the transfer of training messages from short-term to long-term memory, but is the active training of essential skills. According to previous studies, the closer the learning environment is to reality, the more effective learning will be (12-14). Therefore, SP or real patient can be used as a simulation method in medical sciences for training and evaluating students. Use of SP can develop the skills of novice students in a safe, stress-free environment (13, 15, 16). Another advantage of SPs is improving students’ decision-making abilities and self-confidence in offering services (17, 18).

Given the scarcity of information on methods, which are associated with students' self-efficacy in providing sexual health counseling, this study was performed to compare the effects of training by interactive workshops with or without SPs on the self-efficacy of midwifery students in providing sexual health counseling at Mashhad University of Medical Sciences, Mashhad, Iran in 2014.

Materials and Methods

In this quasi-experimental, two-group, before-and-after study, 84 eligible midwifery students at the School of Nursing and Midwifery, Mashhad University of Medical Sciences were recruited after obtaining permission from the ethics committee. The participants had passed the course of sexual dysfunction and were in the seventh semester of B.Sc. or the first or third semester of M.Sc. in midwifery.

The subjects were selected using stratified random sampling, based on their marital status and academic semester. Then, the students in each stratum were randomly assigned to two groups using the table of random numbers, and each group participated in one of two interactive workshops with or without SPs. Students who did not complete the questionnaires before or two weeks after the training or refused to fully participate in the courses were excluded from the study. A total of 22 students were excluded from the study due to their unwillingness to continue the study, interference of the intervention with their academic roles, and transfer to other universities.

Finally, 62 students remained in the study, 36 of whom were allocated to the SP group and 26 to the non-SP group. Data collection tools included a questionnaire on demographic characteristics and academic history of the students and a researcher-made tool for assessing the students’ self-efficacy. The questionnaires were prepared based on the latest scientific literature including books and articles in the field of sexual counseling.

The self-efficacy tool consisted of 24 items on the students’ feeling of competence and self-efficacy in different aspects of sexual health counseling. The items were graded on a five-point scale, ranging from completely agree (score 4) to completely disagree (score 0). The questionnaire was completed by the students before starting the training sessions.

The validity of the demographic and self-efficacy questionnaires was evaluated and confirmed via content validity by ten members of the scientific board. Also, the reliability of self-efficacy questionnaire was confirmed through internal consistency (Cronbach's alpha=0.9). The total score of self-efficacy in providing sexual health counseling was 96. The scores were graded as follows: poor (score: 0-24), moderate (score: 24-48), good (score: 48-72), and excellent (score: 72-96).

Five different scenarios were planned in the workshops and five SPs were trained to play these scenarios, each concerned with communication, taking sexual history, disease diagnosis, and decision-making regarding a specific condition or disorder. The training sessions were held for 10 hours in form of a two-day workshop for each group. On the first day, theoretical subjects (e.g., counseling techniques, taking sexual history, sexual counseling for healthy individuals, sexual counseling during pregnancy, lactation, and adulthood, and counseling on different sexual disorders) were presented, using lectures, slideshows, and question-answer method for five hours.

On the second day, students in the SP group were divided into five sub-groups, each consisting of 6-7 students practicing with an SP for 30 min; afterwards, all the students were gathered as a large group. One student from each small group, as the group representative, interacted with the SP in the presence of all students and took the patient’s sexual history, diagnosed the condition, and proposed the preferred therapeutic approach. Then, other students discussed the case and gave their comments. At the end of each session, the status of the presented case was summarized by the researcher in collaboration with the students.

In the non-SP group, the students were divided into five sub-groups and the five mentioned scenarios were presented in form of written cases. After discussions about each case in small groups, the students gathered as a large group. One student from each small group repeated the process of sexual history taking and presented the findings of small-group discussions including the possible diagnosis and the preferred therapeutic approach. Then, the students discussed the case, and finally, the results were summarized by the researcher in collaboration with the students.

Duration of training on the second day was five hours in each group. Theoretical and practical training in both groups was mainly performed by the researcher (M.Sc. student in midwifery counseling); also, a small part of the training was presented by a professor of reproductive health. Two weeks after the training, the self-efficacy questionnaire was again completed by the students of both groups.

