10 page paper (due in 24 hours)
budsimpson
KingsonOwanari-CapstonePaper2.pdf
Master of Public Health Capstone Project
Online Counseling Service for Survivors of Sexual Assault in British Columbia: A Business
Case
By Owanari Kingson, BSc, MPH Candidate.
Senior Supervisor: Dr. Kate Tairyan, MD, MPH.
Second Reader: Caitlin Johnston, BA, MSc.
August 3, 2017
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TABLE OF CONTENTS
Definition of Terms ...................................................................................................................................................4
INTRODUCTION ........................................................................................................................................................6
Project background. .............................................................................................................................................8
EXECUTIVE SUMMARY ........................................................................................................................................... 11
1 BACKGROUND ............................................................................................................................................... 13
1.1 Problem / Opportunity .......................................................................................................................... 13
1.2 Current Situation ................................................................................................................................... 13
2 PROJECT DESCRIPTION .................................................................................................................................. 19
2.1 Project Description ................................................................................................................................ 19
2.2 Objectives .............................................................................................................................................. 19
2.3 Scope ..................................................................................................................................................... 20
2.4 Rationale for Online services ................................................................................................................. 20
2.5 Anticipated Outcomes ........................................................................................................................... 21
2.6 Stakeholders .......................................................................................................................................... 22
3 STRATEGIC ALIGNMENT ................................................................................................................................ 23
4 ENVIRONMENT ANALYSIS .............................................................................................................................. 24
5 ALTERNATIVES ............................................................................................................................................... 26
6 BUSINESS AND OPERATIONAL IMPACT ......................................................................................................... 28
7 PROJECT RISK ASSESSMENT ........................................................................................................................... 30
7.1 Risk of Project and each Viable Alternative (Not including Status Quo) ............................................... 30
7.2 Risk of Not Proceeding with Project (Status Quo) ................................................................................. 33
8 COST/BENEFIT ANALYSIS ............................................................................................................................... 34
8.1 Estimated Costs ..................................................................................................................................... 34
8.2 Qualitative Analysis – Non-Financial Benefits & Costs: ......................................................................... 37
8.3 Assumptions .......................................................................................................................................... 38
9 CONCLUSIONS AND RECOMMENDATIONS ................................................................................................... 39
9.1 Conclusions ............................................................................................................................................ 39
9.2 Recommendations ................................................................................................................................. 39
9.3 Project Responsibility ............................................................................................................................ 39
9.4 Project Accountability ........................................................................................................................... 39
10 IMPLEMENTATION STRATEGY ................................................................................................................... 40
Critical Reflection................................................................................................................................................... 41
References ............................................................................................................................................................. 43
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Appendices……………………………………………………………………………………………………………………………………………………..48
Appendix I…………………………………………………………………………………………………………………………………………………48
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DEFINITION OF TERMS
Sexual Violence: is defined “any sexual act, attempt to obtain a sexual act, unwanted sexual
comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using
coercion, by any person regardless of their relationship to the victim, in any setting, including but
not limited to home and work”. For example rape, sexual abuse, forced marriage, forced abortion
etc. (WHO, 2002).
Sexual Assault: occurs when physical, sexual activity is engaged in without the consent of the
other person, or when the other person is unable to consent to the activity (RAINN, 2016). The
activity or conduct may include physical force, violence, threat, intimidation, ignoring the
objections of the other person, causing the other person’s intoxication or incapacitation (through
the use of drugs or alcohol) or taking advantage of the other person’s intoxication (including
voluntary intoxication).
Sexual Assault Level 1- Any form of sexual activity forced on another person (i.e., sexual
activity without consent), or non-consensual bodily contact for a sexual purpose (e.g.,
kissing, touching, oral sex, vaginal or anal intercourse). Level 1 sexual assault involves
minor physical injury or no injury to the victim.
Sexual Assault Level 2- A sexual assault in which the perpetrator uses or threatens to use a
weapon, threatens the victim’s friends or family members, causes bodily harm to the
victim, or commits the assault with another person (multiple assailants).
Sexual Assault Level 3- (Aggravated sexual assault) a sexual assault that wounds, maims, or
disfigures the victim, or endangers the victim’s life.
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Crisis Line (Hotline): A phone number people can call to get immediate telephone counselling usually by trained
volunteers.
Telephone Counselling: The delivery of counselling services for a variety of mental health and life problem
concerns via telephone. Services range from crisis lines provided by paraprofessionals to traditional mental health
counselling provided by licensed mental health professionals (Weiner & Craighead, 2010).
E-Counselling: the counsellor and client exchange e-mail instead of meeting face-to-face.
Typically, e-mails are exchanged once a week for an average period of 3 weeks (Health Canada,
2012).
Access to Healthcare (Support service): the degree to which individuals and groups are able to
obtain needed services from the medical care system
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INTRODUCTION
Sexual assault is a serious public health and safety issue, a criminal justice issue and a threat to
human rights globally (Shahali et al., 2014; Decker et al., 2014; Rossiter, Yercich, & Jackson,
2014). In Canada and around the globe, sexual assault is highly gendered (Benoit et al., 2015;
Ontario Ministry of the Status of Women, 2015). Women are more likely than men to experience
some form of sexual assault and this is persistent across time and provinces. In 2014, women
self-reported 553,000 incidents of sexual assaults and accounted for about 92% of all police-
reported sexual assault victims in Canada in 2008 (Canadian Women Foundation, 2016;
Vaillancourt, 2010). In BC, 3.6% of the population reported having experienced sexual assault in
the 2009 General Social Survey (GSS) (Rossiter, Yercich, & Jackson, 2014). Nonetheless,
between 2014 and 2015 the national rate of police-reported level 1 sexual assault increased by
3%, the rate for level 2 sexual assault increased by 13% while the most serious sexual assaults
(level 3) declined by 11% (Allen, 2016). Additionally, some women are even more vulnerable to
sexual assault compared to the rest of the female population due other factors like their cultural
and ethnic background, immigrant status, income and educational level, age, sexual orientation
and physical, cognitive and emotional abilities (Zweig, Schlichter & Burt, 2002). This does not
mean men are not survivors of sexual assault. However, due to more focus on female sexual
assault survivors the nature and prevalence of sexual assault in the male population is limited.
Broader social and political contexts also contribute to and shape the prevalence of sexual
assault in Canada. Structural violence in the form of historical, political-economic and social
processes of Canada shape the way women are treated by the judicial system and the society at
large. Dominant gender roles, rape myths and inherent biases in investigatory procedures of
sexual assault cases all reveal the gendered structural violence women face in their daily lives
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(Benoit et al., 2015). That being said, the prevalence of sexual assault in Canada is difficult to
quantify since only a small proportion of sexual offences are formally documented (Brennan &
Taylor-Butts, 2008). Additionally, interactions between different aspects of a person’s identity
and social location (determined by socio-economic status, age, race, ethnicity, ability, sexual
orientation and employment status) can play a significant role in making certain persons more
vulnerable to sexual assaults than others (Benoit et al., 2015). For example, Aboriginal women in
Canada are 3 times more likely to be victims of violence compared to non-Aboriginal women-
21% Aboriginal women compared 6% non-Aboriginals experience some form of physical or
sexual violence (Province of Newfoundland and Labrador factsheet, 2008; Brennan, 2011).
Furthermore, violent victimization including sexual assault was 2-4 times higher for women with
disabilities than those without (Martin et al., 2006; Canada Dept. of Justice).
Sexual assault may result in severe and long-lasting mental as well as physical health
consequences (Luce, Schragger & Gilchrist, 2010). Compared to Canadian men, women are
more likely to be physically injured, experience disruption in their daily lives and more likely to
fear for their lives (Ontario Ministry of the Status of Women, 2015). Physical health impact of
sexual assault includes assault related injuries, sexually transmitted infections, unwanted
pregnancies, pelvic pain, gastrointestinal disorders, vaginal bleeding or infections, urinary tract
infection, gynecological problems, a range of chronic pain disorders, short and long-term sexual
health problems (Benoit et. al., 2015). Mental health effects of sexual assault include
problematic substance use and substance dependence, posttraumatic stress disorder, clinical
depression, anxiety, suicide ideation or attempts (Campbell, Dworkin & Cabral, 2009; Haskell,
2010). Sexual assault experienced by Aboriginal women has been linked to higher incidence of
homelessness, self-harming behaviour, attempted suicide and suicide as well as other mental
8
health issues. Survivors of sexual assault may also experience stigmatization and ostracism from
family and friends (Krug et al., 2002; Benoit et. al., 2015). Finally, sexual assault has great
economic costs for Canadians. The direct cost of sexual assault in Canada (based on police
reported incidents and estimates based on police, court, health care, social service costs and
personal and productivity costs) is estimated to be about $546 million per year. If the physical
and emotional pain and suffering are included the estimated cost rises to about $1.9 billion
(Benoit et. al., 2015).
