1. Phase 1. Educational Topic Selection and Contents Development based on users’ needs
1.1 STEP 1–1: Literature review
To select topics and contents for sex and menstrual education targeting university students, existing literature, articles, social media, games, and self-diagnosis instruments were conducted. As a result of the literature review, 15 pieces of content were selected (Appendix 1).
1.2 STEP 1–2: Expert Review
Based on the results of STEP 1, four experts (1 obstetrician, 2 sex education experts, and 1 menstruation education expert) reviewed the topics and contents. As a result, genital structure and function, genital abnormalities, dysmenorrhea, contraception, childbirth, sex violence, self-assessment, and 'Obstetrics and Gynecology in our Neighborhood (Wooridongsan)’ have been added. Based on STEP 1–1 and 1–2 results, contents were categorized into 5 topics, including menstruation, contraception, STDs, gender identity, and dating violence.
1.3 STEP 1–3: Student Review
To ascertain the needs of the students, eight participants (six males and two females) were engaged to review the topics and contents identified in the preliminary stages. Feedback revealed a desire for comprehensive information on oral contraceptives, preventive measures for STDs, potential drug side effects, and resources for addressing gender identity concerns. While presenting on dating violence, potentially triggering content was succinctly conveyed using neutral language, and a checklist for recognizing dating violence was incorporated. Furthermore, content focusing on fostering a safe and pleasurable sexual life, along with guidance on healthy masturbation practices, was integrated. Consequently, the topic 'masturbation' was incorporated, augmenting the initial five topics: menstruation, contraception, STDs, gender identity, dating violence, and masturbation.
1.4 STEP 1–4: Video/PDF Content Development
In this study, eight university students collaboratively developed sex and menstruation education content, which was subsequently presented in two formats: PDF and video. The self-reviewed and self-developed educational content, encompassing six themes, was termed SSME 6 < Figure 2>.
2. Phase2. Validation of educational content effectiveness
2.1 General Characteristics and sex and menstruation-related factors
The homogeneity test of general characteristics, sex, and menstrual education-related factors did not reveal significant differences between the two groups. However, it is noteworthy that there was a statistically significant difference observed in the level of sex knowledge between the two groups (Table 1).
Table 1
General characteristic and homogeneity test results (N = 80)
Characteristics
|
Categories
|
Video group
(n = 40)
|
PDF group
(n = 40)
|
ꭓ2 or t (p)
|
n (%) or M ± SD
|
n (%) or M ± SD
|
Sex
|
Male
|
10 (25.0)
|
7 (17.5)
|
0.67(.412)
|
Female
|
30 (75.0)
|
33 (82.5)
|
|
Age
|
|
21.95 ± 1.73
|
22.07 ± 2.61
|
0.10 (.922)
|
Grade a
|
1st
2nd
3rd
4th
|
15 (37.5)
3 (7.5)
14 (35.0)
8 (20.0)
|
13 (32.5)
12 (30.0)
11 (27.5)
4 (10.0)
|
7.24 (.065)
|
Major a
|
Health
Humanities
Natural
Engineering
Arts
Else
|
13 (32.5)
15 (37.5)
3 (7.5)
2 (5.0)
3 (7.5)
4 (10.0)
|
21 (52.2)
8 (20.0)
6 (15.0)
2 (5.0)
3 (7.5)
0 (0.0)
|
9.01 (.109)
|
The Presence of a Sibling
|
Yes
No
|
23 (57.5)
