Background
Relationships in various forms are an important source of meaning in people’s lives that can benefit their health, well-being and happiness [
1]. ‘A ‘distressed’ relationship is one with a severe level of relationship problems, which has a clinically significant negative impact on their partner’s wellbeing. Those in ‘distressed’ relationships report regularly considering separation/divorce, quarrelling, regretting being in their relationship, being unhappy in their relationship, for example’ [
2]. A growing evidence base shows that distress in relationships is associated with public health priorities such as alcohol misuse, obesity, mental health problems, and child poverty, whilst safe, stable, and nurturing relationships are potential protective factors [
3‐
5]. For young people (YP), there is evidence of a significant link between well-being and romantic relationships, suggesting that these relationships (when healthy) can positively influence self-concept, social integration and social support [
6]. However, research indicates that some early romantic relationships can act as stressors regardless of their nature, whilst YP are negotiating other developmental tasks. For example, Olson and Crosnow’s longitudinal analysis [
7] suggested that adolescent romantic relationships are associated with increased depressive symptomatology, particularly for girls.
The term ‘relationship’ has been defined as an enduring association between two persons [
8]. The terms ‘healthy’ or ‘quality’ relationships have been described, defined and measured in various ways. They are ‘complex and ambiguous constructs’ with factors varying for each type of relationship [
9]. Attempts to reach a definition tend to focus on interaction and positive and negative relationship characteristics and behaviours such as the existence or absence of caregiving, respect, support, emotional regulation, and the ability to learn from experience [
10,
11]. It has been theorised that early intervention and the development of these relationship skills in YP may allow them to negotiate early romantic relationships better as well as improve the quality and/or health of adult relationships, normalise help-seeking behaviour and prevent or manage relationship breakdown [
12,
13]. In their 2014 Manifesto, the Relationships Alliance
1 called upon The Department for Education (DfE) “to develop standards for those delivering RSE (Relationship and Sex Education) and set an expectation that schools recognise that developing relational capability is an important function of education and a child’s future” [
14]. Relational capability refers to the capacity to form and maintain safe, stable, and nurturing relationships [
15].
In 2019, DfE published statutory guidance in England on Relationship and Sex Education (RSE) [
16], following the passing of the Children and Social Work Act 2017 [
17]. The new Act stipulates
2 that pupils should learn about safety in forming and maintaining relationships; the characteristics of ‘healthy’ relationships and how relationships may affect physical and mental health and well-being. However, schools have been largely left to work out how to deliver this sensitive area of education, with little practical content guidance to date [
18]. Skills for ‘healthy’ romantic relationships have also been relatively neglected both in research and practice. There are several programmes developed for YP that teach about relationships, but those that currently exist are mainly from the US, and generally focussed on sexual health or relationship violence [
19,
20]. Similarly, research with YP on their perspectives of RSE mostly focus on their views on sex education [
21]. Therefore, despite the increased emphasis on delivering RSE in schools,
3 little is known about how YP view this aspect of the curriculum, or what outcomes they feel it should deliver. This is an important gap to fill to engage YP with the curriculum, and to lay the groundwork for the design, adaptation and evaluation of healthy relationship programmes. Patient and Public Involvement (PPI) work conducted in a prior project [
22] by some of the authors demonstrated a great appetite in YP to learn more about relationships.
Our Beacon project, funded by The Wellcome Centre for the Cultures and Environments of Health, is focussed on ‘Transforming relationships and relationship transitions with and for the next generation’ in two strands (Healthy Relationship Education (HeaRE) and Healthy Relationship Transitions (HeaRT)). As part of the project, we conducted qualitative interviews and focus groups with young people and relationship professionals, with the aims of exploring their perspectives on relationships and relationship education. This paper presents and integrates the findings of these studies, to inform the development of future Relationship Education.
Methods
Recruitment
YP were recruited from a convenience sample of community groups and schools in South-West England, across urban, suburban and rural settings. Young people were contacted through school and youth group leaders, who made the first approach to participants. YP consented for themselves if aged 16 and over; for under 16 s, both parent and young person consent was sought. The YP formed four focus groups with a total of 24 participants. The two focus groups conducted in schools were with Years 9 and 10 pupils (aged 14 to 16 years). Following PPI consultation, these were set up separately for boys and girls; one group with eight girls and one with seven boys. The community group focus groups included young people aged between 14 and 18 and had one group with four boys and one with two boys and three girls.
