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Provider Perspectives on Implementing a Student Health and Counseling Center Intervention for Sexual Violence

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Title: Provider Perspectives on Implementing a Student Health and Counseling Center Intervention for Sexual Violence
Language: English
Authors: Anderson, Jocelyn C. (ORCID 0000-0003-0572-8378), Feinstein, Zoe, Edwards, Clare, Jones, Kelley A., Van Dusen, Courtney, Kehr, Vanessa, Burrell, Carmen (ORCID 0000-0001-7608-4851), Coulter, Robert W. S., Miller, Elizabeth, Chugani, Carla D.
Source: Journal of American College Health. 2022 70(5):1363-1371.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 9
Publication Date: 2022
Sponsoring Agency: National Institutes of Health (NIH) (DHHS)
Contract Number: R01AA023260
T32HD087162
Document Type: Journal Articles
Reports - Research
Descriptors: Counseling Services, School Health Services, School Counseling, Trauma Informed Approach, Intervention, Violence, Sexual Abuse, Drinking, Training, Health Personnel, Attitudes, Program Implementation, Barriers
Geographic Terms: Pennsylvania, West Virginia
DOI: 10.1080/07448481.2020.1797752
ISSN: 0744-8481
1940-3208
Abstract: Objective: To describe provider experiences with implementation of the GIFTSS (Giving Information for Trauma Support and Safety) intervention. Participants: Health and counseling center staff from participating campuses attended trainings between August 2015 and August 2016. Interviews were conducted between May and August 2017. Methods: Providers (n = 230) completed surveys prior to and six months following a 3-hour training on the intervention. Structured phone interviews were conducted with a purposively selected subset of 14 providers. Results: Overall, staff found the intervention acceptable. Implementation barriers noted were time and competing patient priorities. Providers noted variation based on patient and visit characteristics. Clinic commitment, particularly in adopting strategies for universal dissemination of the GIFTSS card, was seen as helpful. Conclusion: Implementation of a brief trauma-informed intervention in campus health and counseling centers was feasible and acceptable to most providers. Opportunities to change organizational culture regarding ensuring adequate time and safety for patients are discussed.
Abstractor: As Provided
Entry Date: 2022
Accession Number: EJ1359138
Database: ERIC
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  Value: <anid>AN0157934473;acl01jul.22;2022Jul14.06:31;v2.2.500</anid> <title id="AN0157934473-1">Provider perspectives on implementing a student health and counseling center intervention for sexual violence </title> <p>Objective: To describe provider experiences with implementation of the GIFTSS (Giving Information for Trauma Support and Safety) intervention. Participants: Health and counseling center staff from participating campuses attended trainings between August 2015 and August 2016. Interviews were conducted between May and August 2017. Methods: Providers (n = 230) completed surveys prior to and six months following a 3-hour training on the intervention. Structured phone interviews were conducted with a purposively selected subset of 14 providers. Results: Overall, staff found the intervention acceptable. Implementation barriers noted were time and competing patient priorities. Providers noted variation based on patient and visit characteristics. Clinic commitment, particularly in adopting strategies for universal dissemination of the GIFTSS card, was seen as helpful. Conclusion: Implementation of a brief trauma-informed intervention in campus health and counseling centers was feasible and acceptable to most providers. Opportunities to change organizational culture regarding ensuring adequate time and safety for patients are discussed.</p> <p>Keywords: Alcohol use; implementation; sexual violence</p> <hd id="AN0157934473-2">Introduction</hd> <p>With approximately one in five students reporting an experience of sexual assault during college, recent research has focused on the prevalence and negative impacts of sexual violence (SV) on college campuses.[<reflink idref="bib1" id="ref1">1</reflink>] Despite the prevalence and awareness of SV as a concern on college campuses, students still largely do not use formal support services, with less than half of students who report sexual assault informing any authority figure (e.g. teacher, parent, resident assistant),[<reflink idref="bib2" id="ref2">2</reflink>] and even fewer reporting to police (2%) or on-campus authorities (4%).[[<reflink idref="bib3" id="ref3">3</reflink>], [<reflink idref="bib5" id="ref4">5</reflink>]] Students report many concerns with seeking help on campus including fear that nothing would be done, embarrassment or shame regarding the situation, or feeling that their situation was not severe enough to warrant seeking help.[<reflink idref="bib2" id="ref5">2</reflink>],[<reflink idref="bib6" id="ref6">6</reflink>],[<reflink idref="bib7" id="ref7">7</reflink>]</p> <p>College health centers, including counseling services, are well-positioned to provide support to students who have experienced SV, as high numbers of students utilize their services, often without barriers such as cost or transportation.[<reflink idref="bib8" id="ref8">8</reflink>],[<reflink idref="bib9" id="ref9">9</reflink>] The clinical setting also provides opportunity for one-on-one confidential interactions with students, which are often missing in prevention programing traditionally offered during online or large group settings during freshmen orientation. Though students report their primary source of SV prevention programing and education comes at the onset of their first year via enrollment requirements and orientation activities, they are amenable to receiving this information in a myriad of ways.[<reflink idref="bib10" id="ref10">10</reflink>]</p> <p>Studies in family planning and adolescent school-based clinics have demonstrated the acceptability and effectiveness of providing education and resources related to intimate partner violence (IPV) and SV during routine clinical encounters, resulting in increased patient knowledge and use of resources and harm reduction strategies.