Karen A. Kalmakis, PhD, MPH, FNP-BC
and Lori J. Banning, MSN, RN
This article was made possible by an educational grant from
Chamberlain College of Nursing
Kalmakis, K. and Banning, L. (February 2012). Web-based Follow-up Information for and Research on Victims of Sexual Assault. Online Journal of Nursing Informatics (OJNI), 16 (1), Available at http://ojni.org/issues/?p=1272
Many victims of sexual assault are lost to follow up for recommended medical and psychological care once discharged from the emergency department. Without appropriate health care follow-up to address the risks of infections, pregnancy and mental health sequelae, victims may suffer significant consequences. In this feasibility study, researchers surveyed sexual assault victims regarding access to computers and comfort using the Internet to obtain information and participate in nursing research. A majority of the women surveyed had access to computers and many would be comfortable obtaining health information and participating in research on-line. Women who indicated they were unsure about use of the Internet for these purposes sighted issues of confidentiality. The results of this study indicate the Internet has promise to reach this elusive population for follow-up health care information and nursing research. Victims whose sensitive healthcare needs often keep them hidden from healthcare providers would benefit from the anonymity afforded by the Internet when seeking accurate and up-to-date health information.
Sexual-assault victims are at risk for sexually transmitted infections, pregnancy, psychiatric disorders, and other negative health consequences of the assault. Despite this risk, many victims of sexual assault are lost to follow-up for recommended medical and psychological care once discharged from the emergency department (Ackerman, Sugar, Fine, & Eckert, 2006; Parekh & Brown, 2003). Given that one in six US women is estimated to have been sexually victimized in their lifetime (Tjaden & Thoennes, 2006) and the serious risks of health sequelae after an assault (CDC, 2010; Davidson, Stein, Shalev, & Yehuda, 2004), innovative interventions are needed to reach these victims. One such intervention would be using the World Wide Web (Web) to enhance follow-up care with the goal of reducing the incidence of long-term health effects after a sexual assault. The Internet has value as a vehicle to link traditionally underserved groups with accessible health information (Cotton, 2003; E. A. Miller & West, 2009). Victims whose sensitive healthcare needs often keep them hidden from healthcare providers would benefit from the anonymity afforded by the Internet when seeking accurate and up-to-date health information. Therefore, the purpose of this study was to determine the feasibility of a Web-based informational site for sexual assault victims and use of the Internet to conduct nursing research with this vulnerable population.
Sexual assault victims are at risk for multiple health problems post assault, both physical and psychological. However, efforts to provide needed follow-up health care to victims have proven unsuccessful. Use of World-Wide-Web represents a promising and innovative way to provide victims with health information to prevent the health sequelae of sexual assault. Furthermore, the Web holds promise for researchers in this highly sensitive area of nursing science.
Despite the high prevalence of sexual assault in the US, only 35.5% of victims were found, in the most recent study on this topic, to have received the recommend medical or psychological care after a hospital forensic exam (Ackerman et al., 2006). Telephone calls and mailings have been found to be ineffective as follow-up mechanisms (Boykins & Mynatt, 2007). For example, only 23% of victims who agreed to be contacted 3 months after the assault could be reached by telephone (Boykins & Mynatt, 2007).
The standard care protocol for sexual-assault victims who seek emergency medical care is to prescribe prophylactic medications for possible sexually transmitted infections (STIs) and pregnancy (Amey & Bishai, 2002; CDC, 2010; Plichta, Clements, & Houseman, 2007). Some of these prophylactic medications require only a single dose; others require days or weeks of therapy. Non-adherence to antibacterial and antiviral medication regimes prescribed at the time of the forensic examination increases the risk that a victim may contract and spread STIs. For example, human- immune-deficiency-virus (HIV) prophylaxis requires 4 weeks of therapy. Starting and maintaining patients on HIV prophylaxis after sexual assault is important to prevent infection. However, a significant barrier to implementing recommended HIV-prophylactic regimes is medication adherence. For instance, only 21% of sexual-assault victims who accepted HIV prophylaxis at the time of the emergency department visit completed the prescribed month of treatment (Linden, Oldeg, Mehta, McCabe, & LaBelle, 2005). The majority of victims who started HIV prophylaxis (55%) failed to keep the follow-up appointments intended to assist them adhere to the medication regimen (Linden et al., 2005).
In addition to prescribed medication regimens, follow-up medical examinations are routinely recommended after sexual-assault examinations to confirm successful prevention of STIs and pregnancy. Similarly, mental-health follow-up visits provide an opportunity to address the psychological impact of a sexual assault, including posttraumatic stress disorder (PTSD) (Masho & Ahmed, 2007; Najdowski & Ullman, 2009) and substance misuse (Kalmakis, 2010; Ledray, 2008; Najdowski & Ullman, 2009). Follow-up visits offer an opportunity for victims to talk about their response to the trauma and its effect on their lives.
Victims’ decisions to follow recommended care are influenced by many factors, including characteristics of the assault, lack of primary-care provider, medical-insurance status, availability of transportation and child care, and comprehension of emergency-department discharge instructions (Boykins & Mynatt, 2007). Lack of follow-up after sexual assault may also be influenced by psychological factors. Victims may experience shame and guilt, depression, PTSD, or other psychiatric concerns that contribute to the failure to seek and obtain health care (Ackerman et al., 2006). With so many possible factors interfering with victims’ ability to comprehend and recall discussions about medications and recommended medical and psychological care, the follow-up appointment may be as important as the forensic exam itself (Boykins & Mynatt, 2007). The low rate of adherence to follow-up care recommendations, combined with the potential high risk of health sequelae, support the importance of identifying new ways to reach victims after a sexual assault to provide preventive healthcare information.