A purposive sampling strategy was used to recruit the relationship professionals, seeking out key people who are likely to provide rich sources of information or data [
22]. Here, ten nationally based relationship professionals (three men and seven women) were purposively sampled for their recognised expertise in the field of romantic relationships either through their research interests or because they were psychotherapists or counsellors. All had a minimum of 15 years of experience in their chosen field, and most had many more. Consent in writing or by audio recording was obtained before the interview.
Procedure
Focus groups with YP were used due to their suitability for exploring ideas within their social context [
23,
24]. The topic guides were developed and refined through accompanying consultations with YP in our Youth Panel PPI sessions. Content included questions and prompts around views on relationships, experiences of Relationship Education, and what YP wanted to get from participating in Relationship Education. The first two focus groups were conducted face-to-face in February 2020. Due to COVID-19, the procedure had to be adapted for the latter two, which were conducted on Microsoft Teams in the summer of 2020. The focus groups were audio-recorded and conducted by TND and SBC with each lasting approximately an hour.
Semi-structured telephone interviews were conducted with the relationship professionals by JE. An interview schedule for the relationship professionals was devised, piloted and refined in team discussions. The topics relevant to this paper were the views of the relationship professionals on what constituted an enduring, mutually satisfying intimate partner relationship, how older children can learn the skills needed to identify healthy and unhealthy relationships and the role, content and delivery of Relationship Education. The interviews were conducted by telephone since there are no significant differences between telephone and face-to-face interview data [
25] and given COVID-19 restrictions at the time. The duration of each interview was 64 min on average.
Analysis
The focus groups with YP and the interviews with professionals were analysed separately rather than in combination, as interview schedules and formats were different for both. Transcription was conducted by an approved University service. NVivo 12 was used to manage the data, analysed using the thematic approach described by Braun and Clark [
26]. In both datasets, a second author coded the first transcripts. Variations between coders were discussed by the team. Themes were developed separately for the YP and the relationship professionals; in this paper we present and compare these themes, identifying difference and similarities in the Discussion section.
Ethical approval
Ethical approval was gained from the University of Exeter Medicine School (UEMS) Research Ethics Committee (reference: Jun20/D/229∆1) for the research with YP and the University of Exeter College of Social Sciences and International Studies Research Ethics Committee for research involving relationship professionals (reference: 201,920–017).
The ethical approach we took is based on the successful and tested approach used by the Shackleton Project (UEMS ethics number 201617–018). We developed a protocol, agreed with teachers and community group leaders, for actions to be taken should a participant appear distressed, wish to withdraw, or should concerns be raised. We were highly aware that this could be a sensitive area, and emphasised to participants that they could withdraw at any point, as well as ensuring that they were aware of sources of support, and of confidential ways to contact the researchers, teachers, or community group leaders (e.g. through private chat on Teams) if they needed to. Researchers were alert throughout the groups for verbal and non-verbal signs that YP might wish to leave or take a break from the discussions, and strategic pauses or break points were included to facilitate this. The researchers were both experienced and well placed to conduct the focus groups with YP. The topics discussed with YP were framed to young people as being around ‘healthy relationships’ and existing RSE guidance. Our approach throughout the research was to engage young people in helping us to understand how Relationship Education could be improved for all YP in general. We used and explained Chatham House Rules to participants but were aware that this is not sufficient as the only measure. Therefore, we used appropriate distancing techniques, discouraging and steering conversations away from personal disclosures as needed and framing questions accordingly, for example, ‘what should young people get out of Relationship Education? We developed a protocol, agreed with teachers and community group leaders, for actions to be taken should a participant appear distressed, wish to withdraw, or should concerns be raised.
All names referred to below are pseudonyms.
Discussion
Four main themes were presented from our focus groups with YP. The first, ‘Good and bad relationships’, presents YP’s views on romantic relationships, and the influences they recognised from parents and culture. The second, ‘Learning about relationships’, explores participant’s views of the benefits of Relationship Education and the skills they want to develop.