For statistical analysis, the gathered data were entered to SPSS version 16.0. The mean scores of self-efficacy questionnaire, obtained by the students in each group before and after the intervention, were compared by paired t-test. Also, the difference in scores between the two groups was analyzed by independent t-test. In case the data were not normally distributed, Wilcoxon and Mann-Whitney tests were performed. P-value less than 0.05 was considered statistically significant.

The subjects were assured about the confidentiality of the data and the results were presented in general. Also, the participants were able to withdraw from the study at any time.

Results

The students' age ranged between 21 and 41 years. The mean age of the participants was 25.5±4.8 years in the SP group and 25.6±4.9 years in the non-SP group. However, Mann-Whitney test results showed no significant difference between the two groups in terms of the mean age (P=0.95).

As demonstrated in Table 1, the majority of students in the two groups were in the seventh semester of B.Sc. in midwifery. Chi-square test results showed that academic semester and educational level were not significantly different between the two groups (Table 1). Also, regarding marital status, the majority of the students in the two groups were married. However, Fisher's exact test results showed no significant difference between the two groups in terms of marital status (P=0.203).

The mean score of students on the theoretical course of sexual disorders (passed in previous semesters) was 17.2±1.3 (out of 20) in the SP group and 17.0±1.9 in the non-SP group. The results of independent t-test showed that the two groups were not significantly different in terms of the mean score on the theoretical course of sexual disorders (P=0.573).

In total, 8.3% (n=3) of the participants in the SP group and 11.1% (n=3) of the subjects in the non-SP group had the experience of counseling with clients suffering from sexual disorders. Fisher's exact test results showed that the two groups were not significantly different with respect to the frequency of providing sexual health counseling to clients (P=1.000).

As table 2 shows the independent t-test results showed no statistically significant difference in the mean score of self-efficacy before the intervention between the two groups (P=0.589). However, two weeks after the intervention, a statistically significant difference was observed in the mean score of self-efficacy in the two groups (P<0.001). Also, two weeks after the intervention, the mean scores of self-efficacy in the SP group were significantly higher than the non-SP group, based on independent t-test results (P=0.005).

Diagram 1 shows that students’ self-efficacy before the intervention was excellent in 2.8% (n=1) of the participants in the SP group and 3.7% (n=1) of students in the non-SP group. The results of Fisher's exact test showed that the two groups were not significantly different in terms of self-efficacy in providing sexual health counseling before the intervention (P=0.761). However, after theintervention, the subjects' self-efficacy was excellent in 55.6% (n=20) of the students in the SP group and 14.8% (n=4) of the students in the non-SP group. The Chi-square test results showed a statistically significant difference between the two groups in terms of the frequency of self-efficacy level after the intervention (P=0.001).

The students’ responses to each item (24 items) of the self-efficacy questionnaire were compared between the two groups by Mann-Whitney test. The results showed no significant difference between the two groups in any of the items of the questionnaire before training, whereas after two weeks of training, significant differences were found between the two groups in the scores of items other than 7, 8, 15, 17, 21, and 23 (in favor of the SP group) (P=0.001) (Table 3).

Discussion

In the present study, the effects of training by interactive workshops with and without SP on self-efficacy of midwifery students were compared. The results showed that the mean score of self-efficacy in providing sexual health counseling services was not significantly different between the midwifery students in the two groups before the intervention, and most of the students in both groups had moderate self-efficacy.

However, after the intervention, the mean score of self-efficacy was significantly higher in students who participated in SP-based workshops, compared to students who participated in workshops without SP. Also, the level of self-efficacy improved (to good and excellent levels) after the intervention in both groups.

In the SP group, 44.4% and 55.6% of the subjects showed good and excellent levels of self-efficacy, while in the non-SP group, 85.2% and 14.8% of the participants were at good and excellent levels, respectively. The results showed that applying SP in interactive workshops significantly increases the effectiveness of training. Although no previous research has compared the effects of workshops with and without SP on students' self-efficacy, several studies have assessed the effects of some active teaching methods on students’ self efficacy.

In this regard, in a study by Jarzemsky and McGrath (2008), use of patient-based active training in the clinical environment improved the students’ self-efficacy, compared to the control group (19). Also, in a study by Sinclair and Ferguson (2009), after the intervention, nursing students’ self-efficacy in care provision for patients with acute conditions was higher in the experimental group (trained by lectures and SPs), compared to the pre-intervention period and the control group (trained only through lectures) (20).