The aim of this study was to collect data on mental health and substance use needs to the be able to estimate the prevalence of mental health and substance use difficulties of people attending SARCs. It was a cross-sectional design.
Setting and sample
The setting was participating SARCs at six sites across England, which were selected with examples from each of the three clusters identified in WP2. The target sample was adults over the age of 18 years who attend SARCs and who consent to participate. The inclusion criteria were as follows:
aged 18 years or older
able to read and understand English (or there are suitable confidential translation services available).
The exclusion criteria are as follows:
lack of capacity to provide informed consent
participation was deemed to significantly increase risk to self or others (e.g. being in an acute mental health crisis as evidenced by being admitted to a psychiatric inpatient unit at the time of recruitment)
attendee of a
SARC that was not participating in the study.
A priori sample size calculation
The sample size of n = 360 across the six sites were calculated based on the following: an estimated population of 4000 across six sites per year and 40–60 referrals per site, per month. Based on a previous audit of mental health needs at a single SARC in England, the SARC staff obtained consent and collected data on 42% of attendees and 38% declined to participate (with limited support to recruit). It should, therefore, have been feasible to obtain consent from 50% of attendees to participate, which meant 20–30 per site, per month. However, because of the impact of COVID-19, several factors impeded recruitment and the target sample was not achieved.
Measures
The measures were selected as they have good reliability and validity and are appropriate for the setting and sample:
demographics questionnaire designed for the study which covered gender, sexuality ethnicity, age, socioeconomic status (by post code) previous contact with mental health services and pre-existing self-reported mental health and drug/alcohol issues (see
Report Supplementary Material 1)
Clinical Outcome in Routine Evaluation 10 (CORE-10) covering anxiety, depression, trauma, physical problems, functioning and risk to self
14alcohol screening tool: Alcohol Use Disorders Identification Test (AUDIT-C)
15Recovering Quality of Life (ReQoL): a quality-of-life measure developed specifically for those with mental health conditions
17drug use screening tool: Drug Abuse Screen Tool (DAST)
18Structured Assessment of Personality Abbreviated Scale (SAPAS): a brief screening tool for personality disorder.
19
Information on each outcome measure cut-off scores is provided in Appendix 2.
Data management
The information provided by participants was treated as confidential and, in accordance with the Data Protection Act 2018 and General Data Protection Regulations, any personal data (identifiable details) were stored separately from the research data (i.e. answers given during on the questionnaire). Research data were anonymised using a study number. The only exception to this confidentiality was if the research team had concerns about current or future risk of serious harm to the participant or to anybody else. Similarly, confidentiality was broken if participants disclosed details of intention to commit a crime or if participants shared details of a crime for which they had not been convicted. If that happened, the research team followed SOPs, which covered things like informing the participant’s GP or other relevant services (on a need-to-know basis only). Researchers always tried to discuss this with participants first where possible.
A data management plan (MiMoS_23240_Data Management Plan_v1_16.08.2019) was developed for WP3, 4 and 5 to complement this protocol.
Recruitment and enrolment
The recruitment strategy was informed by a trauma-informed approach aiming to empower participants to have control over decisions to participate in research.9 The research team worked with the LEAG group to develop a range of options for people to opt to engage with the study and they designed our recruitment materials and participant information sheet.
Sexual assault referral centre staff mentioned the study to people during their attendance at the SARC. Because of the pandemic, some of this contact was via telephone so the staff emailed PDF versions of the leaflet and obtained consent to be contacted by the research team. More details of this procedure can be found in the study protocol. Participants could also refer themselves to the study via the study website. Once consent to be contacted was received, the MiMoS researcher made contact via the potential participant’s preferred contact method. A total of five attempts at contact were made, after which the potential participant was not contacted again. If the researchers were able to make contact, they would then provide the information necessary for the participant to make a fully informed decision to participate or not. Participants were given at least 24 hours (or longer if needed or requested) to consider the information before deciding whether to take part. Once consent was obtained, the baseline study questionnaire was sent via a link emailed to the participant using the University of Leeds online survey (Online Survey). There was also an option to complete a paper version of the questionnaire. A further option for completing the questionnaires was over the phone with a researcher. In this instance, the researcher completed the online consent form and questionnaire over the phone with the participant, obtaining text or email confirmation of consent.