[[<reflink idref="bib11" id="ref11">11</reflink>], [<reflink idref="bib13" id="ref12">13</reflink>]] Assessment for IPV and SV in college health centers, while recommended, appears to be limited.[<reflink idref="bib15" id="ref13">15</reflink>] For example, in a study across five college health centers, only 10% of female students reported that they were screened for IPV or SV, highlighting missed opportunities to offer patients prevention discussion and harm reduction counseling.[<reflink idref="bib16" id="ref14">16</reflink>]</p> <p>Providing a universal, trauma-informed education, assessment, and referral intervention in campus health settings has the potential to provide important support and resources to a wide range of students without requiring specific disclosure or help seeking.[<reflink idref="bib17" id="ref15">17</reflink>] While a promising strategy, integration of such clinic-based interventions into routine practice within college health and counseling centers requires attention to previously documented provider and clinic level barriers, including comfort discussing sexual and partner violence, fear of patient disclosures, and lack of time.[<reflink idref="bib18" id="ref16">18</reflink>],[<reflink idref="bib19" id="ref17">19</reflink>] Additionally, considerations specific to serving students on a college campus, such as Title IX and Clery Act reporting concerns, practice limitations related to resources or university policies, and the isolation that can occur for both patients and providers in a campus environment need to be explored and addressed. Given the high prevalence of SV on college campuses and the unique role campus health providers have to offer prevention education and interventions in a confidential setting to college students, this manuscript examines college health and counseling center providers' experiences with implementation of a brief intervention designed to increase college students' knowledge of SV and supports available to them and their peers. The two aims of the present study were (<reflink idref="bib1" id="ref18">1</reflink>) to assess provider-reported outcomes related to implementation of SV content into their practice, and (<reflink idref="bib2" id="ref19">2</reflink>) to qualitatively explore providers' experiences with implementing the intervention. We used a mixed-methods approach to more fully understand providers' experiences.</p> <hd id="AN0157934473-3">Methods</hd> <p></p> <hd id="AN0157934473-4">Overview</hd> <p>The present data were collected as part of a 2-armed cluster randomized controlled trial conducted at 28 college health and counseling centers in Pennsylvania and West Virginia. The parent study enrolled over 2,200 college students prior to a health or counseling center visit and followed them for one year to obtain information on alcohol use and SV-related outcomes. A computer-based exit survey immediately following their health center visit included information related to intervention implementation including whether they received the intervention card, and whether their provider discussed SV-related topics during the visit. The University of Pittsburgh Institutional Review Board (IRB) approved study procedures prior to campus recruitment. Full protocol details can be found in a prior publication.[<reflink idref="bib17" id="ref20">17</reflink>]</p> <hd id="AN0157934473-5">Participants</hd> <p>Providers and staff from health and counseling centers on participating campuses attended a three-hour training session on either an SV prevention intervention (intervention arm) or a brief alcohol counseling intervention (control arm). Alcohol use counseling, using an educational card similar in format to the sexual violence intervention described below, was selected as the attention control comparator instead of a "true control" because alcohol use screening was a consistent and agreeable practice across the 28 diverse campus clinics participating in the study. Campus providers and staff attended trainings between August of 2015 and August of 2016. These sessions were intended to include all staff (e.g. nurses, physicians, administrators, social workers, therapists) in a campus health or counseling center. American Medical Association (AMA) continuing medical education credits were provided for participating providers.</p> <hd id="AN0157934473-6">Study procedures</hd> <p></p> <hd id="AN0157934473-7">Staff and provider trainings</hd> <p>Intervention condition training sessions were conducted by the parent study principal investigator (<bold>EM</bold>) and SV prevention advocates involved as study collaborators. The intervention training utilized "Giving Information for Trauma Support and Safety" (GIFTSS), a trauma-informed brief intervention developed by an interdisciplinary team of community-based practitioners, sexual assault victim advocates, and researchers (including input from a national advocacy partner, Futures Without Violence). This intervention training covered universal patient education concerning SV using an educational safety card (see supplemental A), discussion of harm reduction behaviors to reduce risk of alcohol-related SV for self and peers (e.g. bystander intervention), and information and supported referrals to victim services on or near campus in the event of problem drinking or SV disclosure. Providers were instructed on how to utilize the safety card with the script, "We've started giving this card about relationships to all our patients so they can be informed, know how to get help for themselves, or help others," to encourage each patient to take a card (or several) if it was safe for them to do so. The training was presented and thoroughly reviewed at a stakeholder meeting with representatives from local and national victim advocates. The entire training was piloted with student health clinic staff at a university outside of Western Pennsylvania. Control sites received a similar three-hour training session on screening, brief intervention, and referral protocols for alcohol use based on the National Institutes of Alcoholism and Alcohol Abuse recommendations.[<reflink idref="bib20" id="ref21">20</reflink>] The control condition included an alcohol use safety card, with similar instructions to providers for how to discuss with patients, and to encourage patients to take the cards with them. In-person or video-recorded trainings were conducted for control sites by study co-investigators with expertise in alcohol use among adolescents and young adults in collaboration with campus or community-based alcohol and substance abuse care providers.