Sexual Health – Where Theory Meets Life

Triece Turnbull and Mark Forshaw analyse the contribution of health psychology

Pages: 748-751

Health psychology has the potential to become a leading force in sex and relationship education (SRE). Government bodies, schools and parents all need the specialist knowledge of health psychologists so that a coordinated approach can be employed to give young people the information they need to make informed choices over their personal relationships and sexual behaviour. This, in time, should reduce currently high rates of teenage pregnancy, sexually transmitted infections and abortions that are well documented in the literature from the UK.

In 21st-century Britain the negative outcomes of sexual risk-taking behaviour in young people are well documented (Mueller et al., 2008; Sales et al., 2009). Although government strategies have previously been put in place to address the negative outcomes associated with young people’s behaviour, the teenage pregnancy and sexually transmitted infection (STI) rates have continued to rise (DCSF, 2010; Rogers & Evans, 2011). This is in addition to the UK having high abortion rates, which has also raised concerns regarding Britain’s sexual health strategies and the sex education that is provided (Paisley, 2009).

Taking into account the facts relating to sexual health, it is imperative that effective strategies be deployed before the negative sexual health outcomes for the UK worsen. The government is treating sexual behaviour as a public health issue, but although steps are being taken to improve the current sexual health situation it is important to address these and seek improvements for the future, drawing upon the right people and suitably qualified health professionals who can make a difference. For decades we have relied upon teachers, health promoters and health educators, but the rates of teenage pregnancy have risen. Something about the way we do things at present is not working.

Over the last decade various criticisms have been raised regarding governmental attempts to provide effective sex and relationship education (SRE). However, statutory SRE guidance (Department for Education & Employment, 2000) needs to be adhered to, which incorporates key guidance to ensure that primary, secondary, special schools and pupil referral units in England deliver effective SRE. Regrettably, the Office for Standards in Education, Children’s Services and Skills (Ofsted), who are the authority responsible for inspection and regulation of SRE provisions, suggests that some teachers do not have the confidence, knowledge and skills to deliver effective sex education. According to Ofsted (2010), this is in part due to teachers feeling embarrassed when teaching sensitive subjects, and in part because they have not been given expert training to teach SRE properly. Young people themselves say that they want properly trained teachers who are confident and competent to teach SRE as part of PSHE education (UK Youth Parliament, 2007), so it may be that more specialist teachers are needed to teach SRE.

Although it is important that schools follow the SRE guidance in relation to the quality of SRE provided, it is also vital that they follow the recommendations to include parents in the sex education that is given (DfEE, 2000). Many parents are happy for schools to undertake the role  of providing SRE to their children (Sex Education Forum, 2011), but parents do recognise their responsibility to educate their children, especially since they play a central role in their development, growth and health. Some may even use computers to increase communication, allowing parents and their children to learn about SRE topics together (Turnbull et al., 2010a, 2011a).

However, research has shown that some schools do not inform parents of the SRE that is taught to their children (Turnbull, 2011a, 2011b) and parents do not see the school SRE policy, which should detail the sex education that is provided (Turnbull et al., 2011b). These factors have been found to act as a barrier to discussing sexual matters openly within families (Turnbull et al., 2008). Parents also admit to not always having the up-to-date SRE knowledge to discuss sexual matters openly with their children (Turnbull, 2011a; Turnbull et al., 2011a, 2011b).

It is clear that many parents want to be involved in the SRE that is given to their children, and they need support in this area. This mainly needs to come from schools, but also strategies need to be developed to improve parents’ knowledge so they feel equipped to talk to their children about sexual matters. Government bodies, education authorities and parents are all striving to change the direction of the current SRE delivery that leads to sexual health problems in the UK. But barriers need to be removed and unity is needed in the approach to giving young people the SRE they need and deserve, which is an area where qualified health professionals can make a difference.

Fundamentally, SRE in the context of high quality Personal, Social and Health Education (PSHE) provision needs to be given the same precedence as other subjects within school and awarded equal importance as improving health and prevention of illness. At present emphasis is put on the physical consequences associated with pregnancy, STIs and abortions rather than on the emotional and psychological well-being that is linked with poor SRE, which in turn influences people’s sexual choices and sexual behaviour. This is where we need an approach that goes beyond the training of the current providers. We need people trained in understanding human behaviour in a health context, and it is surprising to think how little, historically, that has been recognised. Health psychology in particular as a discipline is perfectly positioned to embrace the current needs of SRE and sexual health as it focuses not only on the biological and social but also on the psychological factors that can influence health and illness. This is especially so in providing young people with the information they need regarding relationships, emotions and self-esteem (UK Youth Parliament, 2007). In short, we’ve been missing a trick for a very long time.