The third theme, ‘the role of schools’, is about experiences of Relationship Education teaching in the school setting and how and when this should be taught. The final theme of ‘Beyond Relationship Education’ focuses on some of the limitations of teaching relationships, and YP’s needs for support beyond the classroom. From the interviews with relationship professionals, we identified three relevant themes: what they viewed as the essential qualities of healthy relationships; how YP learn to relate (primarily through observing the parental role model) and the role that Relationship Education in schools might have in teaching YP how to instigate and maintain a healthy relationship. Many of the views of YP and relationship professionals were similar, but there were areas of contrast and variations in emphasis. Below, we discuss some of the key findings, drawing out implications for public health and education policy and practice.
YP and relationship professionals clearly recognised the importance of building relational capability. Relationship professionals emphasised the need for a developmental approach, which viewed relationships as requiring work rather than a more fatalistic view that relationships are either ‘good’ or ‘bad’ and that their trajectory is determined accordingly. An emphasis in Relationship Education on managing expectations, stressing that ‘good’ relationships do not just happen, as the relationship professionals advocated, would possibly counteract the “Disneyfied” portrayal of relationships in the media that the YP recognised were unhelpful. While the relationship professionals stressed the need for flexibility, adaptability, commitment and resilience as critical to maintaining relationships over the life course, these skills were not at the forefront of the YP’s minds. In contrast, YP often presented dichotomous views of relationships, possibly reflecting similar dichotomies presented in discussions at school around sex education [
21]. YP appeared to be attempting to categorise relationships, using this dichotomous framework as a starting point. However, they also expressed a need to be able to better assess the quality or direction of a relationship, in order to take action, such as ‘cutting off’ a bad relationship. This was something they viewed as being a skill they could learn in Relationship Education. In line with the evidence discussed in the introduction, YP themselves also perceived a clear link between relationships and mental health; some raised this in terms of the impact of relationship breakdown, but there was also recognition that early relationships could set up ‘unhealthy’ patterns of relating which could affect mental health later in life.
Both the YP and the relationship professionals felt that schools were an important setting for teaching and learning about relationships, particularly in terms of offering what was seen as an ‘unbiased’ perspective and a universal offer. However, many YP felt that the existing Relationship Education offer was too ‘clinical’ and were keen to focus more on relational aspects. This view has been previously expressed in other research with YP around sex education, and by Ofsted’s review of the curriculum [
21,
27]. Relationship professionals in our study called for a nuanced approach to Relationship Education that is skills-based and reflective of YP’s complex lived experiences [
28]. The YP discussed the importance of building first on a strong ‘relationship with self’, which could be fostered through Relationship Education. Indeed, research suggests that self-compassion is associated with healthier romantic relationships [
29] and many evaluations of Relationship Education programmes also measure ‘self-esteem’ as an outcome [
30‐
33]. This chimed with the views of the relationship professionals who emphasised that ‘concern for the self’ was a prerequisite of being able to show concern for others. Related to this, the concept of building on previous knowledge and revisiting and reflecting on content as in a spiral curriculum [
34] was also favoured by YP. For YP, the timing of the introduction of content around romantic relationships was more contested, with concerns over introducing pressure and expectations versus the risks of failing to address beliefs and norms until it was too late. The relationship professionals’ preference was to introduce age appropriate Relationship Education in primary schools.
Despite seeing benefits to Relationship Education, YP also identified limits due to its complexities and subjectivities, and some questioned whether this was a role for schools. This links to a broader debate about what education is for [
35]. Several relationship professionals and YP interviewed highlighted the merits of trained external providers of RE. This resonates with Pound, Langford and Campbell [
21] who found that YP want experts to teach them about sex and suggest that teachers should be specially trained and become a distinct group from other teachers. However, the DfE does not address these issues in its guidance [
16].
