small groups for sexual assault/rape victims

MAJOR ARTICLE

What survivors want: Understanding the needs of sexual assault survivors

Michelle L. Munro-Kramer, PhD, CNM, FNP-BCa, Alexandra C. Dulin, BAb, and Caroline Gaither, PhD, FAPhAc

aSchool of Nursing, University of Michigan, Ann Arbor, MI, USA; bRackham Graduate School, University of Michigan, Ann Arbor, MI, USA; cDepartment of Pharmaceutical Care and Health Systems, University of Minnesota, College of Pharmacy, Minneapolis, MN, USA

ARTICLE HISTORY Received 15 January 2016 Revised 27 December 2016 Accepted 5 February 2017

ABSTRACT Objective: Sexual assault is a pervasive crime on our college campuses and many survivors do not seek post-assault resources. This study will explore components of alternative interventions to consider in the development of campus-based interventions for sexual assault survivors. Participants: Three stakeholder groups including survivors (n D 8), healthcare providers (n D 6), and advocates (n D 19) were recruited from May 2014 to December 2014 from two university campus communities using flyers and purposive sampling. Methods: A qualitative study design utilized semi-structured interviews and semi-structured focus groups with survivors, healthcare providers, and advocates. Results: Five themes emerged to consider for future campus-based sexual assault interventions: (a) culture of caring, (b) one-stop shop, (c) validation, (d) survivor control and agency, and (e) confidentiality. Conclusions: Although accessible and effective options for post-assault care do currently exist, participants described alternative future interventions that were either (a) print materials or (b) technology-based.

KEYWORDS Interventions; post-assault care; rape; sexual assault

Sexual assault is a pervasive public health issue, with many negative health outcomes. Sexual assault encom- passes penetration as well as other forms of sexual con- tact that occur without the survivor’s consent.1 Rape refers specifically to oral, vaginal, or anal penetration that has occurred without the survivor’s consent.1 In any given year in the United States, data suggest that 1.3 mil- lion women will experience rape, and there are currently almost 22 million women rape survivors in the United States.2 The college years are associated with even more risk for women, with an estimated 1 in 5 women and 1 in 16 men enduring a sexual assault during their college career.3 This makes sexual assault, specifically rape, the most frequent violent crime occurring on college campuses.4,5

Sexual assault can result in acute and long-term physi- cal and mental health complications including physical injury, sexually transmitted infections (STIs), pregnancy, mental health issues such as post-traumatic stress disorder, and concerns for one’s safety.6–8

Models of post-assault care

Colleges and universities are compelled to address this risk with both prevention and interventions, including facilitating access to comprehensive care. The mandate

to do so is particularly strong at this time from both gov- ernmental bodies (ie Dear Colleague Letter distributed by the US Department of Higher Education in 2011 and the Clery Act, 20 U.S.C. x 1092, most recently amended in 2008) and public outcry. In the immediate post-assault period, a survivor of sexual assault in a campus environ- ment could choose any of the following options for post- assault care: (a) comprehensive care at an emergency room or rape crisis center often delivered by a sexual assault nurse examiner (SANE); (b) visits with individual resources (counseling, physical health, pharmacy, legal, campus-based resources); or (c) they may choose not to pursue any care. The gold standard for comprehensive post-assault care includes a SANE exam at an emergency department or rape crisis center, which is generally rec- ommended within 72–120 hours in order to facilitate pregnancy and human immunodeficiency virus (HIV) prevention (if indicated) as well as evidence collection.6–8 Many survivors also piece together individ- ual resources from a variety of resource agencies includ- ing rape crisis centers, counseling centers, health centers, community pharmacies (to obtain emergency contracep- tion), law enforcement agencies, and campus support (ie sexual assault centers, Title IX officers, counseling, housing). However, more often than not, survivors elect not to pursue any post-assault care. Sexual assault often

CONTACT Michelle L. Munro-Kramer [email protected] School of Nursing, University of Michigan, 400 N. Ingalls, Room 3188, Ann Arbor, MI 48170, USA. © 2017 Taylor & Francis

JOURNAL OF AMERICAN COLLEGE HEALTH 2017, VOL. 65, NO. 5, 297–305 http://dx.doi.org/10.1080/07448481.2017.1312409

goes unreported and/or untreated despite the high rates of sexual assault and the health concerns surrounding it. In fact, only a minority of survivors seek post-assault health services.9 Thus, it is important to explore alterna- tive interventions to help college-age survivors’ access post-assault resources and care.