The participants received a £10 e-voucher for participation in the prevalence study.
Welfare checks and safeguarding
The MiMoS researcher was able to log into the Online Survey and review the responses. If any of the responses indicated risk to self/others, a welfare call would be undertaken as per the SOP. All MiMoS researchers had access to an on-call senior team member (EH, ML, BLE) if they required advice about risk and action to be taken. All action was documented using identity numbers to protect anonymity recorded in the secure shared Microsoft Teams folder.
The demographics of our prevalence study sample, both non-recent and recent cases, was initially compared with routine data collected from the six sites over the course of the national survey (WP2) to assess the representativeness of our sample. The final dataset was then weighted for demographics (e.g. age, sex, deprivation).
Analysis
A direct estimate of the prevalence of mental health within SARC attendees was determined from the sample and weighted estimates produced for the SARC sites. Additionally, a further weighted national estimate was produced (if demographic data could be obtained for all 47 SARC sites; see Appendix 3). Analysis of other health, well-being and behavioural measures followed the same principle to produce direct (and site-specific and national weighted) estimates. Prior to producing these estimates, the dataset was analysed to determine how or whether demographics, site or method of data collection influenced prevalence measures.
Findings
WP3 was an aspect of the MiMoS study that was most affected by the COVID-19 pandemic. The target sample of 360 was not achieved due to challenges related to the COVID-19 pandemic. Recruitment started in the spring of 2020 and was almost immediately suspended due to the first lockdown in March 2020 (all NHS research was suspended at that time unless it was COVID-19-related) and restarted in September 2020). Once the study was able to restart data collection, it continued to be affected by the continuing pandemic during the autumn, winter and to the spring of 2021, with to the third wave and second national lockdown. For this reason, the study remained open to recruitment from September 2020 to the end of May 2021, extending the original six-month recruitment window. A decision was made to end recruitment rather than extend it further as there was no indication in the spring that it was going to be possible to recruit anywhere near our target in a reasonable period of time. Even with extending the recruitment window there was no sign that recruitment was picking up to the expected pre-COVID-19 estimated pace. It is also important to note that of the original six SARCs, recruitment only occurred from four of the services due to changes to services during the COVID-19 pandemic at some of the SARCs, which made additional recruitment difficult. In addition, some SARCs saw a dramatic drop in attendees during the lockdown periods. The decision to end recruitment was agreed by an independent study oversight group and with the funder. The decision to remove the planned six-month follow-up was also approved and the amendment made to the NHS ethics protocol.
Recruitment
Participants were recruited from four of the six case study sites. A total of 236 consents to contact were received from people who had recently attended a SARC, of which 157 (67%) were contacted by a member of the MiMoS team. Of those contacted, 78 (50%) gave informed consent to participate and completed the online screening (). Two were excluded from the analysis as they were under 18 years of age, leaving 76 to be included in the analysis.
Sample characteristics
The sample was recruited mostly from the London SARC. However, on comparing sample characteristics from London and non-London, there were very few demographic differences except that in London:
there were slightly fewer people who identified as white
participants had slightly higher educational attainment, were more employed and fewer were living in temporary accommodation
slightly lower mental health needs were identified and lower prescription of medication for mental health and alcohol/drug treatment.
Most of these differences were not statistically significant except for those living outside London who were more likely to state that they were prescribed medication for mental health or substance use difficulties (64%) than participants living in London (36%) (Pearson Chi-square p ≤ 0.05). Therefore, the sample was not disaggregated by London/not-London.
London and the south were less affected by the impact of autumn local area lockdowns compared with the north of England, and this is one of the reasons why recruitment was more successful in these areas. Most of the sample (80%) were in the 18–24 years and 25–34 years age groups. The vast majority were women (91%), with 6% identifying as male and 3% identified as trans/non-binary. In terms of sexuality, most (73%) identified as straight; 8% as gay/lesbian and 19% as bisexual. Most (65%) of the sample identified as white; 13% as Asian/Asian British and 13% as Black Caribbean, African, British.
The survey demographics were compared with national data from the 2018–19 Sexual Assault Referral Centre Indicators of Performance (SARCIP) returns. This showed that the survey was broadly representative of the overall SARC population in 2018–19, with a slightly lower proportion of people identifying as white due to the dominance of participants from London and slightly more participants aged 25–34 years.
