This study is a sequential exploratory (qualitative – quantitative) mixed methods design that consists of three consecutive phases. Following a qualitative approach, the researchers in this study will explain the facilitators and strategies associated with promoting sexual knowledge and social skills of teenagers with (MID) during puberty. In the second phase, the researcher will design an appropriate interventional program by using the results of the first phase and literature reviews. To this end, a literature review of papers and texts will be used in addition to the results of qualitative study. Then, the suggested program will be authenticated based on the prioritization guidelines. In the third stage, the efficacy of interventional program on increasing of the sexual knowledge and social skills of teenager’s girls and boys with MID will be investigated in a semi-experimental study. The collected data will be processed by SPSS Version 23.0 software and analyzed with descriptive-analytic statistical methods (Fig. 1).
First phase: qualitative study
At this phase, the researcher attempts to discover strategies and training methods to design an interventional program for teenager’s girls and boys with MID for increasing their sexual knowledge and social skills in puberty. This study is conducted via qualitative content analysis method.
Participants in the qualitative phase
Research community of the first phase comprises books, intervention guide, articles, mild intellectual disability adolescent girls and boys, parents, siblings, teachers, psychologists, consultants, specialist of children with special needs, professors, all of whom have the experience of dealing with problems of mild intellectually disabled adolescent.
Sampling method
In the present study, the participants are selected with a purposeful sampling method. They are selected according to the content, age, educational level, work experience, socioeconomic condition, and the pertinent research.
Inclusion criteria for participants
The inclusion criteria include the willingness to participate in the study and with informed consent for sharing information and participating in interviews. Ability to understand and express the experiences and Iranian nationality. For psychologists, consultants, specialist of children with special needs, having at least 4 years of working experience is necessary.
Also, to conduct the research, the following criteria and limitations were considered:
Articles published between 2000 and 2017, intervention articles included statistical population and sample, Studies involving at least one adolescent ages 12 to 16 years with mild intellectual disability, Studies about the effects of educational, behavioral, and psychological interventions and the consequences of the interventions were clearly conducted in theses, handbooks, interventional guides and educational programs.
Research environment
The participants have access to welfare and rehabilitation centers, exceptional education schools, consulting centers, psychological clinics, research institutes, university of psychology. The interviews will be performed at the time and place of the participants’ desire for their ease and comfort and more cooperation of them.
Data collection process
After selecting participants, the researcher will introduce the main objectives of the study. Then, the researcher will receive written consent regarding the participation in the research, further interviews, and recording the interviews. The researchers will ensure that the participants have their freedom to discontinue their cooperation with the study whenever they want. After obtaining a verbal and written consent from the participants, the interviews will be recorded using iPhone device. In case the sound recording is not allowed, interviews will be conducted by taking notes. Data will be collected through individual, in-depth, open, interviews, focus group discussions and field notes. The concerns of participants, especially parents, teachers, and siblings, were sought to gain the necessary confidence. The interviews will begin with the open questions for example “What is sex knowledge? What information should a teenager with MID have about sex in puberty? Can these people increase sexual knowledge? What methods can be used for sexual education to girls and boys with MID? What social skills should be taught to girls and boys with MID and by what method? What role will the family play in the training process? Then, according to the responses, the direction of the interview was guided. The data collection will continue until no new data code will emerge in the interviews.
Data analysis
Data will be analyzed using conventional content analysis. This method tends to reduce information and provide a detailed description of an issue (44). The researcher gradually summarizes the data under study to finally reach the most important concepts and themes relevant to the research topic. After recording the interviews, researcher explored the data to obtain a full understanding of the interviews. The encryption process was used in which encoding evidence grouping and naming ideas reflects broader perspectives. After generating the codes using the induction method, similar codes are merged and those with similar meanings fall into the same category to create subsets which is conducted by constantly comparing all the data. Finally, using the inductive process, similar subgroups fall into the main category. There are a variety of procedures for the thematic analysis process.