Post-assault care seeking

In a recent study, 11.5% of rape survivors reported their experience to law enforcement officials, just over 18% sought medical attention after the rape, and 17.8% sought assistance from an agency that provides support to victims of crimes.10 A different study examined the use of any type of services and found that of the five community social systems available to rape survivors (medical, mental health, legal, rape crisis centers, and religious organizations), only one-third of survivors pur- sued care from one or more of the systems.11 Finally, a separate study demonstrated that less than one-third of women reported their sexual assault to a physician, a rape crisis center, or to the police.12

Thus, despite the post-assault concerns survivors may face, there are numerous barriers to care that may pro- hibit them from utilizing existing resources.13 Social mores and perpetuations of rape myths inherently influ- ence how survivors view their own assault and what actions they take in the post-assault period.14 It appears women are more likely to report the stereotypical stranger rape associated with physical injuries than a rape perpetrated by someone they knew to formal sour- ces like the police or a physician.9,12,14,15 Other barriers to care that have been identified are the cost and avail- ability of services, as well as the stigma attached to receiving services for sexual assault.16 Specifically among college women, feelings of shame or guilt were identified as reasons survivors did not report sexual assault, as well as not recognizing the event as a sexual assault.13 An integrative review of the literature condensed the poten- tial barriers to care for sexual assault survivors to (a) per- sonal factors encompassing emotional states, fear of external exposure, and lack of knowledge and (b) envi- ronmental factors such as structural or organizational barriers and societal rape myths.17 These barriers prevent survivors from getting the care and resources that they may need, and suggest that there may be a need to de- stigmatize post-assault care seeking and identify alterna- tive methods to make accessing care easier to reach this vulnerable and often hidden population.

This research team has conducted previous research that was specifically focused on the use of over-the- counter emergency contraception, such as Plan B, among female rape survivors during the post-assault period. The

impetus for the current study was past research that identified that 7.3% of individuals purchasing Plan B emergency contraception in a university pharmacy set- ting were doing so after unwanted vaginal intercourse.18

These “hidden” survivors valued the confidentiality and easy accessibility over-the-counter Plan B afforded but realized it provided an incomplete mode of post-assault care. However, their desire to access care on their own terms and in a confidential manner surpassed their desire to seek out other sources of care or report the assault in the immediate post-assault period.18 We there- fore wanted to explore what survivors and the healthcare providers and advocates they may access services from, view as ideal components and modes of delivering post- assault care. This qualitative study will therefore use sur- vivor, healthcare, and advocacy perspectives to identify characteristics and components of innovative interven- tions that could provide information about post-assault options for survivors of sexual assault who are not cur- rently accessing post-assault care via available modalities.

Methods

Design

This study utilizes a qualitative study design to begin to explore desired alternative models for post-assault care from the perspectives of three stakeholder groups (col- lege-age sexual assault survivors, sexual assault advo- cates, and healthcare providers). Approval was obtained from the University of Michigan, Health Sciences and Behavioral Sciences Institutional Review Board as well as all participating institutions.