Prevalence of mental health, alcohol and drug needs
A series of standardised screening tools were used to measure mental health, well-being and substance use needs. The moderate to severe cut-off score for the CORE-10 is above 2 and the clinical cut-off (indicating those in need of psychological therapy compared to a non-clinical population is 1). We are deliberately reporting the percentage of those scoring in the higher severity range and therefore likely to be experiencing an elevated level of psychological distress requiring specialist mental health assessment and support ().
Prevalence of mental health, alcohol and drug problems in SARC users by various demographics
These results showed an overall prevalence (95% CI) of:
76% (65–85%) with moderate–severe psychological distress (CORE-10)
12% (6–21%) scored between 8–15, indicating ‘increasing risk of alcohol problems’ (AUDIT-C)
94% (86–98%)
PTSD (PC-PTSC-5)
87% (77–94%) were in the clinical range for low quality of life (Re-QoL-10)
45% (33–57%) moderate to severe health problems (Re-QoL)
26% (17–39%) moderate to severe drug problems (DAST)
63% (50–74%) personality disorder (SAPAS).
In 2018–19, 14,357 adults (aged 18 years or over) attended SARCs across England. By applying the unadjusted prevalence of mental health or substance use conditions to this total () we estimate that, of these 14,357:
National prevalence estimates of mental health, alcohol and drug issues in SARC attendees
10,911 had moderate–severe psychological distress
1700 had increasing alcohol risk
12,511 had clinically low quality of life
6423 had moderate to severe health problems
3800 had moderate to severe drug problems
8973 had a probable personality disorder.
The prevalence of each mental health condition or substance misuse varied slightly by various demographics (age, ethnicity, sex/gender) – but disaggregated sample sizes were relatively small. When applying the disaggregated prevalence to the disaggregated national SARC population for 2018–19 (see Appendix 3), the weighted estimates show broadly similar numbers of SARC attendees with identified mental health issues, alcohol and/or drug use.
Although sample sizes are small, a cross-tabulation between outcomes shows that there is some tendency for dual diagnosis of mental health and substance misuse (). These differences were statistically significant only for 72% of individuals with moderate to severe drug misuse who also had health problems (compared with 38% of those with no/low drug misuse).
Prevalence of mental health problems in SARC users with and without alcohol and/or drug problems
Summary
The analysis indicated consistently elevated levels of psychological distress across the sample recruited. All participants completed the scales in the immediate period after visiting a SARC but at least one week was allowed prior to data collection to allow the initial and acute reaction to trauma to subside. Elevated levels of PTSD were also identified. These results are not surprising considering the recent sexual assault experience but illustrate the importance of using standardised screening tools to identify need and inform what sort of follow-up and access to trauma-specific psychological therapy may be needed. There was some tendency for substance use concerns to co-occur with psychological distress. A larger sample could explore this trend with more certainty; however, accessing effective treatment for co-occurring mental health and substance use can be a challenge, especially psychological therapies (which can exclude those who have active alcohol or drug issues). There are limits to this study because the sample size required was not reached due to impact of the COVID-19 pandemic. However, the sample is representative of people who attend SARCs as well as the rates broadly concur with previous prevalence studies of mental health of SARC attendees.1,3
Realist synthesis of literature review
Realist methodology
The mixed-methods study was informed by an iterative programme of realist inquiry, which used realist evaluation20,21 and realist synthesis approaches22 to develop and refine programme theories and provide an increasingly evidence-informed theoretical framework to understand emerging findings.
The initial programme theories explained how the SARCs, and related services are intended or expected to achieve specific outcome patterns. As the project proceeded, further theories were developed and refined to encapsulate the diversity of experiences and explain what works, for whom, in what circumstances and why. The programme theories were developed and refined iteratively using tools such as logic models, if–then statements and context, mechanism and outcome configurations (CMOCs) and supported by data from a range of sources including WPs 1–5.
While each WP produced its own discreet outputs, an iterative approach was taken; each stage was informed by the findings of the previous stages, as well as within each stage (e.g. qualitative interview schedules were modified as patterns were identified, and theories were developed which were tested at the subsequent interviews).