For decades, several approaches in health psychology have proved useful at understanding sexual behaviour and the social cognitions relating to attitudes and sexual experiences. For example, from as early as the 1940s sex surveys have been employed to investigate people’s sexual habits from a behavioural perspective (e.g. Johnson et al., 1994; Kinsey et al., 1948). In the 1960s greater attention was given to the physiology of human sexual behaviour (Masters & Johnson, 1966), and more recently health psychology has turned its attention to using health psychology models to focus upon measuring the beliefs, attitudes and perceptions of people and their sexual behaviour, including studying safer sex practices, such as condom use (Abraham & Sheeran, 1994; Bayley et al., 2009). Although these approaches are beneficial in explaining, understanding and predicting sexual behaviours and sexual attitudes, qualified health psychologists are able to provide sexual health information and have a profound effect on the delivery of SRE if only they get chance to do so. Examples of the beneficial areas where health psychologists have contributed towards facilitating learning in relation to SRE and sexual health include:I    teens’ sexual experience and preferences for school-based sex education (see Newby et al., 2012); interventions to change individuals’ behaviour in relation to safer sex (see Hancock & Brown, 2011); effectiveness of school-based sex education (see Wight, 2011); SRE in the family context using interactive technologies (see Turnbull et al., 2010b); risk of chlamydia infection among young people attending a genito-urinary medicine clinic (see Newby et al., 2012) and school-based condom promotion leaflets (see Hill & Abraham, 2008).

However, how do health psychologists work in practice compared to other health specialists regarding sexual health? If we were to use chlamydia in young people as an example, health specialists would take the stance of emphasising the use of a condom to prevention infection and reduce national statistics. They would also point out the risks associated with acquiring chlamydia and the problems this can have on reproductive health (i.e. risk of fertility if not treated). Although this information is important, health psychologists would be looking at advancing upon these determinants of preventing chlamydia by accessing young people’s knowledge, risk perceptions and self-efficacy to use condoms. They would identify the reasons for young people not using a condom to prevent chlamydia and put interventions in place that are purposeful to the individual to meet their specific aims of preventing infection. A good example of how this has been achieved in practice is by Joshi et al. (2012), who looked at using intervention mapping to develop a computer-based sex education lesson on chlamydia for secondary school pupils. Their initial aims were to conduct a needs assessment, followed by intervention objectives and practical strategies. From this they were able to develop an intervention plan that allowed for delivery and evaluation to demonstrate that their approach had been effective in preventing chlamydia. Various strategies have been employed by sexual health specialists that have not demonstrated overall effectiveness (Kirby, 2007), which is why it is imperative that health psychologists are involved in the design and delivery of such programmes associated with the promotion of sexual health.

Perhaps there is a misconception that qualified health psychologists focus upon how people cope with and manage illness? In fact they are well trained to promote health and change risky behaviours by working with the government and the National Health Service, if only they themselves, and others around them, will see it. Properly qualified health psychologists have a vital role to play in relation to research and teaching and as independent SRE sexual health consultants. Therefore, utilising their skills and knowledge they can have a massive impact in the future on providing SRE and promoting positive sexual health.

It’s time for a coordinated approach to sexual health issues. In essence, a comprehensive sex education programme needs to be developed, in collaboration with relevant bodies such as the British Psychological Society and its Division of Health Psychology, that follows the legislation and SRE guidance given by the DfEE (2000). Although SRE facts would be the main element regarding content, the programme also needs to challenge people’s beliefs, attitudes and perceptions relating to sexual health and sexual behaviour. We would advocate an e-learning programme that would I     allow a uniformed approach for teaching SRE to all children and young people; give teachers and parents the knowledge to teach SRE and work together when educating children and young people of sexual matters; mirror the content detailed in the SRE guidance by the government; and provide a system where sex education can be measured on its effectiveness and altered if needed to meet changing demands of SRE guidance and policy.