Sample and setting

All participants were recruited from two Midwestern University campuses and their surrounding communities from May 2014 to December 2014 until saturation was reached. The sample for this study included individuals from each stakeholder group affiliated with the partici- pating university campuses or community institutions. Inclusion criteria for the sexual assault survivors included: (a) females (because the impetus for this study is past work focused on emergency contraception and pregnancy prevention), (b) survivor of a sexual assault that occurred within the last 5 years using the Sexual Experiences Survey (SES),19 and (c) college students of childbearing age (18–45 years old). Inclusion criteria for the healthcare providers included: (a) presently employed as a healthcare provider (ie pharmacist, phar- macy technician, advanced practice nurse, or physician) and (b) interacts with patients in a university

298 M. L. MUNRO-KRAMER ET AL.

environment. Since we know some survivors choose to access certain components of care (eg over-the-counter emergency contraception, STI screening) at the phar- macy or via their regular healthcare provider we deliber- ately recruited a wide range of healthcare providers to capture all of the individuals that might interact with sexual assault survivors. Inclusion criteria for advocates included: (a) presently employed or volunteering as a sexual assault advocate (eg counselor, social worker, SANE, or volunteer) and (b) interacts with survivors.

Procedures

Recruitment Sexual assault survivors were recruited using posted flyers at the healthcare centers, counseling centers, and within large public buildings of the two participating university campuses. Participants responded to a generic e-mail address on the flyer indicating they were inter- ested in participating in a study on “unwanted inter- course.” Screening included telephone administration of the SES to ensure the participant met the inclusion crite- ria. Advocates and healthcare providers were recruited via purposive and snowball sampling. E-mail correspon- dence was used to ensure eligibility.

Sexual assault survivors One member of the research team conducted all the survi- vor interviews in a private room in a central building on each respective campus. The researcher met all survivor participants in the lobby of the building, escorted them to the private room, and then reviewed the informed consent process. Comprehensive written informed consent was obtained prior to enrollment in the study. All survivor par- ticipants were notified that they could skip any question or decide to end their participation in the study at any time. The sexual assault survivor participants first answered a brief questionnaire to capture demographics and charac- teristics of the assault (SES)19 as well as questions about post-assault care. Afterwards eight individual semi-struc- tured interviews (19–52 minutes) were conducted with sexual assault survivors. Sexual assault survivors were que- ried about their current knowledge of post-assault care options, their personal decision-making in pursuing post- assault care, what information they would like available in the post-assault period, and the method in which they would like this information provided. Each survivor was asked to summarize the key points they wanted the research team to remember. This summary helped to ensure that the participant’s most crucial points had been captured by the interviewer and the key points were used as an audit tool to ensure rigor in the analysis phase of the study. Survivors received a snack during the interview as

well as a $10 Starbucks gift card for their time. All survivor participants were also given a resource sheet which provided the contact information for campus and community-based resources in the area that provide men- tal healthcare, physical healthcare, advocacy, and legal support.

Healthcare providers and advocates Focus groups and interviews with healthcare providers and advocates were grouped based on location and type of employment (ie all healthcare providers on one campus were grouped together, while all advocates on another campus were grouped together). Two healthcare providers who could not attend the focus groups were instead inter- viewed individually. Focus groups and interviews were arranged in a private conference room that was convenient for each group. Comprehensive written informed consent was first obtained from all participating healthcare pro- viders and advocates, then they were reminded that they could decline to answer any question or stop participating in the study at any time. Each healthcare provider or advo- cate participant then completed a brief demographic ques- tionnaire followed by participation in the focus group or individual interview. Focus groups were conducted by two members of the research team, while individual interviews were conducted by one team member. A total of five semi-structured focus groups (30–58 minutes) and two individual semi-structured interviews (19–20 minutes) were completed with the advocates and healthcare pro- viders. Questions asked during the focus groups and inter- views with healthcare providers and advocates included general questions about: (a) survivor expectations in the post-assault period, (b) interventions that would be helpful (or what has been unhelpful in the past) to sexual assault survivors in the post-assault period, (c) alternative meth- ods/locations for providing post-assault care, and (d) job- specific questions such as sharing how they think survivors view a SANE exam or whether or not they think survivors are utilizing over-the-counter emergency contraception in the post-assault period. Healthcare providers and advo- cates were also asked to provide a summary of the key points discussed during the study as a way to ensure the research team captured the key points and to ensure rigor during data analysis. All healthcare provider and advocate participants received snacks during the focus group and were provided with a list of campus and community resources for mental healthcare, physical healthcare, advo- cacy, and legal services.