The goal of this capstone was to develop a business case for an online sexual assault counselling
service that can be used by BC Women’s Hospital (BCWH). The business case will be shared
with BCWH Sexual Assault Services team, who will use it as a starting point to develop a more
detailed business case. The following sources were drawn on to develop a business case that best
fit the online counselling project: 1) reading of related literature 2) course-based knowledge 3)
Some knowledge of the organizational structure of BCWH sexual assault services.
PROJECT BACKGROUND. BC Women’s Hospital and Health Centre Sexual Assault Services (SAS) comprises of specially
trained female nurses, nurse examiners, doctors, and counsellors. They provide free services to
people of all gender aged 13 and over who had experienced an assault within 7 days of their
assault. The service options include assessment and treatment of injuries, sexually transmitted
infections, and pregnancy prevention, as well as forensic sample collection and a report for
police (for those patients who want to involve police). They also provide referrals to health,
legal, and community-based support services. In addition to patient care, they provide training
and education to health care providers and other professionals working in the area of sexual
assault.
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In 2015, the SAS team decided to expand their counselling services by providing a province-
wide service that caters to clients/patients that are attended to by the Sexual Assault Nurse
Examiners (SANEs) at VGH and UBC Hospital’s urgent care as well as any other sexual assault
survivors who for some reason could not access support services. This decision was made in
order for the SAS department to accomplish one of their strategic goals. The goal is to be a
provincial resource for sexual assault survivors and counselling services by providing up-to-date
referral information on available services, increasing the reach of counselling service and
increasing the number of minority populations accessing support services.
In order to understand the need for an online counselling service, it is important to discuss the
various approaches to sexual assault prevention. Sexual assault interventions are usually targeted
towards the three public health prevention categories:
1. Primary prevention: approaches that take place before sexual assault occurs to prevent
initial victimization e.g. public education.
2. Secondary prevention: Immediate responses after sexual assault has occurred to deal with
the short term consequences of violence e.g. immediate crisis counselling for survivor,
medical attention in case of injuries.
3. Tertiary Prevention: Long-term response after sexual assault has occurred to deal with
the lasting consequences of victimization (e.g. by providing ongoing counselling for
survivors) and providing evaluation and treatment of the perpetrators (Centers for
Disease Control and Prevention (CDC), 2004; Marshal, Laws & Barbaree, 2013).
BC Women’s Hospital and Health Centre Sexual Assault Services (SAS) participates in all three
categories of sexual assault prevention. However, until recently BCW’s sexual assault services
has been focused on its secondary prevention strategies. This includes assessment and treatment
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of injuries, pregnancy prevention, forensic sample collection, medical reports and referrals to
community-based support services. They offer these services through Vancouver General
Hospital emergency department and UBC Hospital’s urgent care centre. BC Women’s SAS also
provides follow up counselling care to survivors who indicate their willingness to be called by
the SAS resident counselor.
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EXECUTIVE SUMMARY
BC Women’s Sexual Assault Counselling Service
Project Description
The need this project hopes to address includes the long waiting list for and lack of access to
counselling services for survivors of sexual assault. The proposed service is an online and/or
phone counselling services for survivors of sexual assault. The service aims to reach those who
may not have available services (for example, only a few physically available services which
serves wide geographical regions as is the case in Northern BC) or those that may be reluctant or
unable to seek face-to-face services (e.g. male, marginalized women etc.) (Finn & Hughes,
2008).
Project goal
To provide confidential, non-judgmental telephone/online support, crisis intervention,
information and referral services.
Project objectives
- To double the number of sexual assault survivors in BC receiving crisis counselling and support services by 2020.
- To facilitate continuity of care and support for 80% of clients by providing accurate referrals upon completion of a counselling session.
- Upon completion of counselling services, 25% of survivors will have a referral plan to necessary community services.
- To double access to respectful, empathetic and emotionally supportive counselling services and 70% increase survivors coping skills, knowledge at the end of each section.
- To increase the number of men and marginalized populations seeking sexual assault counselling and support services by 15% by 2025.
Current Situation
Sexual assault may result in severe and long-lasting mental and physical health consequences
(Luce, Schragger & Gilchrist, 2010). Very few survivors seek post assault care services.
Barriers survivors face include:
- Long waitlists for survivors seeking counselling appointments in community- based programs. Of clients on a waitlist with Stopping the Violence (STV)
counselling programs, 80% receive individual counselling within three months
and 88% receive group counselling within three months. The ideal practice is to
reduce wait time for those in need.
- Members of the LGBTQ+ community, marginalized and minority women (e.g. Aboriginal women, immigrant and refugee women, women with disabilities, sex
trade workers) may be at higher risk of experiencing violence including sexual
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asssault along with unique barriers to support and protection (Rossiter, Yercich, &
Jackson, 2014). These include inaccessibility of existing services and resources,
lack of specialized services that target their particular need and social isolation,
lack of awareness of available services (Clifford, Porteous & Varcoa, 2007;
Logan et al., 2005). For Aboriginal survivors, there is added fear of being isolated
and shamed by their community, lack of confidentiality, distrust of “white
institution”, multiple barriers such as substance abuse, mental health issues etc.
(BC Ministry of Public Safety and Solicitor General, 2007).
- Finally, there are much fewer cultural, social and physical support system for males (Bullock & Beckson, 2011; Donnelly & Kenyon, 1996).
The project would be an addition to BC Women’s Hospital Sexual Assault Services. The project
would implement a new telephone/online platform. The telephone aspect of the project would be
modelled after BC Women’s CARE counselling service. The online would be modelled after other
online chat counselling services in Ontario as well as RAINN, USA.
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1 BACKGROUND
[BC Women’s Sexual Assault Counselling Service]
1.1 PROBLEM / OPPORTUNITY
The problem this project hopes to address is the long waiting lists common with most
community-based sexual assault services program in BC. It also aims to improve access to
counselling services for survivors of sexual assault from diverse populations. This creates a need
for innovative ways to increase access to post-assault services across BC. The proposed service
is an online and/or phone counselling services for survivors of sexual assault. The goal of this
Project is to provide confidential, non-judgmental telephone/online support, crisis intervention,
information and referral services. The service aims to reach those who may not have available
services (for example, only a few physically available services which serves wide geographical
regions as is the case in Northern BC) or those that may be reluctant or unable to seek face-to-
face services (e.g. male, marginalized women etc.) (Finn & Hughes, 2008). Additionally, this
project builds on existing infrastructure at BC Women’s Hospital such as the CARE program.
1.2 CURRENT SITUATION
In 2014, Canadian women self-reported 553,000 incidents of sexual assaults while the rate of
police-reported sexual assault of women by intimate partner rose by 17% between 2009 and
2013 (Canadian Women Society, 2016). Interpreted in terms of proportion, 39% of Canadian
adult women reported having had at least one experience of sexual assault since the age of 16
(Ontario Ministry of the Status of Women, 2015). In BC, 3.6% of the population reported having
experienced sexual assault in the 2009 General Social Survey (GSS) (Rossiter, Yercich, &
Jackson, 2014). Sexual assault may result in severe and long-lasting mental and physical health
consequences especially when left untreated (Luce, Schragger & Gilchrist, 2010; Finn and
Hughes, 2008). Research shows that sexual assault survivors are 13 times more likely to attempt
suicide than non-crime victims and 6 times more likely than victims of other crimes (Finn and
Hughes, 2008; Munro, 2014). However, very few survivors seek out acute care services
following a sexual assault. Many Sexual Assault Nurse Examiners (SANE) programs in
accordance with recommendations from the World Health Organization (WHO) schedule a
follow-up service within two weeks of the initial exam with survivors who reach out to the
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program (Darnell et al., 2015; WHO, 2003). This follow-up provides a medical checkup and
assessment for needs for psychosocial and mental health service. Unfortunately, linking sexual
assault survivors to follow-up assessment of medical and psychosocial needs is challenging
resulting in many survivors not receiving needed services (Darnell et al, 2015; Ullman, 2007). In
addition, most survivors do not pursue mental health services or counselling within the year of
the assault and some survivors would never seek mental health services for problems related to
the assault. This has resulted in low utilization of mental health services by sexual assault
survivors (Darnell et al., 2015; Logan et al., 2005).