We used a comparative realist evaluation approach comprising detailed investigation of the relationship between organisational processes and contexts,23 which generated a holistic understanding of the phenomenon under investigation.24 Using this methodology, the study sought to explain and understand current SARC service provision by considering how variations in service provision and processes interplay with important aspects of individual service users, thereby influencing how mechanisms work and produce different outcome patterns.21 This was achieved by developing, refining and testing hypotheses (programme theories) that described how various outcome patterns (O) were observed depending on whether the contexts (C) allowed specific mechanisms (M) to operate. These hypotheses are called CMOCs. A simple example could be the following:
Mechanism (resource) – identification of need and referral to external mental health services.
Context – previous positive/negative experience of mental health services.
Mechanism (response) – service-user decision to take up the referral.
Outcome patterns – attending/not attending mental health services, which influences longer-term expected outcomes such as improved wellbeing and reduced risk of further assault.
A CMOC incorporating these elements could be constructed as follows. It is expected that identifying a mental health need and subsequent referral to external mental health services (M) will result in improved wellbeing (O). However, if the service user has had previous adverse or unsatisfactory experiences of these services (C) and as a result decides not to take-up the referral (M) then the anticipated desirable mechanism (decision to take-up the referral) will fail to ‘fire’. Not only will the anticipated benefits of attending these services not be realised (O), but the service user might experience adverse outcomes such as despair or lack of hope (O), thereby potentially leading to worsening of psychological state and higher risk of further assault.
In this CMOC, the key elements that influence outcome patterns (O) are the referral process mechanisms (M) and whether they operate as expected, which is dependent on the context (C) of previous experiences of referral to these (or similar) services.
Realist review
To generate initial programme theories that would then be refined and tested in the case studies and other WPs, a realist review was undertaken. This used outputs identified in the WP1 systematic review. In line with realist methodology,20 the review aimed to create an initial framework for understanding how SARCs respond to mental health/substance misuse while identifying gaps in knowledge and key areas of interest. The review aimed to address the following question:
The review was based on international literature. However, the findings were prioritised for relevance to the UK sexual assault service models.
Methodology
The review protocol was registered on PROSPERO (CRD42020182808) and the review follows the RAMESES publication standards for realist reviews.22
The realist review included papers from the systematic review and built on its searches.7 We updated the search in the PsycINFO and MEDLINE databases (20 March 2020) using broad search terms and synonyms for SARCs. The search was limited to humans but there were no language restrictions. We also consulted experts in the field to identify additional key papers. The purpose of the review was to develop a theoretical framework and initial programme theories that were specific to the SARC setting, which would then be further refined through the research activities of the other work streams.25 Therefore, a single comprehensive search, specifically focused on SARCS, rather than iteratively developing additional theoretically driven searches was considered appropriate for the purposes of the programme as a whole.
All retrieved records were independently screened for relevance by two reviewers in a web-based review management system (Covidence, Melbourne, Victoria, Australia). Any disagreements were resolved by discussion and, where necessary, after discussions with a third researcher. A data extraction schedule was drafted, piloted and further developed. We extracted data using Microsoft Excel®.
A separate row was used for each theory, whether this was a complete theory or fragment, rather than for each paper. This approach ensured that theory-rich papers did not result in theory-dense outputs and allowed more precise categorisation and comparison of theories. Data were extracted in the form of form of context (C), mechanisms (M) and outcomes (O), and included ‘if–then, leading to’ statements. This approach ensured that relevant details were extracted for theory development and the relationships between C, M and O were articulated. Training sessions and workshops were held for the team to develop skills and knowledge in realist synthesis. However, where members of the data extraction team were less comfortable with describing theoretical relationships, the ‘if–then’ statement column was completed later, by more experienced members of the team using the extracted data and with reference to the original sources.
Extracted information also included theory description, position in pathway, intervention, expected outcomes, for whom, in what setting; generalisability for UK SARCs, usefulness, plausibility, relevance and trustworthiness of the theory. We extracted data for all included papers, found both from the original and the updated search. Most members of the review team extracted data and were involved in discussions around theory generation.
Microsoft Word® was used to collate extracted data according to their position in the pathway. The extracts were then compiled into themes and subthemes that were relevant to these pathway positions. These documents were then reviewed and the contents synthesised into further refined ‘if–then’ statements and CMOCs. Regular discussions among the review team facilitated theory generation. During this process, consideration was given to associations with existing mid-range theories or the development of bespoke theories.