Accuracy and reliability of qualitative data
To have a reliable analysis, dependability, credibility, and transferability standards will be used [45]. Also, in order to improve the credibility of this study, a combination of data gathering methods such as individual interviews in different locations and times, focus group discussions, and field noting and the maximum variation in selecting the participants will be used. to study the validity of the findings, some examples of code extraction methods and their corresponding interview narratives will be reviewed by an external supervisor. For transferability, findings will be presented to people who have similar characteristics with the participants in order to compare the results of this study with their own experiences. Regarding verification, the researcher will explain the whole procedure. In order to verify the coding procedure, some of the research colleagues and professors, who are acquainted with qualitative research analysis and do not want to participate in this research, are asked to review the procedure.
Second phase: designing interventional program
The purpose of this phase is to design an intervention program to increase the sex knowledge and social skills of MID adolescent in puberty. In this phase, educational approaches and techniques are extracted based on the results of qualitative phase and studies conducted and their review. The method of review will be narrative review electronic and library resources including reference books, theses and experts and based on the intervention guide of Intervention Guide of Social Skills Improvement System (IGSSIS) and Intervention Guide for Behavioral and Emotional Issues (IGBEI) and other guidelines. Databases that will be used to search and identify related articles, are PubMed, Google scholar, SID, Scopus, Science Direct, Springer, Cochrane Library, MEDLINE, Elsevier and ProQuest. All the studies published between 2000 to 2017, both in English and Persian languages with qualitative, quantitative, and mixed methods study and with the keywords: Adolescence, Puberty, Intervention, Treatment, and Therapy, sex knowledge, sexual abuse, social skills, Communication, Parental training and parenting styles were investigated related to MID adolescents and their mother.
Holding a panel of experts
At this stage, the drafting of the strategies extracted from the qualitative research and review of the text will be prioritized using the decision matrix. In this way, these strategies will be presented to a number of experts in the first Delphi round in terms of cost, ease of implementation, timing and effectiveness; and for each dimension, a score between 1 and 3 will be considered. After completing their decision matrix and gathering opinions, the priority-based strategies given by each member will be prioritized for each dimension of interventions and strategies. Then, an intervention program will be designed for the highest priority strategies and in the second round of Delphi, a preliminary version of the proposed intervention program will be designed, presented, and evaluated in panel discussion in the presence of the research team and experts (including psychiatric specialists, psychologists, teachers, consultants, specialist of children with special needs, and professors). A few days before the meeting, a copy of the proposed intervention program will be accessible to the panel members to write their comments. Then, based on the panel members’ views, the corrections will be made to the designed intervention program, and subsequently implemented in the quantitative phase (Phase III of the study).
Third phase: quantitative study
Type and direction of the quantitative study
The quantitative phase of the research will be conducted via a four-group semi -experimental study.
The studied population
The targeted populations for quantitative study consisted of all boys and girls with MID from Exceptional Public Schools and their mothers.
Research sample
The research sample included girls and boys adolescents with MID and their mothers, selected through cluster sampling.
Research environment
This study was conducted in Exceptional Public Schools of girls and boys with MID in Yazd, Iran. The reason for selecting such kind of environment is the easy access to MID adolescents and their mothers.
Sample size
Sample size will be 15 participants in each group considering 95% confidence interval, 80% trial power, d = 7 and S= 14.
Sampling method
This clinical trial has two intervention groups and two control groups, selected through cluster sampling. At the beginning of each area, one schools for girls and boys with MID were selected and then from each school, the selected number of classes and in the next step number of students were selected randomly.
The inclusion criteria
Inclusion criteria of each group consisted of the adolescents with MID (IQ=60-70 with Wechsler Intelligence Scale for Children WISC-IV), between the age of 12-16, healthy eyesight and hearing, and literate parents (more preferable for the research).
Exclusion criteria
Non-cooperation and parental dissatisfaction with continuing work and failure to receive 50% of the intervention for any reason.
Study variables
In this study, the designed interventions were considered as an independent variable. On the other hand, sexual knowledge (SK) and social skills (SS) of mild intellectually disabled adolescent girls and boys were be deemed as dependent variables.