</p> <hd id="AN0157934473-8">Intervention components</hd> <p>The intervention consisted of three main components: 1) discussion of confidentiality and its limits; 2) introduction of SV as a health care concern including use of the GIFTSS card to facilitate discussion of specific topic areas based on patient concerns; and 3) provision of SV-related resources for all patients regardless of disclosure, with direct "warm referrals" for patients who disclose SV during a clinical encounter. The intervention was distinct from screening interventions in that direct assessment and notation of a positive or negative response is not the primary indicator for a resource or referral sharing. The primary intervention goals were universal education and resource sharing with all patients.</p> <hd id="AN0157934473-9">Data collection and measures</hd> <p>Participants completed a pre-training survey (<emph>n</emph> = 320) and a follow up survey approximately six months after the training (<emph>n</emph> = 236; 74% retention, see Figure 1). Pre-training surveys were completed on paper and the research team members entered these data into a secure data management system.[<reflink idref="bib21" id="ref22">21</reflink>] Entries were quality checked by a different member of the research team. Pre-training and 6-month follow up survey measures included investigator-developed items to assess attitudes, practices, and perceived barriers regarding discussion of SV, alcohol, and bystander behaviors with their clients. Surveys were adapted from previous clinic-based intervention studies by the study team for relevance for the college health setting, and pilot tested with college health providers not involved in the trial.[<reflink idref="bib18" id="ref23">18</reflink>] Participants were compensated $30 for their time when they completed the 6-month follow-up survey.</p> <p>PHOTO (COLOR): Figure 1. • • •</p> <p>Ten to 21 months after their training, a subsample of campus health and counseling staff were purposively selected from each intervention site to include diverse roles and responsibilities (e.g. clinic directors and direct care staff) as well as other campus characteristics (e.g. public and private institutions and urban and non-urban campus locations) and invited to participate in a follow up interview about their experience with implementation of the intervention. In total, 65 providers were contacted via email and invited to participate in the interview portion of the study. Of those, six emails were undeliverable. From the 59 deliverable emails, 20 providers (33.9%) responded and were interested in participating and 14 (23.7%) were able to schedule and complete interviews.</p> <p>The interview guide included questions regarding how providers used the GIFTSS card in their practice (see supplemental B). Structured telephone interviews were conducted with those who consented to participate. Interviews lasted between 10-40 minutes, and were audio recorded, professionally transcribed, and de-identified for analysis. Participating providers (<emph>n</emph> = 14, from 10 intervention sites) were compensated $50 for participating in an interview.</p> <hd id="AN0157934473-10">Data analyses</hd> <p>Descriptive statistics were calculated to characterize the sample's demographics, clinical training, and experience; Wald log-linear chi-squared tests were used to assess for differences in these characteristics by treatment arm. Providers' reports of their clinical practices regarding SV topics were dichotomized as "rarely or some of the time" vs. "most or all of the time"; "not applicable" responses were excluded. We used generalized linear mixed models to compare differences from baseline to follow up between the treatment arms. Intervention-arm providers additionally reported changes in confidence and comfort in discussing specific topics; these 5-point Likert scales were recoded into three categories: agree/strongly agree, undecided, and disagree/strongly agree. These findings were presented descriptively. All analyses accounted for clustering within schools and were conducted in SAS v9.4.[<reflink idref="bib22" id="ref24">22</reflink>] Significance was set at α = 0.05 for all analyses.</p> <p>Transcribed and de-identified interviews were coded using Dedoose qualitative analysis software,[<reflink idref="bib23" id="ref25">23</reflink>] and analyzed following a qualitative descriptive process.[<reflink idref="bib24" id="ref26">24</reflink>] First round coding using a directed content analysis approach, with pre-determined codes was completed by three of the authors (CVD, JCA, ZF), and second round coding was completed using additional inductive codes.[<reflink idref="bib25" id="ref27">25</reflink>],[<reflink idref="bib26" id="ref28">26</reflink>] Grouping of codes into categories and themes was completed by two authors (JCA, ZF). These thematic data were reviewed first independently from, and later, in the context of the provider survey findings.</p> <hd id="AN0157934473-11">Results</hd> <p></p> <hd id="AN0157934473-12">Demographics</hd> <p>At baseline, 320 student health and counseling staff or providers completed surveys, with 160 from intervention schools (<emph>n</emph> = 12) and 160 from control schools (<emph>n</emph> = 16). The majority were female (74%) and white (82%). Over half (55%) had been working at their current student health or counseling center 5 years or less. No demographic differences were noted between the intervention and control groups. Table 1 summarizes additional provider characteristics.</p> <p>Table 1. Provider demographics.</p> <p> <ephtml> <table><thead><tr><td /><td>Baseline</td></tr><tr><td>Overall</td><td>Intervention</td><td>Control</td><td>Interview (n = 14)</td></tr><tr><td>(n = 320)</td><td>(n = 160)</td><td>(n = 160)</td></tr></thead><tbody valign="top"><tr><td><bold>What is your training background including certifications? (check all that apply)</bold></td></tr><tr><td>Physician (M.D. or D.O.) </td><td char="(">8.4 (27)</td><td char="(">11.9 (19)</td><td char="(">5.0 (8)</td><td char="(">0 (0)</td></tr><tr><td>Registered Nurse, Licensed Practical Nurse, Bachelor of Science in Nursing</td><td char="(">42.2 (135)</td><td char="(">39.4 (63)</td><td char="(">45.0 (72)</td><td char="(">64.3 (9)</td></tr><tr><td>Counselor</td><td char="(">13.4 (43)</td><td char="(">9.4 (15)</td><td char="(">17.5 (28)</td><td char="(">28.6 (4)</td></tr><tr><td>Other</td><td char="(">34.1 (109)</td><td char="(">38.1 (61)</td><td char="(">30.0 (48)</td><td char="(">7.1 (1)</td></tr><tr><td><bold>How many years have you been working at this student health center and/or counseling center?