Data analysis

All demographic data and characteristics of the assault were analyzed using quantitative descriptive statistical

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analyses in SPSS, version 21.0 (IBM, Armonk, NY, USA). All interviews and focus groups were tran- scribed verbatim into NVivo and the constant compar- ative method of analysis was utilized to identify themes.20,21 The first two authors independently read all interview and focus group transcripts to secure gen- eral impressions with the intention of identifying char- acteristics and components of innovative interventions that would provide information about post-assault options for survivors of sexual assault from survivor, healthcare provider, and advocate perspectives. Then a more detailed reading of the transcripts was used to start labeling general ideas into individual coding grids. Next, labels were independently developed for the major ideas. The transcripts, memos, and initial coding decisions were then reviewed by the first two authors together to achieve consensus on coding deci- sions. Through discussion and review of the tran- scripts and coding notes, the first two authors agreed on the five major themes (culture of caring, one-stop shop, validation, survivor control and agency, and confidentiality), the subthemes, and quotes that sup- ported each major theme and/or subtheme.22 Equal weight was given to the responses of all subjects in developing the themes and subthemes. After data satu- ration was reached, the themes and subthemes were reviewed by the third author for validity.23 Rigor was maintained by adhering to the following principles: rigor in documentation, ethics, procedure, and auditability.24

Results

Participant characteristics

The final sample included eight survivors, 19 advocates, and six healthcare providers. All participants were women, with the exception of one male healthcare pro- vider. Of the participating survivors, 62.5% were under- graduates (and thus had a high school degree; n D 5) and 37.5% were graduates (and thus had a bachelor’s degree; n D 3). Additional demographic details can be found in Table 1.

Utilizing questions from the revised SES19 we found survivors in our study were coerced into unwanted sex using a variety of techniques. The most common techniques used by perpetrators included making survivors feel as though they couldn’t say no or their no was ignored (n D 7, 87.5%), emotional threats (n D 6; 75%), criticism/anger (n D 6, 75%), and intoxication (n D 4; 50%). The majority (n D 6; 75%) of the survivors participating in this study knew the perpetrator. Additionally, most of the survivors (n D 6; 75%) had experienced unwanted sex more than one time. Table 2 provides characteristics related to the survivor’s most recent sexual assault.

Emerging themes

Qualitative analysis of the semi-structured interviews and focus groups elicited five major themes to consider as components of potential future interventions for sexual assault survivors within the college environment. These five themes are: (a) culture of caring, (b) one-stop shop, (c) validation, (d) survivor control and agency, and (e) confidentiality. Each major theme also encompasses a number of subthemes that provided additional charac- teristics that would be important to consider for future campus-based sexual assault interventions.

Culture of caring One theme that emerged was the idea of creating a cul- ture of caring where college students, faculty, and staff are aware of the prevalence and severity of sexual assault in the college population and would have the resources and knowledge to help survivors. As a campus health educator described, it would be “creating a culture of where we actually take care of each other around here.” As described by participants a culture of caring would therefore encompass the subthemes of help a friend and peer support. Survivors supported the idea of helping a friend as a way to increase awareness about a crime that most people do not think will happen to them. One 18- year-old survivor noted, “I want to be prepared for my friend if something happens to her. So, that probably

Table 1. Demographic characteristics of participants; n(%).