17 (42.5)
|
24 (60.0)
16 (40.0)
|
.05 (.820)
|
Experience in Dating
|
Yes
No
|
30 (75.0)
10 (25.0)
|
33 (82.5)
7 (17.5)
|
.67 (.412)
|
Sex Education Experience
|
Yes
|
40 (100.0)
|
40 (100.0)
|
-
|
Menstruation Education Experience
|
Yes
|
40 (100.0)
|
40 (100.0)
|
-
|
Satisfaction with the previous sex and menstruation Education
|
|
3.34 ± 0.54
|
3.17 ± 0.59
|
-1.38 (.173)
|
Sex and Menstruation Education Period a
|
Kindergarten
|
4 (10)
|
3 (7.5)
|
-
|
Elementary School
|
26 (65.0)
|
29 (72.5)
|
Middle School
|
39 (97.5)
|
37 (92.5)
|
High School
|
36 (90.0)
|
37 (92.5)
|
University or Higher
|
9 (22.5)
|
12 (30.0)
|
Sex and Menstruation Education Content a
|
Gender Equality
|
33 (82.5)
|
33 (82.5)
|
-
|
Masturbation
|
10(25.0)
|
7 (17.5)
|
Pregnancy and Childbirth
|
33 (82.5)
|
31 (77.5)
|
Sex and Contraception
|
26 (65.0)
|
30 (75.0)
|
Prevention of STDs/AIDS
|
20 (50.0)
|
22 (55.0)
|
Menstruation
|
26 (65.0)
|
25 (62.5)
|
Menstruation Products
|
9 (22.5)
|
14 (35.0)
|
Dealing with Pornography
|
16 (40.0)
|
11 (27.5)
|
Gender Sensitivity
|
14 (35.0)
|
5 (12.5)
|
Dating Violence
|
26 (65.0)
|
23 (57.5)
|
Sex and Menstruation Knowledge Acquisition Path a
|
Lecture
|
11(27.5)
|
8 (20.0)
|
7.56 (.272)
|
TV
|
1 (2.5)
|
1 (2.5)
|
Computer
|
16 (40.0)
|
10 (25.0)
|
Smartphone
|
7 (17.5)
|
17 (42.5)
|
Books
|
3 (7.5)
|
2 (5.0)
|
Friend
|
1 (2.5)
|
2 (5.0)
|
Parents
|
1 (2.5)
|
0 (0.0)
|
Sex Knowledge
|
|
9.95 ± 4.22
|
11.63 ± 2.96
|
2.056 (.044)
|
Sex Attitude
|
|
83.95 ± 5.10
|
84.08 ± 5.86
|
.103 (.918)
|
Sex Communication
|
|
13.90 ± 2.75
|
14.15 ± 2.84
|
.400 (.691)
|
Menstruation Knowledge
|
|
8.53 ± 2.41
|
9.10 ± 2.21
|
1.114 (.269)
|
Menstruation Attitude
|
|
120.05 ± 13.13
|
120.48 ± 10.04
|
.163 (.871)
|
aFisher’s exact test |
2.2 SSME6 Effect
The efficacy of the educational interventions on several outcome measures, including knowledge and attitude towards sex and menstruation, and sex communication, was assessed. Preliminary analyses indicated no salient differences in these dependent variables pre- and post-intervention across both groups. However, post-intervention assessments post-SSME6 revealed a significant augmentation in sex knowledge within the Video group (t=-2.66, p = .010). Similarly, the PDF group exhibited a noteworthy increase in menstruation knowledge post-SSME6 (t=-2.74, p = .008) (Table 2).
Table 2
Comparison of the effect of the Video group and the PDF group (N = 80)
Variables
|
Group
|
Pre test
|
Post test
|
t(p)a
|
Different
(post-test
-pre-test)
|
t(p)b
|
M ± SD
|
M ± SD
|
Sex Knowledge
|
Video
|
9.95 ± 4.22
|
12.33 ± 3.77
|
-2.657 (.010)*
|
2.35 ± 5.45
|
-1.68(.097)
|
PDF
|
11.63 ± 2.96
|
12.98 ± 3.12
|
-1.965 (.053)
|
1.38 ± 2.65
|
Sex Attitude
|
Video
|
83.95 ± 4.99
|
84.85 ± 4.76
|
-0.824 (.413)
|
0.90 ± 3.75
|
0.49 (.627)
|
PDF
|
84.08 ± 5.86
|
85.90 ± 4.95
|
-1.506 (.136)
|
1.83 ± 4.14
|
Sex Communication
|
Video
|
13.90 ± 2.75
|
14.63 ± 3.17
|
-1.093 (.278)
|
0.73 ± 3.35
|
-0.74(.460)
|
PDF
|
14.15 ± 2.84
|
13.70 ± 3.37
|
.645 (.521)
|
-0.45 ± 3.52
|
Menstruation Knowledge
|
Video
|
8.53 ± 2.41
|
9.78 ± 3.18
|
-1.981 (.051)
|
1.25 ± 2.40
|
0.49 (.625)
|
PDF
|
9.10 ± 2.21
|
10.53 ± 2.66
|
-2.608 (.011)*
|
1.43 ± 2.11
|
Menstruation Attitude
|
Video
|
120.05 ± 13.13
|
122.28 ± 10.65
|
-0.832 (.408)
|
2.23 ± 8.69
|
0.37 (.716)