An example of the development of synthesised CMOCs is provided below. This example is positioned at the ‘pre-SARC’ point in the process pathway.
Initial ‘if–then’ statements
The following ‘if–then’ statements were constructed directly from the literature by extracting CMOCs from the source documents and then formulating the relationships between these elements in the extraction form.
49: If sexual assault service staff members (i.e. forensic nurses) are educated and trained appropriately, then they can carry out public health/preventative activities, resulting in a safer community.26
87: If someone attends a SARC they will benefit from the multi-agency model because of the joined up approach between bureaucratic systems. If they do not trust statutory services however then they may be wary of the SARC because of its perceived links with the police and health system.27
126: if the services and structures around sexual assault support and the legal system are perceived as fair and supportive, then a higher proportion of assaults would probably be reported.28
144: If survivors are unaware of SARCs or don’t think they fit the criteria, then they will either not present at all or may present outside the forensic window. This may be because e.g. they think their injuries aren’t serious enough, they are too traumatised to help-seek, or they have internalised rape myths. Therefore, SARCS should aim info strategies specifically at those at risk and should ensure it’s clear who is eligible for support.29
Extracts and synthesised statements retained their extracted theory ID number at every stage, to allow referral back to the extraction form and source documents. This ensured that important meaning was not lost and allowed clarification of details. demonstrates how this specific information extracted from the source documents was synthesised. This stage of the process produced less detailed, yet generally applicable key principles, which could be used to guide the other work streams and potentially be tailored for implementation in any SARC setting.
Example of how data were synthesied
Findings
The initial programme theories were developed from the study proposal and discussions with the study team. For instance, the prevalence of unmet needs indicated problems with the start of the pathway, such as access, referral, and case-finding issues. Rates of mental health service-use, PTSD and substance use are also known to be high in users of SARC services. However, it was not clear how well these needs were being assessed or met during first contact or subsequently (e.g. through referral pathways or follow-up). A process/logic model was developed, which included assumptions about what good-quality care would look like, possible decisions at key points in the pathway and important questions for the study to answer.
Initial hypotheses were developed, which assumed that attending a SARC would be a good thing for those with mental health and/or alcohol/drug use needs. In theory, attending a SARC means that:
Survivors can have their mental health and/or alcohol/drug needs assessed; can be referred to talking therapies or drug and alcohol services where needed; can be supported to access other services to have their healthcare needs met, which might otherwise cause stress; that is,
SARC attendance provides a point from which formal support services can be accessed.
and
In the immediate aftermath of assault, survivors can gain reassurance that they will be believed; they can have negative appraisals about blame challenged by
SARC staff; can regain a sense of control and safety. That is,
SARC attendance might reduce risk for developing/exacerbating MH/SU difficulties through informal (trauma-informed) ways that survivors are treated, which increase sense of safety.
These two processes may also interact – survivors are more likely to disclose difficulties and take up services where they have experienced trauma-informed care. The synthesis aimed to develop initial programme theories that begin to describe how these formal and informal processes impact on outcomes for people with histories of mental health problems and substance use.
The findings were grouped into three time points to reflect the journey of service users through support services and to highlight places in this journey that can facilitate or impede improved outcomes. Within each section is a theory statement, developed from CMOCs that provide an explanatory interpretation of the synthesised literature. The sections are titled as followed:
Pre-
SARC – this includes awareness of the
SARC service, what is known about its purpose, how it is accessed (via police, third party service, self-referral).
Within the
SARC – first attendance and initial impressions, process and procedures, assessments and methods of assessment, the forensic examination (consent, capacity, being informed, psychosocial support, physical environment), follow-up support, appointments, signposting and information giving.
Post
SARC – how referrals to external agencies are conducted, follow-up support (e.g. for legal processes), satisfaction with support, gaps in onward service provision.
These are presented below and in summary form in .
Pre-sexual assault referral centre
Sexual assault referral centre role in raising awareness and supporting system integration of such centres
Background
SARCs have only been introduced recently and therefore there is variable awareness of their existence within the general population and referral agencies. UK service specification (2018) says that SARC services and what they provide are not well known. Therefore, raising awareness and promoting SARC provision and ease of access to services is a priority. One area of interest is how SARCs work with other agencies and the communities they serve to raise awareness of their existence, what services are offered and how to access them.