</bold></td></tr><tr><td>Less than 5 years</td><td char="(">55.0 (176)</td><td char="(">48.1 (77)</td><td char="(">61.9 (99)</td><td char="(">28.6 (4)</td></tr><tr><td>5–10 years</td><td char="(">17.5 (56)</td><td char="(">19.4 (31)</td><td char="(">15.6 (25)</td><td char="(">42.9 (6)</td></tr><tr><td>Greater than 10 years</td><td char="(">21.6 (69)</td><td char="(">22.5 (36)</td><td char="(">20.6 (33)</td><td char="(">28.6 (4)</td></tr><tr><td><bold>How do you describe your gender?</bold></td></tr><tr><td>Female</td><td char="(">83.8 (268)</td><td char="(">82.5 (132)</td><td char="(">85.0 (136)</td><td char="(">–</td></tr><tr><td>Male</td><td char="(">14.1 (45)</td><td char="(">15.0 (24)</td><td char="(">13.1 (21)</td><td char="(">–</td></tr><tr><td>Transgender</td><td char="(">0.3 (1)</td><td char="(">0 (0)</td><td char="(">0.6 (1)</td><td char="(">–</td></tr><tr><td><bold>How do you describe your ethnic background? (check all that apply)</bold></td></tr><tr><td>Caucasian/White</td><td char="(">92.2 (295)</td><td char="(">89.4 (143)</td><td char="(">95.0 (152) </td><td char="(">92.9 (13)</td></tr><tr><td>African American/Black</td><td char="(">3.1 (10)</td><td char="(">5.0 (8)</td><td char="(">1.3 (2)</td><td char="(">0 (0)</td></tr><tr><td>Other</td><td char="(">2.5 (8)</td><td char="(">2.5 (4)</td><td char="(">2.5 (4)</td><td char="(">7.1 (1)</td></tr><tr><td><bold>What is your age?</bold></td></tr><tr><td>20–39 years</td><td char="(">36.6 (117)</td><td char="(">33.1 (53)</td><td char="(">40.0 (64)</td><td char="(">28.6 (4)</td></tr><tr><td>40–59 years</td><td char="(">52.2 (167)</td><td char="(">53.8 (86)</td><td char="(">50.6 (81)</td><td char="(">64.3 (9)</td></tr><tr><td>Greater than 60 years</td><td char="(">9.1 (29)</td><td char="(">10.0 (16)</td><td char="(">8.1 (13)</td><td char="(">7.1 (1)</td></tr><tr><td><bold>Have you ever attended any professional development sessions specific to alcohol and sexual violence in college health settings?</bold></td></tr><tr><td>No</td><td char="(">45.6 (146)</td><td char="(">40.0 (64)</td><td char="(">51.3 (82)</td><td char="(">–</td></tr><tr><td>Yes</td><td char="(">53.4 (171)</td><td char="(">59.4 (95)</td><td char="(">47.5 (76)</td><td char="(">–</td></tr><tr><td><bold>Are you a practice manager/administrator?</bold></td></tr><tr><td>No</td><td char="(">80.6 (258)</td><td char="(">81.3 (130)</td><td char="(">80.0 (128)</td><td char="(">42.9 (6)</td></tr><tr><td>Yes</td><td char="(">18.8 (60)</td><td char="(">17.5 (28)</td><td char="(">20.0 (32)</td><td char="(">57.1 (8)</td></tr><tr><td><bold>Are you currently providing direct care to college clients? (This includes mental health counseling, health education, clinical services, social services)</bold></td></tr><tr><td>No</td><td char="(">17.8 (57)</td><td char="(">18.1 (29)</td><td char="(">17.5 (28) </td><td char="(">–</td></tr><tr><td>Yes</td><td char="(">81.6 (261)</td><td char="(">80.6 (129)</td><td char="(">82.5 (132)</td><td char="(">–</td></tr></tbody></table> </ephtml> </p> <hd id="AN0157934473-13">Intervention implementation rates</hd> <p>Intervention implementation rates were calculated based on students' report of having received the GIFTSS card and having discussed a variety of violence related topics with their health care provider in exit surveys immediately following their baseline clinic visit. For receiving the card, these rates varied widely between sites, ranging from 17–93%, with an overall implementation rate across all sites of 49%. Similarly, disparate implementation was found in the control group ranging from 7–88% (overall 47%). Rates were also varied for discussing a violence related topic during the visit with 6–100% of students in the intervention arm reporting a discussion with their provider during the study visit and 5–67% of students in the control arm reporting such discussion.</p> <hd id="AN0157934473-14">Clinical practice change</hd> <p>Staff who indicated that they provided direct care to students (<emph>n</emph> = 261) were asked a series of 12 questions regarding how often they incorporated SV and alcohol-related content into clinical encounters. At 6-month follow up, providers who received the trauma-informed SV training reported increased levels of talking to students about SV and relationship violence across all visit types (See Figures 2 and 3), though these differences were not statistically significant compared to the control group. Additionally, at 6-month follow up, providers who received the intervention training reported feeling more comfortable and confident talking to students about sexual health and alcohol-related topics including unwanted sexual experiences and unhealthy relationships. They were also more comfortable making referrals and supporting students to call victim advocacy services when needed.</p> <p>Graph: Figure 2. • • •</p> <p>Graph: Figure 3. • • •</p> <hd id="AN0157934473-15">Intervention acceptability</hd> <p>Most providers felt that the card was well received by students, and that it made them feel empowered as healthcare providers to be able to provide information about SV. Many expressed that the card enhanced the patient education they were already doing around SV, and several said it increased their awareness of how common SV is and changed their perception of who may be a victim. One provider said the intervention made her think a lot more about the relationship between alcohol, consent, and SV:</p> <p> <emph>"When we started, I just never thought of alcohol abuse and it all going together...I didn't think of it as sexual assault in that type of manner because you're drinking. You know what you put in your body. I guess I in a way thought, well, you gave your consent there, but you have to think of it in a way that's an impaired judgment. It did change my thought process."