|
PDF
|
120.48 ± 10.04
|
123.15 ± 13.15
|
-1.023 (.310)
|
2.67 ± 10.69
|
Health-ITUES
|
Video
|
|
86.75 ± 11.23
|
|
|
1.139(.258)
|
|
PDF
|
|
89.45 ± 9.94
|
|
|
|
Impact
|
Video
|
|
4.66 ± 0.55
|
|
|
-0.354(0.724)
|
|
PDF
|
|
4.62 ± 0.50
|
|
|
|
Usefulness
|
Video
|
|
4.45 ± 0.62
|
|
|
0.626(0.533)
|
|
PDF
|
|
4.56 ± 0.48
|
|
|
|
Easy of use
|
Video
|
|
4.18 ± 0.73
|
|
|
1.697(0.094)
|
|
PDF
|
|
4.44 ± 0.66
|
|
|
|
Control
|
Video
|
|
3.85 ± 0.88
|
|
|
1.450(0.151)
|
|
PDF
|
|
4.12 ± 0.76
|
|
|
|
Quiz score (total)
|
Video
|
|
9.48 ± 2.72
|
2.69 (.009)*
|
|
|
PDF
|
|
10.83 ± 1.63
|
|
|
Menstruation
|
Video
|
|
1.48 ± 0.64
|
1.73 (.088)
|
|
|
|
PDF
|
|
1.70 ± 0.52
|
|
|
Contraceptive
|
Video
|
|
1.63 ± 0.63
|
1.25 (.214)
|
|
|
|
PDF
|
|
1.78 ± 0.42
|
|
|
STDs
|
Video
|
|
1.60 ± 0.59
|
1.92 (.059)
|
|
|
|
PDF
|
|
1.83 ± 0.45
|
|
|
Sex Identity
|
Video
|
|
1.65 ± 0.62
|
2.57 (.013)*
|
|
|
|
PDF
|
|
1.93 ± 0.27
|
|
|
Dating violence
|
Video
|
|
1.33 ± 0.76
|
2.50 (.015)*
|
|
|
|
PDF
|
|
1.70 ± 0.56
|
|
|
Masturbation
|
Video
|
|
1.80 ± 0.52
|
1.06 (.295)
|
|
|
|
PDF
|
|
1.90 ± 0.30
|
|
|
t(p)a = independent t-test within group; t(p)b = independent t-test between groups (difference), STDs = Sexual Transmitted Disease, *=p < 0.05 |
Additionally, there was a statistically significant difference in the total score of the quiz (t = 2.69, p = .009), which was higher in the PDF group than the video group. In the sub-area of the quiz, the gender identity quiz (t = 2.57, p = .013) and a dating violence quiz (t = 2.50, p = .015), a significant difference between the two groups was confirmed (Table 2).
The usability score of the PDF group was evaluated with a higher score. In the subdomains, the PDF group was evaluated with higher scores than the video group in perceived usefulness, perceived ease of use, and user control, excluding impact (Table 2).
3. Post-interviews
The study participants expressed concerns regarding their prior education on sex and menstrual, noting it was marked by a lack of comprehensive explanations, irrelevant information, and monotony attributed to the uniformity of content. In assessing the SSME6, participants found content delivered in PDF format, generated using PowerPoint, to be more comprehensible compared to purely text-based materials. However, one notable limitation pertained to the extensive textual information in the educational material, which compromised readability and sustained attention. Several participants expressed a preference for video-based content. Those exposed to the video format acknowledged its merits, particularly the inclusion of pertinent information presented in detail, supplemented with visuals, thereby enhancing understanding. Nonetheless, criticisms arose regarding the extensive duration of the educational content, with several participants finding it challenging to maintain focus due to the artificial sound of the AI-generated voiceovers. Moreover, a call was made to include more male-centric content and pragmatic information.
3.1 Opinion on Existing Sex Education
Most students did not have experience receiving sex and menstrual education in university. They said that they were provided sex and menstrual education together when they were in middle and high school, so they lost their concentration and felt ashamed.