Marginalized and minority women (e.g. Aboriginal women, immigrant and refugee women,
women with disabilities, sex trade workers) may be at higher risk of experiencing violence
including sexual assault along with unique barriers to support and protection (Rossiter, Yercich,
& Jackson, 2014). For example, Aboriginal women in Canada are 3 times more likely to be
victims of sexual assault compared to non-Aboriginal women- 21% Aboriginal women
compared 6% non-Aboriginals experience some form of physical or sexual violence
(Newfoundland and Labrador factsheet, 2005; Brennan, 2011). Furthermore, violent
victimization including sexual assault was 2-4 times higher for women with disabilities than
those without (Martin et al., 2006; Canada Dept. of Justice). Marginalized survivors also suffer
from societal traumas which include intergenerational trauma, race-based trauma, sexism,
racism, classism, heterosexism, historical trauma, insidious trauma, cultural violence etc. These
may result in mental health effects for example PTSD, physical health disparities and substance
abuse that predate the sexual assault trauma. However, current models for recovery may not fully
address the mental health needs of minority survivors (Bryant-Davis, Chung & Tillman, 2009;
Ullman, 2007).
Barriers in Accessing Support Services
The impact of the social determinants of health as well as an individual’s socioeconomic status,
ethnic and racial background on healthcare access disparity has been well documented (Carillo et
al., 2011). According to the Health Care Barriers Access model, there are three categories of
modifiable healthcare access barriers- Financial, Structural and Cognitive/Individual barriers. All
three categories of barriers are mutually reinforcing and affect health care access individually
and synergistically. Financial barriers to healthcare access occurs when patients are uninsured or
15
underinsured i.e. individuals with health insurance who cannot access healthcare due to financial
burden imposed by addition fees (Parikh et al., 2014). Structural barriers can be defined as
“forces that work outside the individual and beyond the individual’s control to foster or impede
health or health behaviors, and they often distally impact health outcomes in diffuse and
indefinite ways” (Levi et al., 2014). They describe healthcare system’s availability and such
barriers may be found within or outside the healthcare facility. Examples of structural barriers
include lack of transportation, inability to obtain convenient appointment times, limited
availability and proximity of facilities (Carillo et al., 2011; Kroll et al., 2006).
Cognitive/Individual barriers are based on an individual’s beliefs and knowledge of disease,
prevention and treatment as well as the communication between client and provider. Example of
individual barriers include lack of awareness of accessible facilities, linguistic barriers etc.
(Carillo et al., 2011).
One major barrier survivors experience in accessing mental health and counselling services is
long waitlists for women seeking support in community-based centres (Women against Violence
against Women (WAVAW), 2016). Of clients on a waitlist with STV counselling programs, 80%
receive individual counselling within three months and 88% receive group counselling within
three months (Suleman, & McLarty, 1997). There is also the social constraint placed on
community-based services as they typically operate during business hours which could exclude
patients who work during these hours and cannot afford to take off-days. Additional barriers may
also include travelling to and from appointment and for care-givers (for example those taking
care of children) searching for additional support while they attend their appointment (Ritterband
et. al., 2009). The unique barriers faced by all marginalized populations include- inaccessibility
of existing services and resources (due to physical availability or because of perceived
inaccessibility), lack of specialized services that target their particular need, lack of awareness of
available services, social isolation and stigma (Clifford, Porteous & Varcoa, 2007; Logan et al.,
2005; Munro, 2014).
Specifically, survivors with disabilities face barriers in accessing services due to inadequate
services, immobility and difficulty in physically accessing services. For example, physical
accessibility to those who are sight-impaired or hearing impaired is often incomplete or non-
existent (BC Ministry of Public Safety and Solicitor General, 2007). They may be isolated from
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sources of social support and assistance and maybe unaware of available services. Immigrant
women may not know about the availability of services available to them. They may also lack
knowledge of immigration and refugee laws and rights. They could face language barriers,
isolation and if the abuse is occurring within marriage, the threat of being sent back home (BC
Ministry of Public Safety and Solicitor General, 2007). Those with precarious citizenship status
or no legal status may be afraid that their stay in the country may be jeopardized and hence
would be reluctant to seek services for fear of deportation (Benoit et. al., 2015). Gay and lesbian
survivors may have problems in (perceived) accessibility of sexual assault services in general
and support services in particular as mainstream services were originally designed for
heterosexual women. A research indicates that lesbian women were unlikely to use any resources
but rather needed more lesbian- or women-centred resources. However, in Canada, there is still a
scarcity of gay/lesbian specific services and many members of the LGBTQ+ are unaware of
mainstream services that are sensitive to their needs (St. Pierre & Senn, 2012; BC Ministry of
Public Safety and Solicitor General, 2007). For Aboriginal survivors, there is added fear of
being isolated and shamed by their community, lack of confidentiality, distrust of “white
institution”, other barriers such as substance abuse, mental health issues etc. (BC Ministry of
Public Safety and Solicitor General, 2007). In addition, counselling of Indigenous patients using
methods used by the cultural mainstream has been said to perpetuate colonial oppression. Hence,
many Indigenous people often do not/would not engage in services that do not value their way of
knowing (King, Smith & Gracey, 2009; WAVAW, 2014).
Although many victim service programs serve women with multiple barriers, very few of these
services specifically tailor services to the unique needs of such clients (Zweig et. al., 2002).
Current services in BC are “provided mainly in English, are not suitable for all age ranges of
women, rarely make accommodation for physical and mental health issues, are often Euro-
centric and are primarily aimed at heterosexuals” (Haskell, 2010). This creates accessibility
issues for many marginalized populations that do not fit into the dominant culture of these
support services. In 2007, there were fourteen victim service programs in BC which focused on
Aboriginal crime victims. Of the fourteen programs, only three specialized in serving domestic
or sexual assault victims and only one specifically served youths. Furthermore, only four victim
service programs specifically serve immigrant victims of crime, two of which specialize in
serving survivors of sexual assaults (Clifford, Porteous & Varcoa, 2007). The number of services
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has not increased since 2007 due to lack of funding for “women’s” services (WAVAW, 2016).
However, organizations like WAVAW connects Aboriginal women with available Friendship
Centres and cultural centres located in British Columbia (WAVAW, 2014). Nevertheless, as
Aboriginal women in Canada are more vulnerable and are 3 times more likely to be victims of
sexual assault compared to non-Aboriginal women, WAVAW alone cannot cater to the entire
population in need (WAVAW, 2014).
The publicity of sexual assault as a “female-only” issue has contributed to the neglect and
isolation of male survivors of sexual assault (Davies, 2000). This neglect together with the social
gender norms that view men as sexually aggressive, strong and better able to protect themselves
makes it difficult for men to admit to that they have been sexually assaulted. Additionally, male
survivors may be reluctant to disclose their experiences for fear of being labelled future
perpetrators or homosexual, as well as fear of treated as social outcasts, liars or emotionally
weak. Finally, there are much fewer cultural, social and physical support systems for males
victims (Bullock & Beckson, 2011; Donnelly & Kenyon, 1996; Neame & Heeman, 2003;
McDonald & Tijerino, 2000). Most community-based victim service programs in BC (usually
run and managed by women) cater mainly to female and children survivors although some
programs have provisions for all genders. In fact, there are only about 3 male specific support
services in BC. This is problematic for male survivors as they similarly suffer from the emotional
and mental effects of assault that their female counterparts face. Additional societal pressures
may cause more unique mental health issues requiring men to have targeted services that can
help address these unique challenges brought on by cultural norms. Some examples of this
unique mental health issues include self-identity crisis, sexual dysfunction and frequent sexual
activity with many partners (McDonald & Tijerino, 2000)
Severity of Sexual Assault
As previously stated, sexual assault may result in severe and long-lasting mental and physical
health consequences. Women in Canada are more likely to be physically injured, experience
disruption in their daily lives and more likely to fear for their lives compare to men (Benoit et al.,
2015). Physical health impact of sexual assault includes assault related injuries, sexually
transmitted infections, unwanted pregnancies, pelvic pain, gastrointestinal disorders, vaginal
bleeding or infections, urinary tract infection, gynecological problems, a range of chronic pain
18
disorders, short and long-term sexual health problems (Benoit et. al., 2015; Kimerling &
Calhoun, 1994). For Aboriginal women, in particular, sexual assault has been linked with the
rising rates of HIV/AIDS (Hawkins, 2009). Physical health problems including those related to
stress, substance abuse and risk taking can also arise from the mental health consequences of
sexual assault (Benoit et al., 2015).