</emph> </p> <p>Providers also perceived a benefit to patients, and many noted that it sparked important conversations with students about SV, consent, bystander intervention, and alcohol. One provider said, "One male student started a conversation based on the card...he said that he had a friend who was concerned about this whole issue of sexual assault...we had a conversation about consent, triggered by this card." Several other providers mentioned they thought the card showed students that the health center was a safe place for them to come if they experienced SV.</p> <hd id="AN0157934473-16">Barriers to and facilitators of implementation</hd> <p>From the interviews, most providers felt that the GIFTSS card was useful to facilitate patient education and was beneficial to students, but many also discussed challenges and barriers to using the card with patients. Factors that impacted universal implementation of the card by providers included structural factors, provider comfort discussing the card, and the card design and content. One general theme that emerged throughout the interviews was that once sharing the card with students was incorporated into their clinic routine, providers reported feeling more comfort and greater ease with implementing the intervention.</p> <hd id="AN0157934473-17">Structural factors</hd> <p>Fear of disrupting clinic flow and increasing wait times for other patients caused some providers to feel anxious about introducing the card. In the pre-training survey, 36% of providers reported that time was a factor that limited their ability to assess for SV or relationship abuse during a patient encounter. During the follow up interview, one provider noted,</p> <p> <emph>"It's hard, because it's never a two-minute discussion or intervention...It usually turns into this big kind of ordeal. Because it's very emotional. It brings up a lot of mental health issues...it's important. It's just I don't know that I have the time all the time. I hate to tell somebody who's pouring their soul out to me, 'Oh, can you make another appointment for this? I really, really think this is important, but I don't have any time.'"</emph> </p> <p>Other providers felt that the card facilitated a quick introduction of important information without requiring a long conversation. One provider said,</p> <p> <emph>"I can't necessarily sit there and have a full-on discussion about a person's full sexual history of if there was violence involved or what not. It was nice to be able to hand [the card] and be like, 'Here. You can certainly read through it. If you have questions, you can always come on back and talk to us.'"</emph> </p> <p>However, this provider also expressed discomfort with asking patients to make another appointment to discuss their experiences of SV. She continued,</p> <p> <emph>"Then you're kinda like kicking 'em out the door at the same time. I feel like, 'Here. This is important. We wanna talk to you about it. It kinda needs to be a whole separate other discussion to have you talk about it with us.'"</emph> </p> <p>Clinic administration's (i.e. nursing or physician manager, clinic director) commitment to the intervention played an important role in making the intervention routine for providers. One clinic added prompts to their electronic medical record system, so that providers received a reminder to hand out the card while doing intake and could check a box saying they had done so. This type of consistent reminder and documentation during every visit helped that provider remember to give out the card. Other clinics assigned all staff to hand out the card, from the front desk to the nurses and physicians, so that distribution became a team effort, and students were more likely to still receive a card even if the provider forgot to give them one. In general, clinic-wide policies to distribute the card universally to patients helped providers feel more supported to hand out the card during every visit. One provider noted, "We made it sort of a department-wide policy to just give [the card] to all students. That made it really easy for me to remember." However, another provider mentioned that when the clinic was short-staffed, they often forgot to hand out the cards to patients, and a provider who was the only one designated to distribute the card in her clinic stated that she only gave the card out "occasionally."</p> <hd id="AN0157934473-18">Provider comfort</hd> <p>Provider comfort was another factor that influenced implementation. Prior to training, some providers reported that worry about upsetting a patient (10%) or being unsure of what to do about a disclosure (8%) were both reasons that limited their assessments of SV or IPV. During the interviews, several visit characteristics were identified that influenced provider comfort. Several providers stated they were more likely to give the card out during reproductive or sexual health visits, and expressed discomfort introducing the card during visits for something unrelated to the card, like a cough or a headache. One provider said she felt that students who were coming in because they felt unwell were not interested in hearing about the card and that it felt harder to engage with them about it. She explained "...the pregnancy test, or even sometimes UTI's...those were more comfortable conversations...If students felt really awful, or with a fever...I didn't find that to be as easy of a time..." Additionally, multiple providers said they were more likely to give the card to female patients. One noted, "I really did hand them out to many more females than males...I remembered more when I was in a room with a female." Providers also voiced concern that patients would feel targeted by the intervention. The use of scripts helped mitigate this feeling of unease – many providers said they liked the scripts that were provided during the training, and others talked about coming up with their own way of introducing the intervention. They discussed trying to make students feel more comfortable by framing the card as something they were giving out to everyone or explaining that the card was part of a research study. Others said that introducing it as something students could give to their friends made the conversation about the card more comfortable. One provider noted,</p> <p> <emph>"I would always say, to kind of reduce the stigma and help the students feel a little bit more comfortable and make them think that, okay, I'm not saying that you have been a victim. If you or a friend have ever experienced anything like this, this card could be helpful. You know, so I would always add that in when I was introducing the card."