Survivors (nD8)

Advocates (nD19)

Healthcare Providers (nD6)

Age—range (mean) 18–28 (21.88) 26–64 (40.42) 36–68 (51.67) Gender Female 8 (100.0) 19 (100.0) 5 (83.3) Male N/A 0 (0.0) 1 (16.7)

Education High school degree/GED 5 (62.5) 1 (5.3) 1 (16.7) Associate’s degree 0 (0.0) 2 (10.5) 0 (0.0) Bachelor’s degree 3 (37.5) 9 (47.4) 0 (0.0) Master’s degree 0 (0.0) 7 (36.8) 3 (50.0) Doctoral degree 0 (0.0) 0 (0.0) 2 (33.3)

Race White or European American

5 (62.5) 18 (94.7) 5 (83.3)

Black or African-American 3 (37.5) 0 (0.0) 1 (16.7) Other: Biracial 0 (0.0) 1 (5.3) 0 (0.0)

Ethnicity Not Latino(a)/Hispanic 6 (75.0) 15 (78.9) 3 (50.0) Latino(a)/Hispanic 0 (0.0) 1 (5.3) 0 (0.0) Other 2 (25.0) 2 (10.5) 3 (50.0) Missing 0 (0.0) 1 (5.3) 0 (0.0)

Years of experience in field < 1 year 3 (15.8) 0 (0.0) 1–5 years 7 (36.8) 1 (16.7) 6–10 years 2 (10.5) 0 (0.0) 11–15 years 6 (31.6) 1 (16.7)

>15 years 1 (5.3) 4 (66.6)

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would be a bit—I can see myself being a little more ame- nable to that idea, ‘cause no one thinks it’s gonna happen to them.” All participants described the value of having a peer support group to talk to and to help them feel like they are not alone. Another 18-year-old survivor stated, “And I think that would really be good. You know, or like a resource group where everyone sits and talk[s]

about it. ‘Cause I felt like I was the only one going through it, I felt like nobody else gets sexually assaulted. It was a lot of why me?”

One-stop shop The next theme described by study participants was the concept of having one place to go to access all needed resources, or a one-stop shop. A campus advocate reflected on the trauma sexual assault survivors experi- ence “where it’s shock and survival mode” and the survi- vor needs to find “ways to get connected” with resources. Participants provided detailed descriptions of subthemes that included all resources available in one location and links between resources and referrals. Unfortunately, sur- vivors of sexual assault on college campuses often have to cobble together all of the support they may need. As one campus advocate reflected, it is a “drain for them to cross the plane to tell anybody” yet they often have to travel across campus to access different resources. Partic- ipants were therefore adamant that all resources be avail- able in one location. One community advocate summarized, “like it really needs to be simple and they need to know that if they go to one place they can get as much done as they possibly can right then.” There is also a dire need to have links between resources and referrals. Due to reporting regulations for universities there are often confidential and non-confidential resources on campus that lead to confusion for students. Survivors were especially prone to this confusion after a traumatic situation, as a 21-year-old survivor mentioned that “hav- ing an initial confidential source would be a lot easier in terms of navigating where to go from there versus being given a whole bunch of resources and not necessarily know which one is best for your situation.”

Validation The third theme garnered from the data was valida- tion. Participants described a number of subthemes that would help a survivor feel validated including inclusive, normalizing, self-identify, non-judgmental, and dispelling stigma. Validation was seen as an essential component of seeking resources. As one sur- vivor affirmed when referring to her work on a crisis line, “the most empowering thing for people was being validated.” Multiple participants agreed that any future interventions had to, “be all inclusive” in regard to gender, sexual identity, relationship status, race, ethnicity, etc. During the data collection process we heard numerous stories about sexual assault in same-sex relationships or those perpetrated by a part- ner that survivors did not believe met the definition of sexual assault or warrant services at local sexual assault centers.

Table 2. Characteristics of the assault (nD8); n(%). Used Plan B or other EC in past n(%)

Yes 4 (50.0) No 4 (50.0)

Times experiencing unwanted sex One 2 (25.0) Two 1 (12.5) Three 1 (12.5) Four 1 (12.5) Five or more 3 (37.5)

Unwanted sex because of emotional threats Yes 6 (75.0) No 2 (25.0)

Unwanted sex because of criticism or anger Yes 6 (75.0) No 2 (25.0)

Unwanted sex because intoxicated Yes 4 (50.0) No 4 (50.0)