Mental health effects of sexual assault include problematic substance use and substance
dependence, posttraumatic stress disorder, clinical depression, anxiety, suicide ideation or
attempts (Campbell, Dworkin & Cabral, 2009; Haskell, 2010). Sexual assault experienced by
Aboriginal women has been linked with higher incidence of homelessness, self-harming
behaviour, attempted suicide and suicide as well as other mental health issues. Survivors of
sexual assault may also experience stigmatization and ostracism from family and friends (Krug
et al., 2002; Benoit et. al., 2015). Finally, sexual assault has great economic costs for Canadians.
The direct cost of sexual assault in Canada (based on police reported incidents and estimates
based on police, court, health care, social service costs and personal and productivity costs) is
about $546 million per year. If the physical and emotional pain and suffering are included the
estimated cost rises to about $1.9 billion (Benoit et. al., 2015).
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2 PROJECT DESCRIPTION
2.1 PROJECT DESCRIPTION The project’s goal is to provide a telephone and internet-based one-to-one counselling and
referrals to support services to survivors of sexual assault. Online and telephone services would
utilize both licensed and student counsellors who are also trained in sexual assault survival
counselling as well as E-counselling. Additionally, volunteer counsellors who are trained in
crisis intervention, support skills, and information and referral at their local rape crisis centre or
at BC Women Sexual Assault Services will provide support for the program. The counsellors
would be in charge of providing sexual assault counselling, education and information, provide
referrals to assist with other needs and offer crisis intervention. Resource materials for example
educational materials regarding criminal justice, medical and emotional issues would be
provided to the volunteers to supplement their knowledge of sexual assault crisis information.
Counsellors would be able to access information during a session and can send them to the
client. Clients would be able to access the telephone/online service through various ways
including search engines, referrals, through print media, by word of mouth etc.
2.2 OBJECTIVES
This project has several objectives
- To double the number of sexual assault survivors in BC receiving crisis counselling and
support services by 2020.
- To facilitate continuity of care and support for 80% of clients by providing accurate
referrals upon completion of a counselling session.
- Upon completion of counselling services, 25% of survivors will have a referral plan to
necessary community services.
- To double access to respectful, empathetic and emotionally supportive counselling services
and 70% increase survivors coping skills, knowledge at the end of each section.
- To increase the number of men and marginalized populations seeking sexual assault
counselling and support services by 15% by 2025.
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2.3 SCOPE
Timeframe: Continuous- Project to start within the next fiscal year
Department/Organization: Sexual Assault Service (SAS) - BC Women Hospital + Health
Centre, Vancouver
Function: This project would be an expansion of BC Women’s sexual assault counselling
services which currently offers in person and over the phone sessions with survivors
examined at VGH or UBC Hospital. BC Women’s SAS would be in charge of directing and
overseeing/supervising the counselling service.
Technology: The project would include a toll-free telephone/online platform. The telephone
aspect of the project would be modelled after BC Women’s CARE counselling service. The
online component of the counselling would be modelled after other online chat counselling
services in Ontario and RAINN in the US. Currently, there is no system in place for sexual
assault online counselling in BC.
2.4 RATIONALE FOR ONLINE SERVICES
The rational for an online counselling service is based off: 1) existing research that show that the
rate of sexual assault for Canadians age 15 to 24 is 18 times higher than that of Canadians age 55
and older (Brennan & Taylor-Butts, 2008). 2) The increasing use of internet especially by young
people to obtain information and social support. (Finn & Hughes, 2008). There 25.5 million
internet users in Canada making them the heaviest users of internet in the world (Mental Health
Commission of Canada, 2014). 3) Increasing evidence that online therapeutic services are as
effective as face-to-face counselling (Beattie, Cunningham, Jones, & Zelenko, 2006; Cook &
Doyle, 2002; Richards, 2009). 4) Reluctance of many victims to report victimization to
traditional authorities (Finn & Hughes, 2008).
Additionally, an evaluation conducted on the RAINN national sexual assault online hotline USA
reported that volunteers were able to meet a variety of long-term health and mental health needs
through empathy, problem solving, and information and referrals (Finn & Hughes, 2008; Finn,
Garner, & Wilson, 2011). Patients of other online counselling services have reported decreased
stigma with distance services when compared to face-to-face services (Mental commission of
21
Canada, 2014). Finally, BC Women’s Hospital currently operates a hotline service for their
abortion and pregnancy CARE program hence, this project would be building on knowledge and
resources acquired by the CARE program.
2.5 ANTICIPATED OUTCOMES This section itemizes specific and measurable deliverables of the project. Each outcome includes
an estimated time frame of when the outcome/deliverable will be completed (in terms of elapse
time from project start).
Outcome/Deliverable Estimated Completion
50% increase in knowledge of online sexual
assault counseling by counsellors
1-3 months
10% Increased clients’ awareness of options
and available resources
6 months- 1 year
5% increase in number of disclosed sexual
assault cases to formal sector (counselling
services)
1 year
15% increase in number of SA survivors
seeking counselling and support services
2 years
5% increase in the number of men and
marginalized population seeking
counselling and support service
2-3 years
15% increase in practice of effective coping
and self-care strategies
2-3 years
25% increase in the number of sexual
assault survivors receiving crisis
counselling and support services
5 years
15% increase in the number of men and
marginalized populations seeking sexual
assault counselling and support services in
BC
6-10 years
22
2.6 STAKEHOLDERS Stakeholders: Overview of Business Requirements
Primary – Internal
BC Women’s Sexual Assault
Service- Counselling
Understanding of operation of telephone/online counselling service.
Location for the operation of telephone/online counselling services.
Primary – External
Sexual assault counsellors Training on online and telephone counselling
Supervising student counsellors
Secondary – Internal
PHSA Provision of ongoing funding to the Project
Sexual Assault Survivors Active use telephone and online counselling services.
Secondary – External
WAVAW Collaboration with BC Women to provide support, training and
recruitment of counselors.
Community-based Rape Crisis
Centres
Recruitment of volunteer counsellors.
Dissemination of information to survivors and volunteers.
BC Royal Canadian Mounted
Police (RCMP) and Vancouver
Police Department
Dissemination of information to survivors
23
3 STRATEGIC ALIGNMENT
Description:
Review the business plans of all internal stakeholders and identify specific goals that the project
will help achieve. Identify the level of impact the project has on achieving the various business
plan’s goals by scoring the impact high, medium, or low, using the following guidelines:
High indicates that the project is critical to the achievement of the goal
Medium indicates that the project directly impacts the goal but it is not critical to its
attainment
Low indicates an indirect impact to the achievement of the goal
Goal from BC
Women’s Business
Plan
Level of Impact Explanation (if required)
Be a provincial
resource for
information and
education
Medium
Expand counselling
services to reach
Northern parts of BC
High
Providing inclusive
service to diverse
population
High
24
4 ENVIRONMENT ANALYSIS
Description:
While there is currently no online (chat-based) counselling service in BC for sexual assault, there
is a telephone and texting helpline - WAVAW 24-hour crisis line. In Ontario, they have a
number of telephone, texting and online (web-chat) counselling options with many starting to
include video-chatting as part of their services (example SACHA sexual assault centre, an
Aboriginal specific helpline- Talk4healing). Alberta has the Central Alberta Sexual Assault
Support Centre which includes web-chat options available during operating hours (9am-
4:30pm). In the United States, there is a national sexual assault online hotline (RAINN- USA).
Australia also has sexual assault online counselling services for most of their jurisdiction and
various stages of patient recovery (Forgan, 2011).