All local areas should ensure that there is an opportunity for survivors to access SARC services as self-referrals. Lack of awareness of services is raised in literature from a range of international settings. For instance, a study in the Congo concluded that fear and lack of awareness were the two most important barriers to uptake of services.30
Theory statement
If SARCs raise awareness about their service and provide outreach to the community, then more survivors will access the service in a timely manner, thus providing an opportunity to improve equality of access and improve mental health outcomes. This is because survivors will know about the SARC and what it offers. They may be more likely to recognise that their experience constitutes a sexual assault and have more confidence this will be treated seriously and sympathetically in SARCs and have reduced fear or uncertainty about attending. This may especially be the case for those with pre-existing mental health needs. Awareness-raising may include explaining the definition of sexual assault, the function of the SARC for both forensic and non-forensic cases, who is eligible for support, and the option of self-referral without police input.
SARC role in reducing barriers for vulnerable groups
Background
A strong theme in the literature relates to the under-representation of specific groups within SARC services. This can be at odds with estimates of the demographic profiles of people in the general population that experience sexual assault. For instance, services experience under-representation of people with serious mental illness,31 ethnic minorities32 and people with learning disabilities.33
Theory statement
Specific groups face additional barriers to attending a SARC, including physical and intellectual disabilities and a perception that SARCs are not for their use or cannot meet their needs. Other groups may also face barriers. Men may only report if they have physical injuries and may be put off by the perception that SARCs are primarily for females. Similarly, LGBTQ+ survivors may perceive SARCs as not being for them, and there may be a lack of knowledge and skills among staff, service provision might be gender binary, and there could be a minimisation of experiences of abuse. If SARC staff are aware of the needs and challenges for specific vulnerable groups, then they may be able to reduce barriers and increase the likelihood of SARC attendance. This is because they can direct marketing at specific groups and direct resources to ensure equal access.
Although [service] will provide an excellent service for males … it was felt by one service provider, their publicity is not explicit enough in male society. Marketing needs to be available in pharmacies, GUM clinics, drug services. The marketing needs to state that men do not have to report a crime to the police, as this would put a lot of them off visiting [service] for help. However, since 28th February 2011 there is a separate page dedicated to men on the [service] website also on poster cards and on buses that has made a difference.
(Winters et al.)34
Within the sexual assault referral centre
The experience that the service user has within the SARC can impact on mental health outcomes in several ways. SARCs need to promote service users’ safety, choice and control, to reduce potentially re-traumatising experiences (e.g. Du Mont et al.35). This can include having processes in place to promote trauma-informed care that are influenced by the structure of the service as well as the behaviours of staff members. Furthermore, successfully identifying and responding to mental health and substance-use needs, depends upon the assessment procedures in place and how these are enacted.
Mental health and substance use provision
Identification of mental health and substance use needs
The literature did not highlight consistent approaches across SARCs to identification of need regarding mental health and substance use. However, the development of theory indicated that having standardised processes would improve identification of needs and provide more equal access to therapies and continuing support.
Theory statement
If SARCs use consistent structured assessments that are adapted for specific groups (i.e. psychosocial vulnerabilities, learning difficulties) to identify mental health and substance use needs, then needs and risk will be identified successfully, more equally and in a timely manner. However, identification of need is only the first stage in the process. Appropriate responses then rely on other elements of service provision, such as training, resources, a consistent approach between staff and access to further services. A consistent approach to assessment might be particularly useful in supporting other positive mechanisms, such as helping staff to feel more comfortable asking clients about mental health problems and substance intake. Successful identification is important in addressing symptoms early which is in turn crucial in the progression of mental illness.
Mental health prevention and intervention
Theory statement
If SARCs provide early and timely post assault intervention and in-house psychological support, then attendees might experience improved mental health outcomes. This is because early intervention can reduce immediate and long-term distress and specialist services can tailor support and facilitate disclosure to the police.
Trauma-informed care
Background
Trauma-informed care provision is particularly relevant for SARC service users. The literature is divided into two categories: first regarding the provision of training and second regarding trauma-informed interactions. There is a theoretical link between training in trauma-informed care and subsequent trauma-informed interactions. However, there are other potential areas that could be explored for contexts and mechanisms that contribute towards trauma informed interactions, for instance the culture of the service, staff recruitment strategies, service delivery procedures and even the layout or design of the physical space.