Unwanted sex because of threat of physical harm Yes 2 (25.0) No 6 (75.0)

Unwanted sex because couldn’t say no, or no ignored Yes 7 (87.5) No 1 (12.5)

Knew the perpetrator Yes 6 (75.0) No 2 (25.0)

Time from assault Less than 1 month 1 (12.5) 1–11 months ago 1 (12.5) 1–3 years ago 5 (62.5) More than 3 years ago 1 (12.5)

Care received Plan B/ Over-the-counter emergency contraception 1 (12.5) Emergency room 1 (12.5) Regular provider 2 (25.0) Campus resources 1 (12.5) Other: Off-campus counseling 1 (12.5) No care 2 (25.0)

Treatment received after most recent experience: Physical injury Yes 1 (12.5) No 7 (87.5)

Pregnancy prevention Yes 3 (37.5) No 5 (62.5)

STI testing/treatment Yes 5 (62.5) No 3 (37.5)

Mental health Yes 6 (75.0) No 2 (25.0)

Evidence collection Yes 2 (25.0) No 6 (75.0)

Sexual assault advocate Yes 4 (50.0) No 4 (50.0)

Legal options Yes 2 (25.0) No 6 (75.0)

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All of the participants described a need to normalize the emotions and reactions survivors have after an assault. A campus advocate recommended that future interventions include, “some sort of information about common potential responses. And you may not want to do this now, but you may want to do this later, and its normal to have waxing and waning of your feelings.” There was also strong agreement that survivors need the ability to self-identify. As a 28-year-old survivor summa- rized, “I think, like, so many people will say that they have had unwanted sex, and then if you start peeling the layers off of that, it would turn out that a lot more people have been sexually assault[ed] than we realize.” Partici- pants also described a need for resource centers to pro- vide non-judgmental services and care. That same survivor reflected on her interaction with a healthcare provider and noted, “It would still have been nice to be able to have the peace of mind of like, um, going and get- ting a pregnancy test or going for Plan B, and not being, not being judged for it.” Meanwhile, there is a strong need to dispel the stigma that surrounds the word rape and its use in resource centers like rape crisis centers and rape kits. When reflecting on rape crisis centers, one sur- vivor responded, “And even a lot of people who experi- ence more violent assaults might not go there. Like ‘rape crisis’, that’s, those, that’s like a really powerful combina- tion of words and extremely stigmatized kind of turn of phrase.”

Survivor control and agency There was a strong urge among participants to consider future interventions that optimized survivor control and agency. Some of the solutions that could be incorporated into future interventions to improve survivor control and agency were embodied within the subthemes of deci- sion-tree, expectations, and tailoring. One campus advo- cate noted that, “using gaming technology to help, to allow survivors to make choices about sort of what kinds of experiences they identified, and then what their options are from there…so multiple kinds of decision trees to allow those who are using Plan B [emergency contraception] to self-identify what their experience was and then articulate ranges of options or other things they should consider or other kinds of resources that could be appropriate to the, um, you know, to the circumstances that they’ve sort of self-identified.” A SANE nurse from the community noted that survivors often have expecta- tions about what a SANE exam has to include without realizing that if they say, “I don’t want to do that” then the SANE nurse would respond with “Alright. That’s cool, we’re done.” Finally, participants were very focused on the need to individualize or tailor the resources and information provided to survivors based on their desires

and concerns. As one 22-year-old survivor suggested, “I think that there needs to be more like programs that are kind of open and like designed to, like, be able to tailor to, like, each person’s experience.”