</emph> </p> <hd id="AN0157934473-19">The GIFTSS card</hd> <p>Overall, the card was acceptable to providers, most of whom found it to be relevant and useful. However, there were some aspects of the card that providers felt could be improved. These included replacing the image on the front, which many felt was unclear and confusing to students; listing local resources that were more specific to the campus and region of the health center; adding online resources to increase accessibility; and making the card less heteronormative so that providers could feel more comfortable introducing it to sexual or gender minority students.</p> <p>This feedback was shared with partners at Futures Without Violence and used to develop and refine a new card to better meet the needs of providers and students. The new card uses more inclusive language to talk about sex and relationships, includes more resources, and displays a less confusing and stereotypic image on the front.[<reflink idref="bib1" id="ref29">1</reflink>]</p> <hd id="AN0157934473-20">Comment</hd> <p>Despite their initial concerns that the card would elicit numerous disclosures of SV and disrupt clinic flow, providers primarily stated that they didn't have many students disclose SV because of the intervention. Rather, most student responses were positive or neutral, with the card occasionally provoking more general questions or concerns from students that could be addressed during the appointment. This finding may be particularly important to highlight during intervention training, as the assumption that using the card will provoke an unmanageable amount of SV disclosures does not appear to be warranted, despite being a key barrier to adherence to universal implementation.</p> <p>While we did not find statistically significant differences in provider reported behavior when comparing the control and intervention provider behaviors over time, this was not the primary outcome of the study. Sample size and the clustering of providers within sites severely limits power to detect such differences. Clinically meaningful changes in provider understanding of the relationship between alcohol use, SV, and student use of health services were reported in qualitative interviews. It should also be noted that each of the over 150 providers trained during this study has the potential to provide intervention content to patients over the entirety of their career, potentially exposing thousands of patients to additional content related to SV and alert them to the availability of resources including the health center should they need them at any point during their college career. Providers still noted variations in implementation, largely based on their perception of relevance to the patient (e.g. patient seeking reproductive health care and female patients being seen as more appropriate than male patients or those seeking care for concerns like cold or flu). This was consistent with student reported data in which 49% of students reported having received the card during their study visit.</p> <p>Clinic commitment also plays an important role in the success of implementation. While some commitment is typically required from higher administration to begin a clinic-wide initiative, implementation may be led by an administrator or an implementation champion (i.e. a staff member who is deeply committed to implementation and assumes a leadership position over the project). Strong leadership is critical in creating a climate of change, and a climate that will be receptive to the new intervention. Several "climate-embedding mechanisms" may help to facilitate this process.[<reflink idref="bib27" id="ref30">27</reflink>] For the present intervention, the availability of a variety of scripts for different clinical scenarios, clinical coaching and support in responding to critical incidents may be particularly useful.</p> <p>Implementation is not a static or a singular event, but an ongoing process requiring active engagement. Following initial training in the use of the card, providers suggested other strategies to strengthen implementation, including more opportunity to practice through role playing, modeling, or development of additional scripts to assist providers in increasing comfort using the card in all situations (e.g. student presents with a cold), rather than only those situations where there is some logical link via reproductive or relationship issues. Such clinical coaching and practice should occur on an ongoing basis during early implementation to aid in keeping both the content and the commitment to implementation at the forefront of practitioners' routine practice. These training methods can also be used to engage new staff in addition to addressing implementation concerns among established providers in addressing new patient populations or workflow changes.</p> <p>Consistent with prior literature on provider barriers to addressing IPV, these college health providers described concerns about how to respond to disclosures of SV and time needed to handle these situations with students. Training in brief interventions such as GIFTSS may benefit from greater attention to addressing how disclosures are viewed. Specifically, we suggest that disclosures of SV should be handled with the same immediacy and urgency as other serious medical conditions. Establishing a clinic-wide climate and protocols for responding to disclosures by including confidential campus or community SV advocacy response teams and having standards for this assessment and referral is essential to providing trauma-informed care that places patient autonomy and confidentiality at the core. Developing institutional protocols similar to those a clinic may already have in place for a patient with suspected pneumonia, a newly confirmed pregnancy, or suicidal ideation supports providers in providing this important care and encouraging collaboration with other support services available to students, rather than placing providers in the uncomfortable situation of feeling as if they are choosing between providing care to the patient or disrupting clinic flow. Developing relationships with campus and community partners already working in the victim advocacy space can facilitate referral mechanisms that are supportive for both providers and patients. With such protocols in place, these situations may be less likely to be viewed as something the provider does not have time to address during the current appointment. Addressing disclosures in the moment is particularly important as disclosing SV to a service provider and receiving a negative reaction is associated with higher levels of long term negative outcomes.