WAVAW 24-hour crisis line: The 24-hour telephone crisis line has been in existence for 25
years and offers services to women in Vancouver and the rest of Lower Mainland. The goal of
the project is to provide a year around, toll-free, 24-Hour Crisis Line. In 2015, WAVAW
responded to 3,956 crisis line calls and had 33 women who volunteered to answer after hour
crisis line calls. WAVAW attributes the success of their program to their volunteer program
which provided about 200 hours of volunteer training. While WAVAW received $707, 000 as
donations (about 50% of their total funding) in 2015, it is difficult to ascertain how much was
spent on the 24-hour crisis line.
RAINN (Rape, Abuse& Incest National Network): This is the largest anti-sexual violence
network in the United States. They operate a National Sexual Assault Hotline, accessible 24/7 by
phone and online and closely with more than 1,000 local sexual assault service providers across
the country. They aim to offer confidential support services to survivors regardless of where they
are in their recovery. Since their inception, their telephone and online hotlines have helped more
than 2.5 million survivors. According to their financial audit for 2015, RAINN spent a total on
$3,337,653 on their victims’ service program of which the telephone/online hotline is the major
component.
SACHA Sexual Assault Centre: This provides free telephone support services to women
survivors of sexual assault. They work in coalition with the Ontario Coalition of Rape Crisis
25
Centres. This year, they started a pilot online (web-chat and text) option which runs on Fridays
6pm to 2am and Mondays 6pm to 12am. This pilot program would be carried out until
December, 2017 and would hopefully be expanded following an extensive evaluation.
Talk4Healing: Provides telephone and live chat hotline services to Aboriginals in Ontario. The
service is available in English, Ojibway, Oji-Cree and Cree provided by trained Aboriginal
counsellors. Their goal is to provide services for women living in urban, rural and remote
communities both on and of reserve in a culturally specific manner. By the second year of their
operation, they responded to 4,395 phone calls from Aboriginal women living in their target
region. It was impossible to find out the operational cost of the program.
26
5 ALTERNATIVES
Due to the nature and the impact of sexual assault on the survivor, there are very few alternatives
available to survivors to improve their health outcomes.
Alternative 1: Do nothing (Status Quo). There are over 60 community-based programs located
throughout the province that assist victims of family and sexual violence including sexual assaults (BC’s
Criminal Justice System, 2017). The current number of available services helps meet a critical need for
support of sexual assault survivors. However, there are more people needing services than can be
attended to due to long waiting list in most of these community-based programs. Additionally, most
programs operate normal business hours could make it difficult for some members of their target
population to access their services. Finally, current community-based services may not be able to reach
marginalized or other unreached populations who cannot leave their house for various reasons.
Alternative 2: Telephone only service. A telephone crisis line is the most common option that has been
used to tackle sexual assault crisis intervention. Although, there are numerous 24-hour crisis lines
available in BC, there are only about three telephone counselling services targeted at sexual assault
survivors.
One major advantage of this system is that calls can be made toll-free thereby reducing economic
worries for survivors. Another advantage is the ubiquitous availability of telephone services globally-
In British Columbia, 99.4 per 100 households subscribe to landline and/or mobile wireless telephone
services (Canadian Radio-television and Telecommunications Commission (CRTC), 2016). However,
this option has a few limitations. Firstly, there is some indication that youths perceive chat/online
counselling quality to be equal or marginally better than telephone counselling options (Fukkink &
Hermanns, 2009; Finn, Garner, & Wilson, 2011). Secondly, group counselling options are unavailable
for difficult to reach populations that may desire or require this service.. Additionally, the cost of running
a telephone only service is only marginally less than a combination of telephone and online service.
Alternative 3: Telephone and online service (Recommended). There is an increasing amount of
evidence on the efficacy of online therapy. Evidence suggests that a combination of telephone and
online counselling services may have a better reach than just telephone or online services. This is
because some clients may prefer to write out their discussions rather than talk about their experience.
Having online as well as telephone services provides these options to clients. Evidence from an online
27
counselling service for children and youths in Australia found that young people with more serious
cases used online services more than telephone services. They also found that patients stayed in a
counselling section longer than telephone and reported a greater sense of safety, anonymity and control
in their interactions with a counsellor than on the phone (Beattie et al., 2006). Additionally, there are
major opportunities of creating targeted portals within the online platform, making it easier to provide
culturally sensitive as well as specific support for multi-barriered clients. The presence of a permanent
record provides the client and counsellor opportunities to review and reflect on the process. Finally,
online counselling also provides an opportunity for more in-depth research of counselling interactions.
This is the most expensive in monetary and training costs however, the health and non-health benefits
balance the costs.
28
6 BUSINESS AND OPERATIONAL IMPACT
Description:
For each stakeholder (outlined in Section 3) all business (strategic, longer term focused) and operational
(procedural, detailed focused) impacts that may arise from the project have been identified.
For each impact use the following guidelines:
High indicates that the magnitude of impact is significant and stakeholder support and
preparation is critical to the alternative’s success
Medium indicates that there is a manageable impact to the stakeholder
Low indicates the alternative will have a minor impact to the stakeholder
None indicates that the stakeholder will not be impacted by the alternative
Impact & Description Alternative
1
Alternative
2
Alternative
3
Stakeholder 1: BC Women Sexual
Assault Services- Counselling.
Business impact- change in mode of service
delivery
Low Medium Medium
Operational impact- Recruitment and
training of counsellors required
Low Medium Medium
Operational impact- Redirection of funds
from other SAS Projects
Low High High
Stakeholder 2: Sexual Assault
Volunteer counselors
Operational impact- increased number of
working hours
Low Medium Medium
Operational impact- Number of training and
information required.
Low High High
Stakeholder 3: PHSA
Business impact- Change in budget for
sexual assault services
Low Medium Medium
Stakeholder 4: WAVAW
29
Operational impact- number of people
visitors to WAVAW centre
Low Medium Medium
Operational impact- Number of callers on
telephone service
Low Low Low
Stakeholder 5: Sexual Assault Survivors
Operational impact- Number of survivors
accessing services
Low High High
Stakeholder 6: Rape Crisis Centre
Operational impact- Number of visitors to
community-based programs
Low High High
30
7 PROJECT RISK ASSESSMENT
7.1 RISK OF PROJECT AND EACH VIABLE ALTERNATIVE (NOT INCLUDING STATUS QUO)
Project Risk Assessment Telephone only service Telephone and Online service
Probability Impact Probability Impact
Risk 1 – Lack of support from
PHSA
Medium High Medium High
General Mitigation Strategy: Specific strategy Specific Strategy
Provision of evidence relating
to the need and efficacy of
project
Evaluatio
n report of
existing
services
tailored
towards
sexual
assault.
Refining of
business
case/plan.
Evaluation
report of
existing
services
tailored
towards sexual
assault
Refining of
business
case/plan
Risk 2 – Inability to free-up
critical business resources
Medium Medium Medium High
General Mitigation Strategy Specific Strategy Specific Strategy
Identification and utilization of
alternate cost-effective project
inputs and/or alternate funding
Locating
and
utilizing
cost
effective
project
inputs.
For
example
cost-
effective
telephone
subscripti
on, use of
volunteers
etc.
Identifying
alternative
funding
sources for
example
fundraising.
Locating and
utilizing cost
effective
project inputs.
For example
cost- effective
computer
software,
telephone
subscription,
use of
volunteers etc.
Identifying
alternative
funding
sources for
example
fundraising.
Collaboration
with other
stakeholders
in sexual
assault
services
across BC.
Risk 3- Inadequate Counsellors Low High Medium High
31
General Mitigation Strategy Specific Strategy Specific Strategy
Continuous assessment of staffing
needs
Continuou
s feedback
from staff
and
clients
Periodic
recruitment
of new
counsellors
Provision
of
practicum
placements
for students
in
counselling
and social
work
Continuous
feedback from
staff and
clients
Periodic
recruitment of
new
counsellors
Provision of
practicum
placements
for students in
counselling
and social
work
Risk 4: Project would not reach
varied target population
Medium Medium Medium Medium
General Mitigation Strategy Specific Strategy Specific Strategy
Media awareness be framed for
different populations
Collaborat
ion with
local
communic
ations
firm to
produce
populatio
n specific
and
relevant
promotion
al and
education
al
material.
Conduct a
test launch
in small
regions of
target
population
and
refining
project
from the
results of
test launch.
