Introduction
Sexuality education is accepted as an essential part of health professionals' training (Leiblum, 2001, Weerakoon & Stiernborg, 1996). It is, therefore, important for all health professionals to understand their own attitudes, feelings, and judgments about sexuality and have a basic knowledge of the issues involved. Health professionals need to develop the comfort and competence to address the concerns of their clients at a level appropriate to themselves, their clients and the clinical situation; with the option of referral to higher levels of management (Ramage, 1998; Leiblum, 2001). Research indicates that sensitisation/desensitisation in attitudes and values (Leiblum, 2001, Weerakoon and Steirnborg, 1996), basic knowledge of genital structure, the sexual response cycle and changes in the lifecycle as well as competence in communicating with a client on sexual and relational issues are considered essential (core) components of most sexuality education programs. It is, however, recognised that health professionals work in varying clinical situations and environments and are likely to have differing needs in specific content areas. For example, physical therapists are more likely to encounter sexual concerns associated with physical disability (Brackett, Nash & Lynne, 1996) while occupational therapists are more involved in developmental and intellectual disabilities and aging (Couldrick, 1998; Schneider, Weerakoon & Heard, 1999). This flexibility required to meet individual students' needs make curriculum development difficult. Some recent sexuality education programs have allowed for this by providing students choice in the selection of workshops (Leiblum, 2001, Weerakoon & Steirnborg, 1996)

There are many other constraints to the introduction of sexuality education in a standard health professional curriculum (Weerakoon & Steirnborg, 1996). One of the most important constraints is finding a place for it in the crowded teaching schedule. Sexuality education does not fall easily within a discipline such as medicine, surgery, anatomy, psychology, nor does it fit within a body system such as cardiovascular, respiratory or genito-urinary. The result of this dilemma is that sexuality education is often accommodated either as short workshops or as elective courses. This, however, does not alleviate the problem of students having to find the hours in their timetable to attend the scheduled learning sessions. Other constraints include the lack of trained staff and resources (Bonner & Gendel, 1989; Weerakoon & Steirnborg, 1996).

Accepted instructional methodologies for sexuality education include small group discussions (Bonner and Gendel,1998; Leiblum, 2001; Weerakoon and Steirnborg, 1996), "real life" situations with panels of lay and professional people (Bonner & Gandel, 1989; Leiblum, 2001) and audio-visuals such as film and video (Weerakoon and Steirnborg, 1996). Effective learning methods need many resources as well as time for development and are therefore difficult to develop and implement in any environment lacking such resources.

It has been suggested that computer-based learning could prove the vehicle to overcome many of these obstacles (Leiblum, 2001, Weerakoon, Steirnborg & Wong, 1998). On-line (web-based) learning was initially considered as an option to reduce the dependence on staff and overcome timetable constraints and therefore increase the accessibility to students. It is increasingly being realised that on-line learning has unique features, that when utilised carefully, encourage student-centred constructivist learning (Lesh, Guffey & Rampp, 2000) with access to the resource-rich world wide web environment. In sexuality education it also offers a medium where students can explore attitudinal issues in a safe environment, and discuss sensitive topics in the relative anonymity of an on-line group discussion forum (Weerakoon and Wong, 2002)

This paper describes an on-line (web-based) sexuality education program for health professionals offered in the Faculty of Health Sciences at the University of Sydney. This faculty provides professional training for allied health professionals including physical therapists, occupational therapists, rehabilitation counsellors, medical radiation therapists and leisure and health consultants. Evaluation of the course and future plans to improve it will also be discussed. The program is delivered using the Web CT on-line course delivery platform, which has been adopted by the University at an institutional level, and has support in the form of training and personnel. Web CT is a browser-based learning management system with an integrated suite of tools, including discussion board, quiz and glossary. This simplifies web site design and allows educators to create and manage effective sites without access to extensive computer programming skills.

Description of the program:

The unit is developed on the PLISSIT management model (Annon, 1974). This model which is used in many sexuality education programs (Weerakoon & Stiernborg, 1996) provides a set of hierarchical competencies in sexual health care. This begins with granting "Permission" (P) to a client to have sexual concerns and discuss them, to providing "Limited Information" (LI) on issues, and "Specific Suggestions" (SS) and finally "Intensive Therapy" (IT).

To view a sample of the site go to the URL - http://learn-on-line-admin.usyd.edu.au.
Both the login name and password are SexEdguest.