Trauma-informed ways of working include empowering service users, offering choice and understanding when it is declined, sensitivity and being attentive to signs and symptoms of trauma. Trauma-informed interactions are described as being proactive in offering support, empowerment, dignity and respect, care and compassion. Members of staff should listen, provide choices, explain things carefully, be aware of and attentive to service-users’ needs, take steps to respond to emotional needs, provide continuity of care and acknowledge a range of emotions.
Theory statement: training
If staff members are trained to have a specialism in sexual assault and how to work specifically to support the needs of survivors then the risk of secondary victimisation is reduced. This, in turn can impact on the survivor accessing appropriate services and, ultimately, their recovery. This is because having a sense of control and clarity means that detrimental situations such as fear of unknown procedures are mitigated. These improved outcomes are also found because this specific training can raise awareness of a survivor’s emotional distress and challenge assumptions about sexual assault. It can mean that members of staff are more likely to ask with sensitivity about the assault and refer to appropriate evidence-based treatments.
Theory statement: interactions
If SARC staff provide trauma-informed interactions, this can improve help-seeking, support steps to recovery, reduce psychological harm, lead to increased participation in the legal process and have longer term impacts on physical and mental health. This is because survivors feel respected, cared for, and supported, feel calmer and safer, listened to, in control and informed and are less likely to feel dehumanised, confused and frightened. It reduces denial and self-blame, creates a sense of safety, and creates an environment that will be more psychologically supportive.
Service organisation
Collocation of services
Theory statement
If a multidisciplinary set of staff are co-located in the SARC, this can have advantages for the speed, quality, and variety of care. It can reduce the potential for negative consequences resulting from lack of coordination and continuity of care. This could be more important for attendees with complex needs (such as substance use problems and PTSD risk factors) so that risk factors are recognised and packages of care are coordinated.
Role clarity and integration
Theory statement
Role clarity and integration in the literature is focused on the differentiation of crises workers (or advocates) from the nursing and medical roles involved in forensic medical examinations. While clear role separation is considered broadly beneficial and lack of clarity can lead to confusion and variability of services, there is also an argument for blurring boundaries between roles; specifically, that nurses should be trained to deal with emotional needs as well as completing forensic medical examinations.
Relationships with non-co-located services
Theory statement
There are advantages to working closely with non-co-located services. This can help to expand the services available to SARC attendees and offer specialist support for specific groups. However, this requires ongoing commitment and resources to sustain momentum. There is an indication that if positive communication and relationships are not effectively and consistently maintained, then this might even have a negative effect.
Quality improvement
Theory statement
The literature explicitly discussed the use of data for developing evidence-based services. There are many ways in which the collection, analysis and reporting of routinely collected data can be used to evaluate the performance of the SARC and to inform quality improvement activities, for instance in identifying training needs, providing tailored care and addressing underrepresentation of certain groups.
Post sexual assault referral centre
Staff role in supporting service users to take up follow-up services
Theory statement
If SARC staff offer patient-centred, holistic support at the initial appointment then service users will be more likely to attend further appointments. This is because they will trust service providers, recognise their own needs and be empowered to take the next steps. Additionally, if follow-up appointments are clearly documented and there is a specific staff member to coordinate long-term support then uptake will be improved because service users will not have to arrange their own referrals at a time of distress.
Referral to mental health services
Theory statement: service-user characteristics
Survivors from underserved groups including males and people from the black and minority ethnic community face barriers in engaging with mental health care following a SARC appointment, which can negatively impact mental health outcomes. These barriers include gaps in provision, limited support (leading to more travelling and expense), long waiting lists, dismissive or alienating attitudes from providers and internalised stigmas or negative views of the services.
Theory statement: service level
If SARCs face barriers when referring into mental health services, then service users may not receive the support that they require to meet their needs. This is due to a lack of effective resources at mental health services which can lead to SARC staff addressing the issues themselves, delays in referrals due to ineffective pathways or because the support that is offered by the mental health team is not specialised enough, or too variable in its approach to meet the service user’s needs.