[<reflink idref="bib28" id="ref31">28</reflink>] Therefore, SV disclosure should not be viewed differently from any other concern that a student presents with that warrants immediate intervention, regardless of time constraints.</p> <p>Given the nature of clinic work, successful implementation is likely to involve a multifaceted approach including ongoing training, updating of materials to be relevant to the populations served, and comprehensive support from clinic administration such as incorporation of SV content into documentation systems, clinic environment, and working with staff to identify new ways to integrate messaging and resources into all types of clinic visits.</p> <hd id="AN0157934473-21">Limitations</hd> <p>Limitations of this study include nonrandom convenience sampling for the interviews – the providers and administrators with whom the research team had built stronger relationships over the course of the study were generally more responsive to requests for interviews and therefore made up most of our sample, with a strong bias toward providers who felt positive about the intervention. Both qualitative and quantitative data were self-reported by participants, leaving room for both recall and social desirability biases. Surveys were anonymous and interviews were confidential to address this limitation and encourage honesty. Some individuals who participated in the trainings, surveys, and interviews were administrators who did not have direct contact with patients and therefore could not speak from their own personal experience of implementing the intervention; instead they spoke for the providers they were managing in their centers.</p> <p>As we only conducted qualitative interviews with providers who implemented the GIFTSS intervention and not those in the comparator alcohol use intervention condition, there are areas of implementation differences that we may not be fully capturing. For example, as alcohol use screening or counseling is also a very prevalent concern on college campuses, it is possible that providers implementing the alcohol use condition may report different patient level or structural barriers.</p> <hd id="AN0157934473-22">Implications for college health providers</hd> <p>A brief, universal intervention for relationship abuse and SV awareness and assessment was feasible to implement in campus health and counseling centers and prompted important conversations with patients. Providers noted that support at the administrative level to assist in incorporating SV-related materials into current protocols, practices, and documentation was helpful in working toward universal implementation. Additionally, identifying on and off campus resources and developing clear protocols for direct provider-to-advocate referrals may assist in improving provider comfort with responding to patients when disclosures occur, a key concern noted by providers regarding caring for patients who have experienced SV.</p> <hd id="AN0157934473-23">Conclusions</hd> <p>Incorporation of a brief trauma informed education, assessment, and referral intervention for SV demonstrates feasibility and potential to address an issue of major concern among college students. Campus health and counseling centers are well positioned to address SV as they provide confidential services to a wide range of students. Supporting staff with resources, time, training, and building relationships with SV and partner violence advocacy organizations on and off campus are ways that clinic and campus administrators can assist these efforts.Acknowledgments</p> <hd id="AN0157934473-24">Acknowledgments</hd> <p>The authors would like to thank the many providers, staff, and students at the partnering college health centers and campuses for their enthusiasm and support for this study. The authors would also like to thank the many community-based advocacy service providers who participated in the trainings.</p> <hd id="AN0157934473-25">Conflict of interest disclosure</hd> <p>The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the University of Pittsburgh.</p> <ref id="AN0157934473-26"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Muehlenhard CL, Peterson ZD, Humphreys TP, Jozkowski KN. Evaluating the one-in-five statistic: Women's Risk of Sexual Assault While in College. J Sex Res. 2017; 54 (4–5): 549 – 576. doi: 10.1080/00224499.2017.1295014.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Cantor D, Fisher B, Chibnall S, et al. Report on the AAU Campus Climate Survey on Sexual Assault and Sexual Misconduct. Washington, DC : Association of American Universities; 2015.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> Fisher BS, Cullen FT, Turner MG. 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Chugani</p> <p>Reported by Nurse; Author; Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib10" firstref="ref10"></nolink> <nolink nlid="nl2" bibid="bib11" firstref="ref11"></nolink> <nolink nlid="nl3" bibid="bib13" firstref="ref12"></nolink> <nolink nlid="nl4" bibid="bib15" firstref="ref13"></nolink> <nolink nlid="nl5" bibid="bib16" firstref="ref14"></nolink> <nolink nlid="nl6" bibid="bib17" firstref="ref15"></nolink> <nolink nlid="nl7" bibid="bib18" firstref="ref16"></nolink> <nolink nlid="nl8" bibid="bib19" firstref="ref17"></nolink> <nolink nlid="nl9" bibid="bib20" firstref="ref21"></nolink> <nolink nlid="nl10" bibid="bib21" firstref="ref22"></nolink> <nolink nlid="nl11" bibid="bib22" firstref="ref24"></nolink> <nolink nlid="nl12" bibid="bib23" firstref="ref25"></nolink> <nolink nlid="nl13" bibid="bib24" firstref="ref26"></nolink> <nolink nlid="nl14" bibid="bib25" firstref="ref27"></nolink> <nolink nlid="nl15" bibid="bib26" firstref="ref28"></nolink> <nolink nlid="nl16" bibid="bib27" firstref="ref30"></nolink> <nolink nlid="nl17" bibid="bib28" firstref="ref31"></nolink>