Students enter the program at the homepage from which they can access any of the program components. The introduction section provides information about the program, the schedule and an explanation of the PLISSIT model.

The content modules consist of an introduction followed by the three stages of learning, each corresponding to the first three PLISSIT levels. The fourth level of "Intensive Therapy" has not been included since the provision of intensive sex therapy is not part of the professional role of most allied health professionals. The structure of each of the three PLISSIT learning stages in the program is kept consistent. The aims and objectives for each stage are followed by the relevant resources, learning triggers and activities. An on-line journal is provided and entries are recommended as relevant.

There are links from the content modules to on-line resources and learning activities (group work and individual). These activities are supported by on-line communication tools (see the sample site), which include:

• A Discussion Forum - where students talk to others in their small groups, and the course coordinator posts messages to the groups.
• Let's talk - a synchronous chat space where experts and interesting people could be made available for consultation and discussion.
• E-mail - which allows students to communicate directly with the course coordinator.
• Help section - with a large number of diagrams. This is accessible via links from the homepage and site menu. A print version of "Help" is also provided to the students at the beginning of the unit.

The on-line program was first offered in 2001 as an elective unit, with an enrolment of 58 students. Student evaluations were conducted on-line at the completion of PLISSIT stages 1 and 3. Twenty-five students responded to the first evaluation and 28 to the second. The response rates of 43% and 48% respectively were probably due to the fact that responses to the evaluation questionnaires were optional.

On-line instructional methodology:

On-line learning has several advantages in terms of instructional methodology for sexuality education. Students are able to learn at their own pace and level of professional interest, in a non-judgmental and comfortable environment. This program has been developed to maximise learning in the on-line environment. Some of the activities in the program require group discussion, facilitating the process of collaborative learning. Others, like clinical scenarios, and experiential activities provide a professional focus for learning. The value clarification quizzes allow anonymity for attitude exploration with immediate feedback. The on-line resources and web links, which support the learning activities, can also be used as an independent source of reference material.

Knowledge: required and desired

Knowledge provides the foundation for the exploration of attitudes and values and development of skills (Weerakoon and Steirnborg, 1996). This program requires students to learn core topics (such as genital structure and function, the sexual response cycle and lifecycle issues) with the flexibility to choose further content relevant to their personal and professional interests (desired knowledge). A 30-item mastery type multiple-choice quiz is used to self evaluate student's knowledge of these core topics. The students are allowed two attempts at the quiz. An analysis of their responses is provided, with references to relevant on-line resources. This form of extrinsic feedback (Laurillard, 1993) provides students with the resources and the tools to assess their knowledge and explore topics of which they are unsure.

The course then provides the flexibility for students to select, in consultation with the course coordinator, topics additional to these core areas. The areas that students choose to further investigate (desired knowledge) are determined by their individual interest and includes a range of topics which include sexual concerns in physical and intellectual disability, sexuality and aging, rape and abuse and issues of pornography and prostitution. These choices that form the basis for some of the individual learning activities, are supported by on-line resources and links to web sites external to the program.

Students appreciated the resources, with 96% of those responding to the evaluation commenting that they were useful or very useful.

Attitude and value clarification:

The exploration of attitudes and values is a stated learning objective in PLISSIT stage 1. However, it continues to be foundational to the other stages and learning activities. This is addressed specifically in the attitude questionnaires (see sample site). Students receive immediate feedback on submission of completed questionnaires on 'sexual desire' (see sample site) and 'attitudes'. Submission of the quiz provides an immediate feedback in which the individual studentís response (indicated by a circle) is compared to the responses of all previous respondents (indicated by a bar graph). The feedback acts as a stimulus for reflection and active learning, sensitising students to their attitudes and values in relation to others.

The students appreciated the quizzes, as reflected by comments in the PLISSIT stage 3 evaluation such as:

• "The attitude questionnaire was very useful since it dealt with issues that are not often voiced. It was very educational seeing others' responses"
• "I particularly liked being able to compare my responses with the rest of the class. It was easy to be honest because it was anonymous."