Data collection
The tools used in the quantitative phase of this research about sexual knowledge are researcher-made questionnaires. Following the preceding studies in this area, a 39-item questionnaire including five subscales (physiology knowledge, sexual knowledge, pregnancy, sexually transmitted diseases and sexual identity) was separately designed for girls, boys and mothers in 3 separate forms. In completing the questionnaire items, the respondents had three options including “right”, “wrong” and “I don’t know”. Each correct answer scored one point. In this scale higher scores are favorable. To determine the content validity of the survey, the Lawshe’s method was employed and the CVR and CVI indices were calculated. Additionally, a number of experts and professors were kindly asked to express their opinions regarding the contents after which the necessary changes were incorporated. The content validity ratio (CVR) was separately calculated for each item, the results of which ranged from 0.8 to 1. To calculate the content validity index (CVI), the research items were assessed in terms of relevance, clarity and simplicity. The experts expressed their views using a 4-point scale ranging from 1 to 4 as having a minimum (1) or maximum (4) degree of relevance, clarity and simplicity. In terms of face validity, certain items lacked simplicity or clarity hence the necessary changes were made accordingly. To make some items more understandable for the ID adolescents, the researcher used certain images. To measure the reliability of the survey, the test-retest method was used within a 2-week interval for girls and boys with MID. The correlation coefficients turned out to be 0.80 and 0.87 for the boys and girls, respectively. To further evaluate the internal consistency, the Kuder-Richardson method was used, the results of which turned out to be 0.81 and 0.83 for the boys and girls, respectively.
The SSIS questionnaire, prepared by Gresham and Elliott (2008), contains 79 multiple choice items including four options of “never”, “seldom”, “often” and “always”, coded as 3, 2, 1 and 0, respectively. The questionnaire examines the social and behavioral skills. Each of these scales in turn includes a number of subscales and each of which is assessed by a number of specific items. The “Social Skills” scale consists of seven subscales (Communication, Cooperation, Assertion, Responsibility, Empathy, Engagement, and Self-Control). In this scale higher scores are favorable. The “Behavioral Problems” Scale consists of 4 subscales (Externalized, Bullying, Hyperactivity/Inattention and Internalization). In this scale lower scores are favorable. The questionnaire can be used for the age group of 3 to 18 years and should be completed by parents. In this study, the questionnaire was administered to a group mothers of teenagers with MID, the results of which revealed that it enjoyed an appropriate reliability with the Cronbach’s Coefficient Alpha of 0.83. Research shows that the strength of SSRS is retained in the SSIS and the validity scales improve the psychometric properties [46-47].
The implementation method
This study was approved by the University of Isfahan. The study protocol was in accordance with the ethics committee criteria and informed consent was obtained from all participants in the study. The pre-test was administered to both mothers and adolescents and then the experimental group was exposed to the educational program. In the pre-test and post-test of the control and experimental groups, the SSIS scale was given to the students' mothers, and after explaining the aims and benefits of the research and the method of filling out the questionnaire, sexual knowledge about sexual knowledge was presented. Questionnaire (SKQ) was completed by boys and girls with MID and their mothers with researcher's guidance. The program aimed to teach sexual knowledge for 23 sessions while 15 sessions were allocated for teaching social issues via educational tools. Each session took 60 minutes and used of individualized education program. In each session, according to the content, the researchers used the card training, educational stories, and educational books with illustrations, role play and video training. The learning of student was examined through workbooks and used the reinforcement to increase learning. In training sessions, educational booklets and power point presentations were used for mothers to answer their questions. The control group was not exposed to such an intervention. Following the intervention sessions, the adolescents along with their mothers in both groups were given a post-test. It is worth mentioning that the results of the follow up was obtained with a 1- month interval.
Data analysis
The collected data was analyzed via descriptive statistical methods (mean, standard deviation, minimum and maximum) and inferential statistics (Multivariate covariance analysis (MANCOVA), and Mixed-Design analysis of variance) and by using SPSS 23 software.
Integration of the qualitative and quantitative data
The results of the qualitative and quantitative phases of the study were integrated and finally an interventional program was provided for MID teenagers and their mothers to increase the sexual knowledge and social skills in puberty.