Strengths and limitations
This study is the only research we are aware of that explores in tandem young people and relationship professionals’ perspectives on the ‘relationship’ aspects of RSE. The nature of our sample presents some limitations, as it is possible that the YP were the most articulate and had the strongest views on Relationship Education amongst their peers and the relationship professionals who chose to engage may have had particular perspectives on Relationship Education. In particular, schools may have acted as ‘gatekeepers’ in selecting YP with more positive views on Relationship Education, however, we observed a range of views and dissent from focus groups across all settings. The inclusion of community and youth group members from different backgrounds increases our confidence that we have been able to explore and present a range of perspectives; it is also clear that YP’s views were not homogenous, hence dissenting voices are reflected in the themes. It is unclear as to the effect of the online format of the later focus groups; inevitably discussions require a higher level of moderation and direction. However, participants appeared comfortable with the format, and online research with YP has been found to potentially enhance their autonomy and amplify marginalised voices [
36,
37]. The interview and focus group questions did not seek to explore or privilege relationship education from the perspective of any particular sexuality or identity. Researchers setting the scene were clear with YP that we wanted to explore how relationship education worked for all YP. However, whilst one young person alluded to needing to avoid ‘cookie cutter’ ideas of relationships within relationship education, and many participants used gender-neutral language or examples, we acknowledge that this research may be seen to feed into a heteronormative discourse which should be challenged and explored further in future work.
A purposive sampling strategy was used to recruit the relationship professionals. As selection of such a sample is subjective, purposive sampling is most appropriate for the selection of small samples, as here. Although, a limitation is that equally qualified relationship professionals, not known to the researchers by reputation, may have made different observations. There was a high degree of consensus across the sample.
Implications for policy and practice
This research is supportive of many aspects of curriculum guidance on Relationship Education. However, YP specifically highlighted areas that were priorities for them but are not explicitly addressed in the DfE’s RSE core content framework, such as managing relationship breakdowns, learning coping skills, and managing relationships through life course transitions. To engage YP in meaningful development and reflection during Relationship Education, the curriculum should reflect the content and skills that are relevant to them. Previous research has noted YP’s desire to be involved in future programme design [
20], there was also support from the relationship professionals for Relationship Education to be co-created with YP, echoing the calls in the ‘Young People’s Manifesto’ [
15].
Interestingly, YP and relationship professionals also wanted more of a focus on skills rather than knowledge. Professionals discussed the importance of providing opportunities for YP to observe and rehearse skills during lessons; and of engaging resources to support such learning. However, a recent survey of schools in England by Ipsos MORI and the PSHE Association [
38] discusses the barriers faced in delivery of consistent and high quality Relationship Education, including knowledge, training and resources. Schools reported bringing in third sector organisations to deliver sessions and drawing on resources and lesson plans developed by organisations such as the PSHE Association (
https://www.pshe-association.org.uk/). Cole [
28] found support for the view that there is a lack of teaching proficiency, knowledge and confidence in the delivery of Relationship Education and teachers themselves viewed it as a specialist topic ‘outside their remit’. Currently, the DfE leaves schools to choose their Relationship Education curriculum content to meet their pupil and community needs, but there is clearly a need for schools to be better supported to deliver a more consistent approach to Relationship Education. This should include appropriate access to specialist expertise and resources, and guidance on signposting YP to external sources of help as required. Relationship professionals in our interviews also highlighted that positive relationship behaviours can also be modelled and integrated throughout school curricula and reflected in a school’s ethos. This links with existing research on the importance and influence of different types of relationships in schools on children and YP’s well-being and mental health such as peer to peer relationships, and those between teachers and pupils [
39].
Implications for research
This study raises a range of questions for exploration in future research, including the most effective ways to teach relationship skills, the best way to develop age-appropriate content, and how to integrate ‘relational health’ into a child’s journey through the education system. Available research is predominantly focussed on programmes developed to improve sexual health or reduce violence and abuse. Recent reviews by the authors [
19,
20] have found few programmes focussing on healthy relationships, with a limited evidence base. However, as above, surveys suggest that most English schools do not use formal ‘programmes’ in any case. One implication is that research efforts are best focussed on the co-development, evaluation and implementation of education resources which can be used flexibly and integrate into a health promoting curriculum. A range of stakeholders, should be involved in co-development and evaluation, including YP, teachers, governors, parents, and others in the wider community who support YP’s well-being, as well as relationship professionals such as counsellors and mediators. These stakeholders should reflect the diversity of young people’s sexualities and identities, to ensure that Relationship Education is inclusive and accessible, and does not perpetuate inequalities or marginalisation. Understanding their perspectives on content, delivery, barriers, facilitators and desired outcomes is also necessary to ensure that Relationship Education is acceptable and feasible.
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