Researchers recognise the importance of small group discussions in sexuality education (Weerakoon and Stiernborg, 1996). Sexuality, however, is a difficult topic to discuss. People learn early in life that intimate talk is inappropriate in most circumstances (Aitken and Shedletsky, 1998), and find it difficult to discuss sexuality in a classroom situation. These students may benefit most from on-line learning. This is supported by a developing body of research (Aitken & Shedletsky, 1998, McCormick & McCormick, 1992, Parks & Floyd, 1996) that demonstrates that many people feel less inhibited in their communication and express a feeling of safety and comfort when engaged in on-line discussions. Although the use of on-line learning is new to this area, research indicates that many people demonstrate a willingness and ability to discuss difficult and challenging topics when on line, rather than face-to-face (Aitken and Shedletsky, 1998. Our own experience supports the fact that students who find face-to-face discussion difficult have no problems with the on-line format and actually enjoyed it.

Group activities 1 and 2 are part of PLISSIT stage 1. The first group activity is an "icebreaker" exercise. Students are instructed to post sexual words and phrases they use or have heard of in the Discussion Forum and explain why these are used. This process of 'sensitisation-desensitisation' is used extensively in sexuality education (Weerakoon & Stiernborg, 1996).

The second aims to develop observational skills in client-health professional comfort in sexual issues. Specially scripted video triggers are provided for this exercise. The students are encouraged to reflect on the tasks in their own time before communicating with other group members. A group response to the task is negotiated and e-mailed to the course coordinator. A response is posted on-line by the course coordinator.

The third group activity is part of PLISSIT stage 3. In this activity students explore the options available for the management of sexual concerns and the levels of care available. This exercise is set up to encourage group collaboration. Five clinical scenarios are presented on-line. Students are instructed to identify the problems and discuss in their groups (in the discussion forum) the management in terms of the PLISSIT model using the resources provided. A negotiated group response is sent on-line to the course coordinator.

Of the 25 students who responded to the PLISSIT stage 1 evaluation, 72% commented that they were "more aware of their attitudes and values towards sexual issues" than they were before they started the unit. Forty-four percent of the respondents reported that they were "more comfortable" talking to a client and the others reported no change. None felt "less comfortable" talking to a client.

Although the elective was offered on-line, all students enrolled in 2001 were on campus, and the on-line discussion forum was used by the students to set up appointments for group work, rather than for the actual purpose of communication. This was in spite of 72% commenting on how difficult it was "to find a time to meet".

The group exercises turned out to be a valuable collaborative learning exercise for the students even though not conducted on-line. This was demonstrated by students' responses to the PLISSIT stage 1 evaluation question "What was the best thing about the unit?"

• "Hearing other people's opinions and values and being able to compare them with mine ? then analyse them together as a group."
• "It was really interesting how others' attitudes towards sexual matters differed so much from what I expected. The fact that we were in an academic setting made it ok to talk about sex."
• "The fact that I can now relate better to those in my group, especially those I did not know. We now talk to each other about other things."

• "I learnt a lot about how to deal with situations that may arise in relation to sex. I feel more comfortable about how and when to ask about sex."
• "Bringing sexuality down to a level that everyone can talk about it, relate to it and making it not such a taboo area of discussion."
• "I have learned a great deal about my thoughts and attitudes towards clients and sexuality. This unit has opened my eyes to different areas of knowledge and given me strategies to deal with difficult situations."

The experiential learning activities are designed to enable students to explore individual areas of interest as well as to gain an understanding the role of sexuality in their specific professional environments. Role-play and modelling are the most commonly used methods reported for learning history-taking and appropriate intervention (Weerakoon and Steirnborg, 1996). These have been adapted for on-line learning, and consist of a literature review, an audio taped interview and a visit to a sexual health centre.

The taped interview forms part of PLISSIT stage 1. It provides students with the opportunity to explore their personal comfort in talking about sexuality in a topic area selected by them and obtain feedback on the process from the course coordinator. Students selected a topic from a suggested list and conduct an interview (5-10 minutes) The topics are linked to relevant resources. The individual interview was the only learning activity conducted completely off-line. This, however, was the one that stimulated the greatest dialogue between the students and the course coordinator. Students contacted the coordinator requesting permission to conduct interviews on topics not in the list such as incest experience and description of first sexual intercourse. The course coordinator was able to use the dialogue to explore the students' individual reasons for enrollment in the unit and their goals for the future before suggesting an interview format and topic, establishing a "conversational framework" for learning (Laurillard, 1993).