-
PDF Group A students: “I never received sex and menstrual education in university. In high school, I did not know the words 'gender' and 'dating violence'. While serving in the military, I received sex and menstrual education but only received sex violence education. Menstrual education is also the first.”
-
Video Group B students: “When I was receiving sex and menstrual education at school, I felt ashamed, so I did something else or lay down on the desk in class.”
3.2. SSME 6 Education Content Evaluation
Participants responded that learning new facts they did not know before was useful and that the details were helpful. They said that it was good that the types were subdivided and classified into dysmenorrhea drugs or contraceptives. In addition, they said that it was the first time they knew that topics such as dating violence and masturbation were not covered in existing education through SSME 6.
-
PDF group B students: “It was good that SSME 6 clearly categorizes STDs and informs them. In addition, I didn't know exactly about female masturbation, and I knew that female masturbation was only performed by unusual women. However, SSME 6 provided detailed information about this, which I was satisfied with.
-
PDF group E students: “The subject of dating violence was unfamiliar and amazing because it was the first time, I had encountered it in my life. I know about male masturbation."
-
Video Group B Students: “Through SSME 6, I learned about contraception. I learned about the 10 laws of dating violence, and I studied information on my own for confusing questions while taking the quiz.”
-
Video Group C Students: “It was so nice to learn about things I didn’t know in SSME 6 about prevention of contraception, coping with STDs, 4 gender categories. Contraception and menstruation helped the most. I liked that information was very detailed.
Also, there was an opinion that SSME 6 content is more open than the existing education method because it deals in detail with various content related to sex.
-
Video group A Student: “I thought Korea's sex and menstrual education was very conservative, but SSME 6 is as open as other countries, so it's easy to be approachable. I think this sex and menstrual education should be further developed and spread.
3.3. Opinion on the Mobile-based Sex Education Method from PDF group
The PDF group expected that the video education method would have a greater educational effect than the PDF method. Because PDF is a PPT education material consisting of text and pictures, it can be difficult to maintain concentration. Also, they expected it to be less immersive than a video education method with an audio explanation function, suggesting that the educational effect of PDF is likely to be insignificant.
-
PDF group A students: "When I receive sex and menstrual education in PDF, I skim and skip it, but the video explains in detail so that I can study with more concentration."
-
PDF group E students: "PDF consists of just text and pictures because the video consisted of audio, so I feel like I'm learning kindly. I think the video learning effect will increase even better."
3.4. Opinion on the Mobile-based Sex Education Method from Video group
Most of the video group believed that PDF would have a lower educational effect than video. Since PDF does not provide audio explanations, there is expected to be a difference in the learning effect between video and PDF in that participants read and understand the PDF themselves. They also say that videos can keep students concentrated and engaged more than PDFs because PDFs can be skipped if learners lose interest. Conversely, however, there was also an opinion that PDF materials are highly readable and will be helpful in any education delivery method.
-
Video group C, E students: "PDF has a lot of texts, so I can read them roughly and move on easily, but in the case of videos, the voice was provided even if there were a lot of texts, so it made me concentrate.”
3.5. Limitations of SSME 6 Content and Improvement Plans
Overall, there was an opinion that there was no content in sexual intercourse. This is because most learners acquire knowledge about sexual intercourse through pornography, so they lack awareness of whether they are having proper sex. In addition, the students wanted information on the types and necessity of examinations performed in obstetrics and gynecology, dealing with unwanted pregnancies, and the crime of abortion. Also, there was an opinion that if SSME 6 is released as a mobile app, it should be designed so that others do not know it is a sex and menstrual education mobile app.
-
PDF group D students: "I want to know about proper sex through sex content that is not stimulating."
-
Video group D students: “It would be nice if there were educational content related to preparation such as STD testing and washing before sexual intercourse.”
-
Video group E students: “It would be nice to have content about sexual intercourse. I usually talk about sexual intercourse with my friends, but I can't get the right knowledge because I'm ashamed. It is necessary to prevent teenagers from viewing pornography and learning the wrong sex intercourse.”
3.6. Intention to Recommend for Using SSME 6 Content
Most of them said they would like to recommend it to their friends (regardless of the male or female gender), boyfriends, girlfriends, and teenagers. But they said that it was difficult to recommend it to their families.