Collaboration
with local
communication
s firm to
produce
population
specific and
relevant
promotional
and
educational
material.
Creating
culturally
sensitive web
image and
design.
Conduct a test
launch in
small regions
of target
population
and refining
project from
the results of
test launch.
Risk 5: Secondary Victimization
of clients
Medium High Medium High
General Mitigation strategy Specific Strategy Specific Strategy
Continuous feedback from clients
through survey.
Continuou
s training
of
Re-
assignment
of
Continuous
training of
supervisors
Re-
assignment of
counsellor
32
supervisor
s and
counsellor
s
counselor
responsible
for
victimizatio
n
and
counsellors
responsible
for
victimization
Risk 6: Cost estimates unrealistic Medium Medium Medium High
General Mitigation Strategy Specific Strategy Specific Strategy
More thorough Cost analysis of
industry standards
Industry
expert
prediction
using
proven
practices
to 15%
margin of
error
Reduce the
number of
initial
startup
counselling
stations
Industry expert
prediction
using proven
practices to
15% margin of
error
Start with
telephone
counselling
and then
introduce
online
component
after
telephone
counselling
service
stabilizes.
Risk 7: Vicarious trauma for
student counsellors
High High High High
General Mitigation strategy Specific Strategy Specific Strategy
Provide support system for
counsellors
Debriefin
g
counsellor
s after
every shift
Limit the
amount
hours
working
with clients
per month
Debriefing
counsellors
after every
shift
Limit the
amount hours
working with
clients per
month
Risk 8: Overwhelming already
stretched community-based
services.
Medium High Medium High
General Mitigation strategy Specific Strategy Specific Strategy
Active collaboration with
community-based services to
distribute clients
Periodic
meeting
with
discuss
redistribut
ion of
clients
Active
retention of
clients on
the online
service
Periodic
meeting with
discuss
redistribution
of clients
Active
retention of
clients on the
online service
33
7.2 RISK OF NOT PROCEEDING WITH PROJECT (STATUS QUO) Project Risk Assessment Status Quo
Probability Impact
Risk 1 – Number of people
needing counselling services
increases
Low High
General Mitigation Strategy Specific Strategy
Create awareness and increase
utilization of already existing
alternate support services.
Increase availability
and awareness of self-
help coping strategies.
Increase awareness of
benefits of group
counselling sessions.
Risk 2 – Staff burnout in
community-based programs
Medium High
General Mitigation Strategy Specific Strategy
Increase critical business
resources available to community-
based programs.
Increase funding
available to
community-based
programs. Increase
awareness of human
resource need through
media campaigns.
Increase the use of
blended staffing methods
i.e. a mix of paid staff and
volunteers. Restructure of
current delivery model to
be more targeted.
34
8 COST/BENEFIT ANALYSIS
8.1 ESTIMATED COSTS Timeframe:
Ongoing monitoring system should be in place to capture call volume and the quality of
service. A process evaluation should also be conducted annually to assess the impact of the
counselling service on the target population.
Estimated startup for telephone only service
Budget Item Description Subtotal Total CAD
Personnel Coordinator 1 FTE $3,800/Month x 12
months
$45,600
Personnel Trained full-time counsellors x 3
Office manager (for computer system
and data management)
- $4,347/month per
person x 12months
- $4,200/month x 12
months
$206,492
Project
expenses
Equipment and supplies
- Telephone lines x 6
- Computers x 3
- Telephones x 6
- Desks and chairs x 6
- Automatic call distribution
(ACD) system
- Management Information
System
- File cabinet x1
Counsellor Training
- IPC skills training for telephone
counselling (10 participants for
11 weeks)
- $1,100
- $3,000
- $1,000
- $1,320
- $45,000
- $30,000
- $185
- $1000 per
week
$81,420
$11,000
35
Estimated start-up budget for Telephone and online option.
Project
expenses
Other Direct costs
- Basic telephone services
- Monthly service charge for
internet access
- Office costs (copying, paper,
mail etc.)
- Promotional material
- $300/ month
x 12 months
- $45/month x
12 months
- $180/month
x 12 months
- $2,200
$8, 500
Project
management
Monitoring and Evaluation activities $10,000 $10,000
Project
management
Communication/Correspondence etc. $2,500 $2,500
Project
Management
Report writing $1,000 $1,000
Administration Counselling Supervisor $300/month x
12months
$3,600
Financial
audit/Review
$3,000 per fiscal year $3,000
$373,112
Budget Item Description Subtotal Total CAD
Personnel Coordinator 1 FTE $3,800/Month x 12
months
$45,600
Personnel Trained counsellors x 3
Office manager (for computer system
and data management)
$4,347/month x
12months
$4,200/month x12
months
$206,492
Project
expenses
Equipment and supplies
- Telephone lines x 6
- Computers x 6
- 32’ LCD monitors x 6
- Dual monitor stands x 6
- $1,100
- $6,000
- $1,224
- $984
36
- Telephones x 6
- Desks and chairs x 6
- Integrated Automatic call
distribution (ACD) system and
Computer telephony integration
(CTI) - Five9 cloud contact
system software.
- File cabinet x 1
- Website design
- Management Information
System
Counsellor Training
- Skills training for web-based
counselling (10 participants for
11 weeks)
- $1,000
- $1,320
- $60,000
- $185
- $20,000
- $30,000
- $1,000 per
week
$121,813
$11,000
Project
expenses
Other Direct costs
- Basic telephone services
- Monthly service charge for
internet access
- Office costs (copying, paper,
mail etc.)
- Promotional material
- 300/ month x
12 months
- 45/month x
12 months
- 180/month x
12 months
- 2,200
$8, 500
Project
management
Monitoring and Evaluation activities 10,000 $10,000
Project
management
Communication/Correspondence etc. 2,500 $2,500
Project
Management
Report writing 1,000 $1,000
Administration Counselling Supervisor $300/month x
12months
$3,600
Financial
audit/Review
$3,000 per fiscal year $3,000
$413,505
37
8.2 QUALITATIVE ANALYSIS – NON-FINANCIAL BENEFITS & COSTS: Telephone and online counselling services
Qualitative
Summary
Description Stakeholder(s) Impacted
Benefits:
Health Benefits Decreased stigma with distance
services when compared to face-to-face
services (Mental commission of
Canada, 2014).
Support for survivors to recover from
or at least manage the mental health
effects of sexual assault (Finn &
Hughes, 2008).
Gateway to users to whom access to
traditional means of sexual assault
support are not available.
Reduces inhibition of clients which
may increase the likelihood of
disclosure (Finn & Hughes, 2008)
- SAS Counsellor - Volunteer
counsellors
- SA survivors
Non-Health Benefits Accessibility for remote/marginalized
survivors (Beattie et al., 2006).
Freedom from geographical and
temporal restrictions.
Cost-effectiveness, self-determination
for clients, leveling the power balance
between client and service provider and
presence of a permanent record which
provides the client and counsellor
opportunities to review and reflect on
the process (Beattie et al., 2006; Cook
& Doyle, 2002).
- SAS Counsellor - Volunteer
counsellors
- SA survivors
38
8.3 ASSUMPTIONS
Overall Assumptions
- The project would use a blended staffing model using both paid counsellors and volunteers.
- The Project would be ongoing
- Increased use of counselling services by survivors
39
9 CONCLUSIONS AND RECOMMENDATIONS
9.1 CONCLUSIONS This business case clearly supports the telephone and online counselling option
Alternative Business & Operational
Impact
Project Risk
Assessment
Cost/Benefit Analysis
Alternative
1
Low Low -
Alternative
2
Medium Medium $373,112
Alternative
3
High High $413,505
9.2 RECOMMENDATIONS Recommend the implementation of Alternative 3 since its strategic alignment is high while being
only marginally more expensive than Alternative 2.
9.3 PROJECT RESPONSIBILITY The initial phase of the Project should be managed by the current Program manager of BC
Women’s sexual assault services. She would be in charge of directing, implementing and
monitoring the progress of the project. Subsequently, the project coordinator would be in charge
of overseeing the operations of the project.