As well as delivering these benefits, the e-learning programme will allow teachers and parents to learn about sexual matters from specialists who have the knowledge and skills to train them and increase their confidence so they too can feel comfortable and competent in the delivery of SRE topics. Over time the training will allow for others to learn from this system, which can be modified to keep abreast of any Department for Children, Families and Schools SRE guidance changes resulting from a current review, being part of a wider review for PSHE. Furthermore, a ‘champions’ system could be employed once there are sufficient numbers of trained teachers to train other SRE teachers in order to improve and sustain a holistic approach to teaching SRE. This would provide an overarching approach to teaching SRE whereby the advantages – for children, teachers, parents, and even the health and economy of the nation, could be immense.

Several SRE packages, such as ‘Share’, ‘Ripple’ and ‘Healthy Respect’ (see Wight, 2011) exist to teach about sexual matters, but there is no single e-learning programme, based on health psychology principles, that can be measured on effectiveness when educating teachers, parents and their children. Therefore a structured SRE programme needs to challenge this as it might have massive gains, not just through the dissemination of SRE knowledge, but acting directly upon it. This could then help to reduce teenage/unwanted pregnancies and STIs, and save the National Health Service and sexual health services in particular millions of pounds a year. Utilising the approach discussed is a perfect step forward in SRE and an achievable strategy to tackle the current SRE problems that are leading to the sexual health challenge in the UK. Promoting and encouraging an open culture in SRE and sexual health provides better health and well-being for all and would allow the UK to share its successful SRE strategy with other countries by transferring knowledge to promote positive sexual health at a global level. Let us start thinking in joined-up ways, and let health psychologists be the glue between the policy makers and the service users.

Triece Turnbull
is a sex and relationship health consultant - 
triece_turnbull@yahoo.co.uk

Mark Forshaw
is Principal Lecturer in Psychology at Staffordshire University - m.j.forshaw@staffs.ac.uk

References

Abraham, C. & Sheeran, P. (1994). Modelling and modifying young heterosexuals HIV-preventative behaviour. Patient Education and Counseling, 23, 173–186. Bayley, J., Brown, K.E. & Wallace, L. (2009). Teenagers and emergency contraception. European Journal of Contraception and Reproductive Health Care, 14(3), 196–206.
Department for Children, Schools and Families (2010). Teenage pregnancy strategy: Beyond 2010. Available via tinyurl.com/92k42jy
Department for Education and Employment (2000). Sex and relationship education guidance (0116/2000). London: HMSO.
Hancock, J. & Brown, K. (2011, May). Understanding your population: The need for exploratory work. Paper presented at the British Psychological Society Annual Conference,  Glasgow.
Hill, C.A. & Abraham, C. (2008). School-based, randomized controlled trial of an evidence-based condom promotion leaflet. Psychology and Health, 23(1), 41–56.
Johnson, A.M., Wadsworth, J., Wellings, K. & Field, J. (1994). Sexual attitudes and lifestyles. Oxford: Blackwell.
Joshi, P., Newby, K.V., Lecky, D.M. & McNulty, A.M. (2012, February). Using intervention mapping to develop a computer based sex education lesson on Chlamydia Trachomatis for secondary school pupils. Paper presented at the Midlands Health Psychology Network Conference, Coventry.
Kinsey, A.C., Pomeroy, W.B. & Martin, C.E. (1948). Sexual behaviour in the human male. Philadelphia: W.B. Saunders.
Kirby, D. (2007). Emerging answers: Research findings on programs to reduce teen pregnancies and sexually transmitted diseases. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancies.
Masters, W.H. & Johnson, V. (1966). Human sexual response. Boston, MA: Little Brown.
Mueller, T.E., Gavin, L.E. & Kulkarni, A. (2008).The association between sex education and youth’s engagement in sexual intercourse, age at first intercourse, and birth control use as first sex. Journal of Adolescent Health, 42(1), 89–96.
Newby, K., Wallace, L.M., Dunn, O. & Brown, K.E. (2012). A survey of English teens’ sexual experience and preferences for school based sex education. Sex Education, 12(12), 231–251.
Newby, K., Wallace. L.M. & French, D. (2012). How do young adults perceive the risk of chlamydia infection: A qualitative study. British Journal of Health Psychology, 17, 144–154.
Ofsted (2010). Personal, social, health and economic education in schools. London: Author.
Paisley, I. (2009). Abortion statistics highlight Britain’s roll of shame. Retrieved 23 January 2011 from tinyurl.com/bteynvh
Rogers, S. & Evans, L. (2011, 11 August). Teenage pregnancy rates through England and Wales. The Guardian.
Sales, J.M., Spitalnick, J., Milhausen, R.R. et al. (2009). Validation of the worry about sexual outcomes scale for use in STI/HIV prevention interventions for adolescent females. Health Education Research, 24(1), 140–152.
Sex Education Forum (2011). Parents and SRE. London: National Children’s Bureau.
Turnbull, T. (2011a). Exploring sex and relationship education in British families. Education and Health, 29(2), 35–37.
Turnbull, T. (2011b). Sex education: It’s a family affair. Durex Network: Challenges, 2, 6–7.
Turnbull, T., van Wersch, A., & van Schaik, P. (2008). Sex education in the family context. Health Education Journal, 67(3), 182–195.
Turnbull, T., van Wersch, A. & van Schaik, P. (2010a). Adolescents’ preferences regarding sex and relationship education. Health Education Journal, 69(3), 277–286.
Turnbull. T., van Wersch, A. & van Schaik, P. (2010b). Evaluation of sex and relationship education in the family context using an interactive CD-ROM: A grounded theory approach. European Journal of Contraception and Reproductive Health Care, 15(1), 95–96.
Turnbull, T., van Schaik. P. & van Wersch, A. (2011a). Parents as educators of sex and relationship education: The role for effective communication in British families. Health Education Journal, 70(3), 240–248.
Turnbull, T., van Wersch, A. & van Schaik, P. (2011b). A grounded theory approach to sex and relationship education in British families. Qualitative Methods in Psychology Bulletin, Issue 12, pp.41–51.
UK Youth Parliament (2007). SRE: Are you getting it? London: Author.
Wight, D. (2011). The effectiveness of school-based sex education: What do rigorous evaluations in Britain tell us? Education and Health, 29, 67–73.