Confidentiality The fifth and final theme that surfaced from the data was the focus on confidentiality. Participants echoed that sur- vivors are extremely fearful of losing their confidentiality while seeking resources. This sentiment is reflected by a community advocate who noted, “they think that once they give you that information that it goes to police, or their insurance companies.” Subsumed within the broad theme of confidentiality were the subthemes of use of technology and universal advertising. Participants described technology-based interventions, such as mobile applications or websites, as potential ways to pro- tect confidentiality and privacy. One 23-year-old survi- vor noted, “So that would be creative. Um, the app I think is a good idea, because everybody pretty much has a phone, and I feel like it’s more private too when you’re like by yourself and you’re looking at it and stuff.” Partic- ipants also thought survivors would have more trust in their confidentiality being maintained if the intervention is advertised to everyone and does not focus on a high- risk subgroup like female college freshman. This idea was echoed by a community advocate, “I agree. I think if you blanket present it to everybody then it’s not like somebody is specifically looking at you. You know, like they’re not calling attention to themselves, it’s given to everybody.”

Comment

Although accessible and effective options for post-assault care currently exist, many of our participants expressed a desire for alternative options that incorporated: (a) a cul- ture of caring, (b) one-stop shop, (c) validation, (d) sur- vivor control and agency, and (e) confidentiality. The use of three stakeholder groups in this study including survivors, healthcare providers, and advocates provided more diverse viewpoints about post-assault care and ideal components and characteristics of future interven- tions. Even though the three stakeholder groups are experiencing sexual assault and its implications in very different ways there was consensus on the five themes. Additional conversation with all of the participants (sur- vivors, healthcare providers, and advocates) during the focus groups and interviews led to the discussion about future interventions. Participants from each of the three stakeholder groups suggested future interventions could benefit from the use of print materials or technology.

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Participants from each of the three stakeholder groups viewed print materials as a way for a survivor to access information and connect to resources when they are ready. They suggested print materials be targeted to (a) help a friend, (b) include a comprehensive list of resour- ces with applicable links or locations, (c) use the termi- nology unwanted sex (as opposed to rape or sexual assault) and provide a list of normal reactions, (d) pro- vide a description of what to expect from each resource, and (e) provide a sense of confidentiality. They therefore thought print materials could encompass all of the themes above and could be distributed in campus health centers, at the pharmacy with emergency contraception, or in private locations across campus including bath- rooms and dorm rooms. Past studies have demonstrated that individuals do read and take domestic violence materials (eg palm cards, flyers, or posters) placed in pri- vate settings like a bathroom.25,26

While there are numerous print materials available from local, national, and international organizations that aim to increase awareness about sexual assault and post- assault care, there has been very little investigation into what content those print materials should contain or the method in which they should be distributed. Participants from all stakeholder groups in this study clearly identified the topics and targets of campus-based print materials and all believed that they should be posted universally in loca- tions across campus. For instance, one survivor noted that print materials should be posted “so like everyone has one…kind of like a fire escape plan.” Print materials may be a feasible method to distribute information about sexual assault and resources for survivors within the confines of a college campus environment.

Yet, there has been little exploration into whether or not print materials actually encourage a survivor to seek resources. One study conducted with male veterans who experienced sexual assault found that print materials are acceptable; however, they did not impact the use of men- tal health services over a 6-month period after the mate- rials were viewed.27 Another study with pregnant women found that a wallet-sized card, counseling inter- vention, and outreach intervention all reported decreased abuse but did not demonstrate an increase in use of community resources.28 A more recent study with pregnant women found that (a) a nurse-led intervention which included a brochure, safety planning tips, antici- patory guidance for leaving an abusive relationship, anticipated referrals, and psychosocial support and (b) the control group which included a wallet-sized card with community resources were both effective in reduc- ing multiple forms of violence.29 It is therefore impera- tive that future research explore the impact of print materials on the use of post-assault services.