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  Data: Provider Perspectives on Implementing a Student Health and Counseling Center Intervention for Sexual Violence
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  Data: English
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  Data: <searchLink fieldCode="AR" term="%22Anderson%2C+Jocelyn+C%2E%22">Anderson, Jocelyn C.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-0572-8378">0000-0003-0572-8378</externalLink>)<br /><searchLink fieldCode="AR" term="%22Feinstein%2C+Zoe%22">Feinstein, Zoe</searchLink><br /><searchLink fieldCode="AR" term="%22Edwards%2C+Clare%22">Edwards, Clare</searchLink><br /><searchLink fieldCode="AR" term="%22Jones%2C+Kelley+A%2E%22">Jones, Kelley A.</searchLink><br /><searchLink fieldCode="AR" term="%22Van+Dusen%2C+Courtney%22">Van Dusen, Courtney</searchLink><br /><searchLink fieldCode="AR" term="%22Kehr%2C+Vanessa%22">Kehr, Vanessa</searchLink><br /><searchLink fieldCode="AR" term="%22Burrell%2C+Carmen%22">Burrell, Carmen</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-7608-4851">0000-0001-7608-4851</externalLink>)<br /><searchLink fieldCode="AR" term="%22Coulter%2C+Robert+W%2E+S%2E%22">Coulter, Robert W. S.</searchLink><br /><searchLink fieldCode="AR" term="%22Miller%2C+Elizabeth%22">Miller, Elizabeth</searchLink><br /><searchLink fieldCode="AR" term="%22Chugani%2C+Carla+D%2E%22">Chugani, Carla D.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+American+College+Health%22"><i>Journal of American College Health</i></searchLink>. 2022 70(5):1363-1371.
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  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Data: 9
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  Label: Publication Date
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  Data: 2022
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  Data: National Institutes of Health (NIH) (DHHS)
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  Data: R01AA023260<br />T32HD087162
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  Data: Journal Articles<br />Reports - Research
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Counseling+Services%22">Counseling Services</searchLink><br /><searchLink fieldCode="DE" term="%22School+Health+Services%22">School Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22School+Counseling%22">School Counseling</searchLink><br /><searchLink fieldCode="DE" term="%22Trauma+Informed+Approach%22">Trauma Informed Approach</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Violence%22">Violence</searchLink><br /><searchLink fieldCode="DE" term="%22Sexual+Abuse%22">Sexual Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Drinking%22">Drinking</searchLink><br /><searchLink fieldCode="DE" term="%22Training%22">Training</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Personnel%22">Health Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Attitudes%22">Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Implementation%22">Program Implementation</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Pennsylvania%22">Pennsylvania</searchLink><br /><searchLink fieldCode="DE" term="%22West+Virginia%22">West Virginia</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07448481.2020.1797752
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  Group: ISSN
  Data: 0744-8481<br />1940-3208
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: To describe provider experiences with implementation of the GIFTSS (Giving Information for Trauma Support and Safety) intervention. Participants: Health and counseling center staff from participating campuses attended trainings between August 2015 and August 2016. Interviews were conducted between May and August 2017. Methods: Providers (n = 230) completed surveys prior to and six months following a 3-hour training on the intervention. Structured phone interviews were conducted with a purposively selected subset of 14 providers. Results: Overall, staff found the intervention acceptable. Implementation barriers noted were time and competing patient priorities. Providers noted variation based on patient and visit characteristics. Clinic commitment, particularly in adopting strategies for universal dissemination of the GIFTSS card, was seen as helpful. Conclusion: Implementation of a brief trauma-informed intervention in campus health and counseling centers was feasible and acceptable to most providers. Opportunities to change organizational culture regarding ensuring adequate time and safety for patients are discussed.
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  Label: Entry Date
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  Data: 2022
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  Data: EJ1359138
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      – SubjectFull: Counseling Services
        Type: general
      – SubjectFull: School Health Services
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      – SubjectFull: School Counseling
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      – SubjectFull: Pennsylvania
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      – SubjectFull: West Virginia
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      – TitleFull: Provider Perspectives on Implementing a Student Health and Counseling Center Intervention for Sexual Violence
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            NameFull: Jones, Kelley A.
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          Name:
            NameFull: Van Dusen, Courtney
      – PersonEntity:
          Name:
            NameFull: Kehr, Vanessa
      – PersonEntity:
          Name:
            NameFull: Burrell, Carmen
      – PersonEntity:
          Name:
            NameFull: Coulter, Robert W. S.
      – PersonEntity:
          Name:
            NameFull: Miller, Elizabeth
      – PersonEntity:
          Name:
            NameFull: Chugani, Carla D.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2022
          Identifiers:
            – Type: issn-print
              Value: 0744-8481
            – Type: issn-electronic
              Value: 1940-3208
          Numbering:
            – Type: volume
              Value: 70
            – Type: issue
              Value: 5
          Titles:
            – TitleFull: Journal of American College Health
              Type: main
ResultId 1