9.4 PROJECT ACCOUNTABILITY The project should be sponsored by the Provincial Health services Authorities. As such all
reports and accountability should be directed to PHSA
40
10 IMPLEMENTATION STRATEGY
See Appendix I for logic model
41
CRITICAL REFLECTION
There were several strengths in developing a business case. Firstly, I am very passionate about
working on sexual and reproductive health issues. Although sexual assault is quite a complex
social problem, I find it particularly rewarding to be working in an area that requires a systems
thinking approach to address it. Through my practicum and this project, I have come to
appreciate the difficulty and complexity of sexual assault and its impact on not just the survivor
but on the perpetrator as well as the society at large. This experience has enriched my
understanding of how health and health outcomes influence and are influenced by broad social
context in which individuals are located. Although this was taught in most of my classes, it was
difficult to conceptualize how this operates in a real world setting. Furthermore, I wanted to my
capstone to be relevant in practice and so was very pleased when I was asked to develop a
business case for this BC Women’s SAS counselling service. I consider myself very fortunate to
have come in contact with my preceptor and the rest of the team at BC Women’s SAS who
inspired me to take on this project.
Secondly, the business case gave the opportunity to apply many of the skills I had gathered
through my two year career as a Master in Public Health candidate. I was able to apply the
knowledge I had gained from program planning and evaluation as well as health promotion
courses to name a few. I believe all my courses developed in me the capacity to conduct in-depth
research of literature, critically appraise them and then draw reasonable conclusions from them.
This skill was very important for this capstone project because it required mining for information
on gaps in tertiary prevention for sexual survivors as well as the efficacy of telephone and online
counselling services for dealing with trauma. Additionally, I was able to apply a systems
thinking perspective in many sections of the business case. I found this quite challenging and
42
very rewarding. Finally, the MPH program helped to teach me important professional skills like
collaboration and communication which was the foundation of this project. The capstone
required a lot of input from both the resident counsellor at SAS as well as the project manager in
order to decide the format of the business case as well as the details for the actual project.
Although developing the business case was a very rewarding endeavor, I found the project quite
challenging at times. Firstly, there is no standard business case template which made it very
difficult for me begin my capstone. Once the initial selection was done, I found that some of the
sections were very difficult to complete. For example, it was extremely difficult to draw a budget
for the counselling service as similar services did not publish their financial statements. I also
have very limited experience in designing budgets for organizations. This leads me to my second
challenge- I found that time was a bit of a constraint as I did not have the time to sit with the
team from SAS to draft what would be an appropriate budget for the Project. I would also have
liked to reach out to some of the community-based services that were identified in the review to
have gotten their input in the design of the project. I believe this can still be done before the
project is finalized so that it would be relevant to both the practitioners and clients.
Overall, it was a rewarding experience and I am hopeful that this project would prove to be
beneficial to BC Women’s and other community-based services that work in the field of sexual
assault. I am grateful for the opportunity to be exposed to a variety of perspectives from my
coursework and practicum. I look forward to entering the professional world of public health
practice and facilitating change in my community.
43
REFERENCES
Allen, M. (2016). Police-reported crime statistics in Canada, 2015. Juristat: Canadian Centre for
Justice Statistics, 1.
BC Ministry of Public Safety and Solicitor General. (2007). Sexual Assault: VICTIM SERVICE
WORKER HANDBOOK. BC: Victim Services and Crime Prevention Division.
BC's Criminal Justice System. (2017). Victim Service Programs. BC: Retrieved from:
http://www2.gov.bc.ca/gov/content/justice/criminal-justice/bcs-criminal-justice-
system/understanding-criminal-justice/key-parts/victim-services/victim-service-
programs.
Beattie, D., Cunningham, S., Jones, R., & Zelenko, O. (2006). ‘I Use Online so the Counsellors
can't Hear Me Crying’: Creating Design Solutions for Online Counselling. Media
International Australia Incorporating Culture and Policy, 118(1), 43-52.
Benoit, C., Shumka, L., Phillips, R., Kennedy, M. C., & Belle-Isle, L. (2015). Issue brief: Sexual
violence against women in Canada. Ottawa, ON: Status of Women Canada. Retrieved from
http://www. swc-cfc. gc. ca/svawc-vcsfc/issue-brief-en. pdf.
Brennan, S. (2011). Violent victimization of Aboriginal women in the Canadian provinces, 2009.
Juristat: Canadian Centre for Justice Statistics, 1D.
Brennan, S., & Taylor-Butts, A. (2008). Sexual assault in Canada. Canadian Centre for Justics
Statistics.
Bryant-Davis, T., Chung, H., & Tillman, S. (2009). From the margins to the center ethnic minority
women and the mental health effects of sexual assault. Trauma, Violence, & Abuse, 10(4),
330-357.
Bullock, C. M., & Beckson, M. (2011). Male victims of sexual assault: Phenomenology,
psychology, physiology. Journal of the American Academy of Psychiatry and the Law
Online, 39(2), 197-205.
Campbell, R., Dworkin, E., & Cabral, G. (2009). An ecological model of the impact of sexual
assault on women's mental health. Trauma, Violence, & Abuse, 10(3), 225-246.
Canadian Radio-television and Telecommunications Commission (CRTC). (2016). Canada’s
Communication System: An Overview for Canadians. Retrieved from:
http://www.crtc.gc.ca/eng/publications/reports/policymonitoring/2016/cmr2.htm.
Canadian Women’s Foundation . (2016). Fact Sheet: Sexual Assault and Harassment .
http://www.canadianwomen.org/sites/canadianwomen.org/files/Fact%20sheet_SexualAss
aultHarassmentFormatted_18_08_2016.pdf.
Carrillo, J. E., Carrillo, V. A., Perez, H. R., Salas-Lopez, D., Natale-Pereira, A., & Byron, A. T.
(2011). Defining and targeting health care access barriers. Journal of Health Care for the
Poor and Underserved, 22(2), 562-575
44
Centers for Disease Control and Prevention (CDC). (2004). Sexual violence prevention: beginning
the dialogue. Atlanta, GA: Centers for Disease Control and Prevention.
Clifford, M., Porteous, T., & Varcoe, C. (2007). CRITICAL ELEMENTS OF AN EFFECTIVE
RESPONSE TO VIOLENCE AGAINST WOMEN. Briefing Document: Addressing Gaps in
Services for Marginalized Women. BC Association of Specialized Victims Assistance and
Counselling, BC/Yukon Society of transition Houses, BC Institute Against Family
Violence.
Cook, J. E., & Doyle, C. (2002). Working alliance in online therapy as compared to face-to-face
therapy: Preliminary results. CyberPsychology & Behavior, 5(2), 95-105.
Darnell, D., Peterson, R., Berliner, L., Stewart, T., Russo, J., Whiteside, L., & Zatzick, D. (2015).
Factors associated with follow-up attendance among rape victims seen in acute medical
care. Psychiatry, 78(1), 89-101.
Davies, M. (2002). Male sexual assault victims: A selective review of the literature and
implications for support services. Aggression and violent behavior, 7(3), 203-214.
Decker, M. R., Latimore, A. D., Yasutake, S., Haviland, M., Ahmed, S., Blum, R. W., & & Astone,
N. M. (2015). Gender-based violence against adolescent and young adult women in low-
and middle-income countries. Journal of Adolescent Health, 56(2), 188-196.
Donnelly, D. A., & Kenyon, S. (1996). “Honey, We Don't Do Men” Gender Stereotypes and the
Provision of Services to Sexually Assaulted Males. Journal of Interpersonal Violence,
11(3), 441-448.
Finn, J., & Hughes, P. (2008). Evaluation of the RAINN national sexual assault online hotline.
Journal of Technology in Human Services, 26(2-4), 203-222.
Finn, J., Garner, M. D., & Wilson, J. (2011). Volunteer and user evaluation of the national sexual
assault online hotline. Evaluation and program planning, 34(3), 266-272.
Forgan, M. (2011). Online Counselling Options for Survivors of Sexual Assault. Victoria,
Australia: Soutth Eastern Centre Against Sexual Assault (SECASA); Royal Melbourne
Institute of Technology.
Fukkink, R., & Hermanns, J. (2009). Counseling children at a helpline: chatting or calling? Journal
of Community Psychology, 37(8), 939-948.
Haskell, R. (2010). Reducing barriers to support: Discussion paper on violence against women,
mental wellness and substance use. BC Society of Transition Houses.
Hawkins, K. (2009). Our search for safe spaces: A qualitative study of the role of sexual violence
in the lives of Aboriginal women living with HIV/AIDS. Canadian Aboriginal AIDS
Network.