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Sex Education and the Importance of Health Psychology

WOW! Where did it all start and how have I got to where I am today? The question seems quite simple, but the answer is so much more complex. I will, however, try and give an explanation of my professional journey, especially in relation to my experience associated with the Stage 2 Qualification and the British Psychological Society. However, first of all I will start with an explanation stating what I do and how health psychology has impacted upon the career path I have chosen.

I currently work as a sex and relationship education (SRE) consultant giving expert sexual health advice to health professionals, using information technology to teach effective SRE and governing research that covers all aspects of sexual health, including sexuality. I firmly believe that people’s sexual health is as important as their general health, which is why I am dedicated to encouraging that children and young people are given quality SRE and the sexual health advice they need. However, my research has shown that it is essential that parents are involved in this education so they can support and provide the knowledge to their children in order for them to make informed choices over their sexual behaviour and personal relationships (Turnbull, 2011; Turnbull, van Schaik & van Wersch, 2011a, 2011b; Turnbull, van Wersch van Schaik, 2010a, 2010b, 2008, 2007a, 2007b). This is echoed by the Government who suggest that as well as parents being able to educate their children they are also beneficial in supporting the emotional and physical aspects of their children’s health and assist in preparing their children for adult life (DfEE, 2000). Although I have become recognised in my specialist area I cannot omit my significant academic experiences in psychology that have taken me down the path of SRE and sexual health.