Conclusion
The realist synthesis provided a theoretical framework for the wider study, which was organised around stages in the visual process model. This followed the service-user pathway from access routes, through to initial contact with the service and on to follow-up and referral to other services. Also considered was the likelihood of repeat contact with services.
The findings described how SARCs were intended to work as well as synthesising findings from empirical studies, which described how aspects of SARC services worked for certain groups of users and which recognised unintended consequences. Findings also articulated key concerns about difficulties in providing high quality services and highlighted areas that would benefit from further investigation.
Barriers to access
Important barriers to accessing services are related to lack of understanding and awareness about the existence of services, what they provide and how they are organised. Even when SARC services were known about, fear and anxiety about the consequences of contacting the services could be a significant barrier, especially when considering the prevalence of mental health problems and post-traumatic stress in this cohort. The relationship with the justice system could also be off-putting for certain potential service-users, for instance those with substance use problems.
This lack of awareness applies to the general population as well as organisations and agencies that might be in a position to signpost or refer service-users. There was a lack of evidence about the best ways to organise and deliver awareness-raising activities and where responsibility should lay.
There are further concerns that specific, vulnerable groups might face additional barriers to access, and that (partially as a consequence of low levels of exposure to or identification of these groups) SARC staff might be lacking in skills or knowledge about providing appropriate services.
Identifying and responding to mental health and substance-use needs
The literature suggests that consistent, systematic assessment processes are beneficial, both directly to identify and respond appropriately to unmet needs and indirectly to raise the profile of mental health and substance use problems in the cohort, thereby creating a more supportive culture.
Training in trauma-informed care and the promotion of trauma-informed interactions are also viewed as important elements in the provision of appropriate care. These can reduce distress, prevent re-traumatisation, improve long-term outcomes and potentially improve access through reputation and prior experience, in the case of repeat victimisation.
Service organisation
Multidisciplinary teams could have many advantages, including speed, quality and variety, coordination and continuity of care. A critical area that would benefit from further exploration is the integration or differentiation of roles. Potentially, this could be addressed by initiating a set of core competencies and responsibilities, such as FMEs being trained to deal with emotional needs. However, some elements of role clarity are important to maintain to reduce confusion and variability of service provision.
While relationships with non-co-located services can expand the services available to SARC attendees and provide access to specialist services, maintaining these relationships and positive communication requires resources and ongoing commitment.
There were several ways in which the systematic collection and use of route data could be used to improve and monitor services. For instance, in identifying training needs, providing tailored care, and addressing underrepresentation of certain groups.
Post sexual assault referral centre services
As discussed earlier, attendance at further appointments can be influenced by experiences at the initial appointment. Key mechanisms in the literature associate good outcomes with positive experiences, leading to service-users’ trust, recognition of their own needs and feeling empowered. Practical support can also be important to help coordinate follow-up support, particularly when service users have difficulties in arranging their own care through experiencing distress. There can be significant barriers in accessing mental health services, particularly regarding availability of appropriate services. This can lead to additional pressure being experienced by SARC staff members, particularly when the SARC does not have appropriate resources for mental health support.
Summary
The review identified problems with access that are largely rooted in population education, effectively targeted marketing, and system integration. Key issues are allocation of roles, responsibilities, and resources for addressing these problems, for instance whether the responsibility sits with the SARCs or other agencies.
Specific vulnerable groups might face access barriers and might also not be recognised within the services, unless systematic assessments and routine data capture and monitoring are carried out. This can lead to under-representation of required skills, knowledge and approaches to address the diversity of service-users’ needs. Systematic assessment of needs and good quality routine data capture and analysis could be important for local quality improvement activities that are context-specific and address system-level complexities.
The elements of trauma-informed care that are important in the SARC setting and the ways that these approaches can improve outcomes are clearly articulated in the literature. This review has extended evidence in the field by drawing together various elements into detailed hypotheses.
Questions remain, regarding the ideal make-up of multidisciplinary teams and the differentiation and sharing of roles, responsibilities, and competencies. Continuing coordination and follow-up by the SARC has benefits but clearly relies on the availability of appropriate resources. The extent to which a range of services (especially follow-on services) should be provided in-house or by external organisations is a complex issue, which is associated with system-level integration, available services and resources devoted to the initiation and maintenance of interorganisational relationships.