Henning, K. R., & Klesges, L. M. (2002). Utilization of counseling and supportive services by
female victims of domestic abuse. Violence and victims, 17(5), 623-636.
Justice, C. D. (n.d.). http://www.justice.gc.ca/eng/rp-pr/csj-sjc/ccs-ajc/rr06_vic2/p3_4.html.
45
Kimerling, R., & Calhoun, K. S. (1994). Somatic symptoms, social support, and treatment seeking
among sexual assault victims. Journal of consulting and clinical psychology, 62(2), 333.
King, M. S., & Gracey, M. (2009). Indigenous health part 2: the underlying causes of the health
gap. The Lancet, 374(9683), 76-85.
Kroll, T., Jones, G. C., Kehn, M., & Neri, M. T. (2006). Barriers and strategies affecting the
utilisation of primary preventive services for people with physical disabilities: a qualitative
inquiry. Health & social care in the community, 14(4), 284-293.
Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (. (2002). World report on
violence and health. Chapter 6: Sexual violence. Geneva: World Health Organization.
Levy, M. E., Wilton, L., Phillips, G., Glick, S. N., Kuo, I., Brewer, R. A., ... & Magnus, M. (2014).
Understanding structural barriers to accessing HIV testing and prevention services among
black men who have sex with men (BMSM) in the United States. AIDS and
Behavior, 18(5), 972-996.
Logan, T. K., Evans, L., Stevenson, E., & Jordan, C. E. (2005). Barriers to services for rural and
urban survivors of rape. Journal of interpersonal violence, 20(5), 591-616.
Luce, H., Schrager, S., & Gilchrist, V. (2010). Sexual assault of women. American family
physician, 81(4), 489-495.
Marshall, W. L., Laws, D. R., & Barbaree, H. E. (2013). Handbook of sexual assault: Issues,
theories, and treatment of the offender. Springer Science & Business Media.
Martin, S. L., Ray, N., Sotres-Alvarez, D., Kupper, L. L., Moracco, K. E., Dickens, P. A., . . .
Gizlice, Z. (2006). Physical and sexual assault of women with disabilities. Violence against
women, 12(9), 823-837.
McDonald, S., & Tijerino, A. (2000). Male survivors of sexual abuse and assault: Their
experiences. Canada: Department of Justice.
Mental Health Commision of Canada. (2014). E-Mental Health in Canada: Transforming the
Mental Health System Using Technology. Ottawa, ON: Mental Health Commision of
Canada. Retrieved from: http://www.mentalhealthcommission.ca.
Munro, M. L. (2014). Barriers to care for sexual assault survivors of childbearing age: An
integrative review. Women's healthcare (Doylestown, Pa.), 2(4), 19.
Neame, A., & Heenan, M. (2003). What lies behind the hidden figure of sexual assault. Issues of
prevalence and disclosure, 1, 1-16.
Ontario Ministry of the Status of Women (MSW). . (2015).
http://www.women.gov.on.ca/owd/english/ending-violence/sexual_violence.shtm.
Parikh, P. B., Yang, J., Leigh, S., Dorjee, K., Parikh, R., Sakellarios, N., ... & Brown, D. L. (2014).
The impact of financial barriers on access to care, quality of care and vascular morbidity
among patients with diabetes and coronary heart disease. Journal of general internal
medicine, 29(1), 76-81.
46
Province of Newfoundland and Labrador. (2008). VIOLENCE AGAINST ABORIGINAL WOMEN.
NL: Fact Sheet.
Richards, D. (2009). Features and benefits of online counselling: Trinity College online mental
health community. British Journal of Guidance & Counselling, 37(3), 231-242.
Ritterband, L. M., Thorndike, F. P., Cox, D. J., Kovatchev, B. P., & Gonder-Frederick, L. A.
(2009). A behavior change model for internet interventions. Annals of Behavioral
Medicine, 38(1), 18.
Rossiter, K., Yercich, S., & Jackson, M. (2014). Assessing the complexities and implications of
anti--‐violence service delivery in British Columbia. Report prepared for the Ending Violence Association of British Columbia (EVA BC).
Shahli, S., Mohammadi, E., Lamyian, M., Kashanian, M., Eslami, M., & A, &. M. (2016). Barriers
to healthcare provision for victims of sexual assault: a grounded theory study. Iranian Red
Crescent Medical Journal, 18(3).
St Pierre, M., & Senn, C. Y. (2010). External barriers to help-seeking encountered by Canadian
gay and lesbian victims of intimate partner abuse: An application of the barriers model.
Violence and victims, 25(4), 536-552.
Suleman, Z., & McLarty, H. (1997). Falling Through the Gaps: Gaps in Services for Young
Women Survivors of Sexual Assault. Vancouver, BC: Feminist Research, Education.
Development and Action (FREDA) Centre.
Ullman, S. E. (2007). Mental health services seeking in sexual assault victims. Women & Therapy,
30(1-2), 61-84.
Vaillancourt, R. (2010). Gender differences in police-reported violent crime in Canada, 2008. .
Ottawa, Ontario: Statistics Canada.
WAVAW . (2014). Decolonizing Praxis: supporting survivors after sexual assault.
https://vimeo.com/102073522.
Weiner, I. B., & Craighead, W. E. (Eds.). (2010). The Corsini encyclopedia of psychology (Vol.
4). Hoboken, NJ: Wiley
Women against Violence against Women (WAVAW). (2016). Supporting Survivors, Shifting
Society. Annual Report 2015-16. Vancouver, BC: WAVAW RApe Crisis Centre.
World Health Organization (WHO). (2003). Guidelines for medico-legal care of victims of sexual
violence. Chapter 6 Treatment and follow-up care. Geneva: World Health Organization.
Retrieved from
http://www.who.int/violence_injury_prevention/resources/publications/en/guidelines_cha
p6.pdf.
World Health Organization (WHO). (2002). World report on violence and health. Chapter 6:
Sexual Violence. Geneva: World Health Organization. Retrieved from
http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap6.pdf.
47
Zweig, J. M., Schlichter, K. A., & Burt, M. R. (2002). Assisting women victims of violence who
experience multiple barriers to services. Violence Against Women, 8(2), 162-180.
Appendix 1
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Program: Online Counselling Sexual Assault Logic Model Program Goal: To provide confidential, non-judgmental 24-hour telephone/online support, crisis intervention, information and referral services
ff
- Funding
- 24 Hour Telephone Line
-
Website/Online
Platform.
- Trained sexual
assault
counsellors/vol
unteers.
- Updated
information on
sexual assault
counselling
services in BC.
- Program
stakeholders
- Other human
resources e.g.
knowledge
mobilization
Volunteers
- Recruitment of volunteers - Training of volunteers (online communication skills) - Assignment of volunteers to shifts.
- Media awareness.
- Respond to hotline calls 24- hours a day; 7 days a week. - offer support - Assess safety and offer safety plan. - Provide sexual assault education and information. - Provide referrals to assist with needs. - Offer crisis intervention.
SAS Counsellor(s)
-Development of training material for volunteers. - Design of online platform
- Survivors access counselling services.
# of calls responded to. # of one-to-one chats conducted. # of group chat conducted. # of emails sent. # of volunteers trained. # of hours for each telephone/chat sessionsession
Inputs Activities Pre-intervention Intervention Participation
Outcomes
Ultimate Outcome: - 25% increase in the number of sexual assault survivors receiving crisis counselling and support group services. - 15% increase in the number of men and marginalized populations seeking sexual assault counselling and support in BC.
# of different demographic population using services
# of referrals made. Types of referrals made
Assumptions: Project activities would largely match the needs assessment Various demographic populations would access the service based on its demonstrated advantages e.g. Men would prefer chat option to face- to0face services.
External Factors -Change in funding mechanism from PHSA. - Environmental/Natural disasters e.g. flooding
Intermediate Outcomes: - 15% of number of SA survivors seeking counselling and support services. - 5% increase in the # of men and marginalized population seeking counselling and support services - 15% increase in practice of effective coping and self-care strategies.
Short Term Outcomes: - 50% increase in knowledge of online sexual assault counselling by volunteers. - 10% of SA survivors aware of options and available resources. - 5% increase in number of disclosed sexual assault cases to formal professionals.
Outputs
Evaluation - Annual