In essence, my interest in SRE and sexual health started some 10 years ago when I studied the History of Sexual Behaviour for a public health-related module as part of my BSc (Hons) in Psychology. From there I undertook an MSc in Health Psychology studying Sexual Initiation and Peer Pressure for my dissertation and then in 2004 I started a PhD that used computers to explore the communication of SRE within British families. At this time I was encouraged by my PhD supervisor and mentor, Professor Anna van Wersch, to apply to the Society for enrolment on the Stage 2 Qualification in Health Psychology. Although I saw this as a natural progression in my career I also saw it as a great challenge at that time, worrying about how I could accomplish everything especially as was I already working as a part-time lecturer at the Teesside University, was undertaking a full-time PhD and worked full-time as the SRE Development Co-ordinator for the Middlesbrough area. However, on reflection taking the leap and pushing myself to the edge of reason was one of the best decisions I ever made because it allowed me to realise my own strengths and weaknesses, and what I needed to do to overcome these. For example, I knew I had the skills to multitask; I knew how to organise my time effectively; I knew I was not scared of hard work or that I was not going to be able to take every weekend off; but the one thing that daunted me from the outset (apart from the viva, of course!) was that I had to include a systematic review for the Stage 2 Qualification. I know this sounds totally ridiculous to some people, but I simply did not feel confident as the last (and only) systematic review I did was pretty poor and I would equate it to the worst academic piece of work I ever did. I had the challenge of overcoming this, which I did by reading almost every book and article with systematic review in the title and trying to mimic other people’s styles. I swear I did not plagiarise, but the success to this tale is that although it took me over a year on-and-off to write my systematic review I did eventually achieve it through learning from others, and it was re-formatted and published in the Health Education Journal (Turnbull, van Wersch & van Schaik, 2008).

Although I had fears whilst doing the Stage 2 Qualification I would like to share some of the things that helped make my journey easier. Firstly, I would recommend that every person doing the Stage 2 Qualification should use and treat the Candidate Handbook as though it is their prized possession. I thought that it was only useful for when I developed my supervision plan, especially the section which detailed the Accreditation for Existing Competence (AEC) because I could include some of the work I had undertaken previously from being an SRE Development Co-ordinator. However, whilst I was completing my Stage 2 Qualification I quickly realised that there was valuable information in the Candidate Handbook which often answered some of the silly questions I had. Beyond the stupid questions, Bethan Carley (Qualifications Officer for Health, Counselling and Clinical Neuropsychology) at the Society was always there to offer help, advice and steer me in the right direction. In my experience she is a good port-of-call especially as Bethan is able to assess whether the Chief Supervisor and Registrar, Dr Mark Forshaw, needs to be included in queries and then he can decide whether the advice of the Chief Assessor, Dr Martin Dempster, is needed. What I am trying to say is that there is a great Qualifications Team at the Society who are at your disposal. Use them – I did!

Although the learning materials given by the Society are helpful, as are the team itself, it is also essential for you to use your Stage 2 supervisor. I was fortunate that my Stage 2 supervisor was also my Principal Supervisor for my PhD and, therefore, I would take the opportunity to schedule PhD meetings and add time to it so I could get work signed off or ask for advice if needed. With hindsight this was a smart move on my part as it saved me a massive amount of time and I still got the invaluable wisdom and knowledge of my supervisor without having separate meetings. If candidates were able to arrange their own supervisor in this way then they would be in a win-win situation, but if not I would recommend that they keep to a schedule that is agreed in the contract with the supervisor. This way they get the help and advice that they need so don’t waste time fretting and worrying about problems that can easily be resolved with advice from the supervisor.

A final aspect to my Stage 2 Qualification that served me well was to be extremely well organised. I know I sound sad but my evidence files were colour-coded! When I say colour-coded I don’t just mean different coloured files, but each of the post-it tags were matching as they defined each unit of each competence – I told you I was sad! However, this served many purposes in that: (a) it was be easier to refer from one competence to another with most of them relating to SRE; (b) with some of my work being AEC it was easy to see the distinction between the AEC work and the work that had been carried out, which was detailed in the original supervision plan; and (c) it looked professional, even if I do say so myself. My perfectionist ways regarding presentation and organisation also made it easier to prepare for the viva voce once I had handed my work in to be marked by the assessors.