Participants from all three stakeholder groups also discussed the potential that technology-based interven- tions could hold including interactive websites or mobile applications. Technology-based modalities allow for (a) virtual peer support, (b) comprehensive lists and descrip- tions of resources, (c) the ability to make the intervention inclusive and normalize reactions, (d) allow for decision- making and tailoring of information and resources, and (e) provide confidentiality in accessing resources. Partici- pants from all three stakeholder groups also discussed incorporating useful features such as interactive maps and reminders about appointments (ie you are due for an HIV test). Past research has also substantiated that technology-based options such as the Internet offer an anonymous place for marginalized groups, such as sexual assault survivors, to find information about health with- out encountering the barriers associated with typical face-to-face interactions.30 Since accessibility is cited as a barrier to reporting sexual assault and seeking care, it is important to note that those who have negative percep- tions toward access to healthcare are more likely to look for information about health on the Internet.31 A major- ity of survivors have access to the Internet, and many of them would be receptive to information and resources utilizing technological modalities like the Web.24 As one survivor noted when discussing the possibility of an app: “Your app or whatever you are gonna create, like, would have [a] really unique opportunity to actually be able to get the people that fell through the cracks.”

However, participants in all three stakeholder groups voiced drawbacks to a technology-based intervention. It is unlikely that a technology-based modality would be available to every survivor, potentially due to no access to a smart phone, tablet, or computer for some popula- tions. Furthermore, it is highly unlikely that sexual assault survivors would want to access an interactive website about sexual assault on a public computer. Even with a personal computer there is the possibility that pri- vacy and confidentiality could be compromised by a family member, partner, or friend who views the browser history. Participants from all three stakeholder groups also expressed concern that participants would not download a mobile application in the event that they might one day experience a sexual assault. If a partici- pant does download an app there is also the potential that it could be viewed by anyone that has access to their phone. Despite these concerns, participants were opti- mistic about the potential benefits that technology-based interventions could contribute to reaching survivors. Overall, this highlights the need for a more comprehen- sive technology-based intervention that can address interpersonal relationships in general while providing resources and support in the event of violence or sexual

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assaults. It is essential that a potential technology-based intervention be accessible and recognizable by the entire campus population.

Participants from all three stakeholder groups indi- cated that tools need to be supportive, available in one place, all-inclusive, non-judgmental, and respect privacy. The use of technology and print materials located in eas- ily accessible locations may be feasible alternatives to currently delivered modalities of post-assault care in order to reach those that “fell through the cracks.” How- ever, further research is needed to investigate whether or not print materials impact the use of post-assault resour- ces and how to make a technology-based intervention accessible and recognizable by a large population of col- lege students.

Limitations

Several limitations of our study warrant discussion. This study is limited by its focus on a convenience sample in one geographic region, the Midwest, and thus results cannot be extrapolated beyond this sample. Convenience sampling may not have captured individuals who do not identify as sexual assault survivors. Our results may therefore only encompass the views of those who are ready to discuss their assault and were interested in seek- ing post-assault resources. Second, our sample size was small and was limited to female survivors only, which also limits generalizability. Future research should explore the voices of all survivors (ie men, transgender, same-sex relationships) in order to confirm the interven- tion components those groups desire. Furthermore, it is essential to consider how to provide comprehensive interventions to college-age survivors that are located in a community setting, since this age group has a similar risk of sexual assault as individuals that reside in a col- lege setting.32

However, the strengths of our study include a diverse sample of survivors, healthcare providers, and advocates in order to provide a representative sample. Additionally, the inclusion of three stakeholder groups provided for a range of diverse viewpoints and perspectives.

Conclusions

Survivors of sexual assault experience a loss of control in a very intimate way. This often leaves them feeling vio- lated and in need of social, legal, mental health, and physical healthcare. Yet, there are numerous societal and personal barriers that often delay or prohibit survivors from seeking care. It is imperative that we include survi- vors’ voices while looking for alternative ways to serve their needs. This study aimed to do that by helping to

identify components of future interventions from survi- vor, healthcare, and advocate perspectives. These alterna- tive interventions could be piloted in the university setting to provide survivors with the knowledge, resour- ces, and control to seek post-assault resources. Future work on intervention development, pilot testing, and scale-up should continue to incorporate the voices of survivors and those that serve their needs.

Conflict of interest disclosure

The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethi- cal guidelines, including adherence to the legal requirements, of the United States and received approval from the Institu- tional Review Board of the University of Michigan.

Funding

No funding was used to support this research and/or the prep- aration of the manuscript.

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