Student evaluation of the interview process was positive with comments such as:

• "Doing the interview was good. It made me realise that talking about sex was not as scary as I first thought."
• "The interview taught me that I was not as comfortable asking questions about a persons' sexuality as I had thought I was and needed to learn more about options available to a person with sexual limitations."

Future plans for the course:

This program has been developed in the School of Biomedical Sciences and is based on a biomedical model of sexual health care. Future development will focus on the addition of psychosocial components in resources, discussion and learning activities.
The program has been developed for allied health professionals and does not include PLISSIT stage 4. Further development is likely to include PLISSIT stage 4.

Sexuality is an area where self-reflection and self-assessment play an important role. Stefani, Clarke and Littlejohn (2000) comment on the need to provide students with opportunities for self assessment and reflection on their achievement, so that they can develop a sense of their own personal and professional development. The sexuality education unit has an on-line "reflective journal". Students are prompted to record their feelings and thoughts in this journal. The journal is currently for the private use of the student. Future development of the program will use the journal as a focus of discussion on individual professional goals.

Conclusion:

The adoption of Web CT by the University of Sydney and the availability of resources for staff training and support have contributed to the development of this quality on-line learning experience. This program meets the sexuality education needs of allied health professionals with diverse interests and educational backgrounds. The program utilises the facilities and tools available for on-line learning to provide flexibility in the use of time, place and resources by both students and instructor and opportunities to explore individual interests. By reducing the need for scheduled class time and other resources, this program increases the ease with which sexuality education can be introduced into the crowded health professional curriculum. Since on-line learning is not bound by geographical boundaries, it will encourage collaboration between educators and make sexuality education available in countries where it is currently absent.

References:

Aitken, J.E. & Shedletsky, L. (1998) On-Line Strategy To Teach Intimate and Safer Sex Communication Skills. ERIC document - ED426425

Annon, J.S. (1974) The Behavioral Treatment of Sexual Problems. Honolulu, Hawaii: Kapiolani Health Services.

Bonner, E.M. & Gendel, M.D. (1989) Sex Education in Medicine - Implications for Family life Education. International Journal of Adolescent Medicine and Health, 4, 203-212.

Brackett, N.L., Nash, M.S. & Lynne, C.M. (1996) Male fertility following spinal cord injury: facts and fiction. Physical Therapy. 76, 1221-1231.

Couldrick L.(1998) Sexual issues within occupational therapy, part 1: attitudes and practice. British Journal of Occupational Therapy, 61, 538-544

Laurillard, D. (1993) Rethinking University teaching: A framework for the effective use of educational technology. Routledge, London & New York.

Lesh, Steven G., Guffey, J. Stephen, & Rampp, Lary C. (2000) Changes in Student Attitudes Regarding a Web-Based Health Profession Course. ERIC Digest number AN: ED441386

Leiblum, S (2001) An established medical school human sexuality curriculum: Description and evaluation. Sexual and Relationship Therapy, 16 (1) pp 59-70.

McCormick, N.B. & McCormick, J.W. (1992) Computer friends and foes: Content of undergraduate's electronic mail, Computers in Human Behavior, 8 (4) 379-405.

Parks, M.R. & Floyd, K. (1996) Making friends in cyberspace. Journal of Communication, 46 (1) 80-97.

Ramage, M. (1998) ABC of sexual problems: management of sexual problems. British Medical Journal, 317, 1509-1512.

Schneider, J., Weerakoon, P. & Heard, R. (1999). Inappropriate client sexual behaviour in occupational therapy, Occupational Therapy International, 6, 176-194.

Stefani, L.A., Clarke, J. & Littlejohn, A.H. (2000) Developing a student centred approach to reflective learning. Innovations in Education and Training International, 37 (2) 163-171.

Weerakoon, P. & Stiernborg, M. (1996). Sexuality education for health care professionals: A critical review of literature. In R. Rosen, C. David & H. Ruppel (Eds) Annual Review of Sex Research, 7, 181-217.

Weerakoon, P., Stiernborg, M. & Wong, M. (1999) Computer assisted learning in sexuality education: development. Journal of Sex Education and Therapy, 24, 175-181.

Weerakoon, P. & Wong, M. (2002) Maximising opportunities for learning: Sexuality education on-line. Proccedings of the HERDSA annual conference, Quality Conversations - Research and Development in Higher Education. Annual International HERDSA conference - 7-10 July, 2002, Perth, WA, Australia.

Return to Front Page