In essence, after handing in my portfolio and evidence files to the Society I went through each unit of each competence with a fine-toothed comb. I marked my work as critically as I would as a lecturer marking someone else’s work. In fact, on reflection Health Psychology Update, Volume 20, Issue 3, 2011 21 Sex education and the importance of health psychology I was far more critical of myself than I have ever been of any student. However, I found numerous spelling mistakes, realised that some sentences just did not make any sense whatsoever and I forgot to include the teaching diary that I had prepared. I know that to some these were not grave mistakes, but they were still errors all the same. I did not want to look incompetent and I had spent an enormous amount of time on my Stage 2 Qualification to make it perfect because I simply did not want to fail. To help in not failing I also went back through my work again and thought about, for each unit of each competence, the types of questions that could be asked at the viva. Obviously I am not an assessor so I would not know the questions that were going to be asked. However, I felt that I was just preparing myself as possible for the viva – that was up until the time when I got the letter stating the date and time at when I need to be at the Society’s office in Leicester.
There is almost an element of excitement, but then pure anguish when you open the envelope. At the time I felt more of the latter, so off I went again going through my file thinking of other questions that could be asked, ‘re-marking’ my work. I found a few more spelling mistakes and generated another 28 questions in preparation for the viva. After this I felt as ready as I could be so all that was left was the viva. On the day of the viva I felt nervous as would be expected. I had convinced myself that the day was going to be a good one and that what was meant to be was meant to be. Pass or fail, I had done everything I could. In addition, there were a few things that I saw as positive signs in that on my journey from the north-east of England to Leicester – it was sunny, everyone was smiling (except me!) and the M1 was quiet, which is quite a novel concept. With this I remember thinking, just go in there and do your best, you know your stuff – just do it! Being mentally prepared I arrived at the Society’s office in Leicester. After being sat in the reception for a short while I was asked to go to a meeting room on the first floor. When I arrived I was greeted by two men who were both really pleasant. They informed me that they were going to ask some questions and that the viva was going to be recorded. The latter would normally have made me feel uncomfortable, but it did not seem to matter. I was just in auto-pilot knowing that all I had to do was answer the questions the best I could. Although I can hardly recollect verbatim the questions that were asked I seemed to be able to answer them all okay. However, I do put this down to the organisation and the revision of my work prior to viva. Although the viva itself went okay I was not expecting the assessors to be so nice. I suppose we all have this image that the viva will be gruelling and unpleasant, but it was nothing like that, quite the opposite.

On reflection, the Stage 2 Qualification was not easy to acquire. At times I had to make difficult decisions to fulfil what was expected of me. It was also hard to juggle the workload, but at no one time did I ever wish I was not doing the qualification. I just kept thinking of something that my husband and late father have always said to me and that is… ‘If it was easy, everybody would do it.’ I am proud to be a member of the DHP especially as since passing the Stage 2 Qualification I have progressed and become a Chartered Psychologist, Chartered Scientist and Associated Fellow of the British Psychological Society. I have also become a registrant of the Health Professions Council and I am looking forward in time to being a Stage 2 Supervisor so I can pay forward all the help, support and success that I have achieved.

Acknowledgments

I would like to send special thanks to Professor Anna van Wersch for all her wisdom and encouragement throughout the Stage 2 Qualification. I would also like to send my sincere thanks to the Society’s Qualifications Team for their guidance and support, plus all my family and friends who have supported me on this journey.

Dr Triece Turnbull

References

Department for Education and Employment (2000). Sex and relationship education guidance (0116/ 2000). London: HMSO.

Turnbull. T. (2011). Sex and relationship education in British families: How do we move forward? Education and Health, 29(2), 35–38.

Turnbull. T., van Schaik. P. & van Wersch, A. (2011a). Sex and relationship education in England: What do parents and children want? British Psychological Society: North East England Branch, 4(5). In press.

Turnbull. T., van Schaik. P. & van Wersch, A. (2011b). Parents as educators of sex and relationship education: The role for effective communication in British families. Health Education Journal. In press.

Turnbull. T., van Wersch, A. & van Schaik, P. (2010a). A grounded theory approach to sex and relationship education in British families. Qualitative Methods in Psychology. In press.

Turnbull. T., van Wersch, A. & van Schaik, P. (2010b). Evaluation of sex and relationship education in the family context using an interactive CD-ROM: A grounded theory approach. European Journal of Contraception and Reproductive Health Care. 15(1), 95–96.

Turnbull. T., van Wersch, A. & van Schaik, P. (2008). Adolescents’ preferences regarding sex and relationship education. Health Education Journal, 69(3), 277–286.

Turnbull, T., van Wersch, A. & van Schaik, P. (2007a). Sex education in the British family context: Grounded theory approach. Health Psychology Review, 1(1), 20-21. Also available at: www.ehps2007.com.

Turnbull, T., van Wersch, A. & van Schaik, P. (2007b). Sex education in the family context. Health Education Journal, 67(3), 182–195.

Health Psychology Update, Sex education and the importance of health psychology, 25(10), 748-751.

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