The majority of Americans (74%) accessed the Internet in 2009, with 61% of adults using the Internet to find health information (Fox, 2009). In fact, searching for health information is the third most popular on-line activity for all Internet users ages 18 and older (Zickuhr, 2010). Health information obtained from the Internet is trusted by most users (Bennett & Glasgow, 2009). Indeed, the number of people using the Internet to access health information far exceeds the number using it to communicate with healthcare providers (E. A. Miller & West, 2009). Furthermore, women were more likely than men to access health Web sites (E. A. Miller & West, 2009).
Uninsured individuals have been shown to be more likely to seek alternative sources of health information and advice on-line (E. A. Miller & West, 2009). While being uninsured poses a barrier to using conventional health services, it does not prevent individuals from seeking health information on-line (E. A. Miller & West, 2009). Indeed, a national Web site has been established to provide information to victims of violence, including information for victims of sexual assault (RAIIN, 2009). This Web site provides valuable assistance to victims, but lacks details about follow-up emergency-department recommendations for medications and medical care after a hospital forensic examination. Post sexual assault care is time sensitive, as prevention of STIs and unwanted pregnancy must be addressed within days or weeks after the assault. Additionally, since PTSD and rape trauma syndrome are frequently diagnosed post sexual assault (Taylor & Harvey, 2009), psychiatric counseling should begin as soon as possible. A Web site designed to educate victims about recommended health care post assault would be targeted specifically to the weeks following the assault with reliable, detailed, time-sensitive information for victims. The Internet has value as a vehicle to link traditionally underserved groups with accessible health information (Cotton, 2003; E. A. Miller & West, 2009). Sexual assault victims represent a traditionally underserved group as evidenced by the lack of appropriate follow-up care.
Using the Internet to conduct Web-based research was shown in a review to have advantages such as low cost, ease of use, anonymity for exploring sensitive issues, and access to hard-to-reach populations (Ahern, 2005). However, Web-based research also has challenges, including security, confidentiality, and response errors (Ahern, 2005). The Internet provides anonymity with regard to identifiable personal information in the physical world such as legal name and street address, but it does permit a virtual Internet location; this information is often used by Internet advertisers and marketers (Wallace, 1999). The Internet has been successfully used in women’s health research in the areas of routine mammography screening (Lin, Effken, Li, & Kuo, 2011), alcohol misuse (Finfgeld-Connett & Madsen, 2008), and living with chronic disease (Weinert, Cudney, Comstock, & Bansal, 2011). The Internet offers a venue to reach marginalized populations, cultural groups, and victims whose sensitive health care needs often keep them hidden from healthcare providers but who benefit from the anonymity afforded by the Internet when seeking accurate and up-to-date health information. Thus, the purpose of this study was to explore the feasibility of using the Internet to provide specific health information to victims of sexual assault and to conduct nursing research with sexual-assault victims.
Sexual assault victims attending women’s centers were invited to participate in a survey used to investigate their access to and use of the Internet. The survey included a section for victims to select particular information they considered helpful post sexual assault. The survey included minimal personal information in order to provide victims with anonymity.
A cross-sectional survey design was used to collect data from victims of sexual assault who had visited four women’s centers across Massachusetts. Data were collected during August and September of 2009.
1) Would women who have experienced a sexual assault benefit from a health-focused, nurse-administered Web site?
2) Would victims of sexual assault be willing to participate in Web-based research?
Before data were collected, the study was approved by the University of Massachusetts Amherst Institutional Review Board. Women were recruited by convenience sampling from four women’s centers throughout Massachusetts. Three centers were located in ethnically and racially diverse urban settings, and one was located in a suburban setting. Women were included if they attended these centers, had been the victim of sexual assault, and were able to complete the short paper survey. Women were excluded if they had not been sexually assaulted.
Data were collected by surveying participants on their history of victimization as well as their access to and comfort with using the Internet. Short paper surveys were placed in women’s- centers waiting rooms and offices. The researchers visited each women’s-center to inform the directors about the study and request cooperation in data gathering. Informed consent letters, with the researchers contact information, were attached to each survey. To preserve anonymity participants were not required to sign consent forms. Completion and return of the surveys denoted consent. The researcher-developed survey included four close-ended questions with yes, no, or unsure options. The fifth question was multiple-choice and required respondents to check all options that applied. Women were asked to indicate their age by choosing between six age ranges. Surveys of participant who reported being less than 18 years of age were discarded, this applied to one participant.
An expert panel, including two sexual-assault nurse examiners, one women’s-center director, and one research consultant, was asked to rate the clarity, relevance, and representativeness of each item in the questionnaire. Based on feedback from the panel, a range was established for age, rather than a specific number, and race/ethnicity was removed to eliminate threats to anonymity. Finally, additional options for Web-page content were added to question five. No identifying information was obtained; all completed surveys were placed in a box at the centers until retrieved by the researchers 2 weeks later.
Survey data were analyzed by descriptive statistics (percent) using Microsoft Excel (Microsoft, 2008).
Of the 41 women who responded to the survey, 3 were excluded from data analysis, as they had not been victims of a sexual assault. One under age woman was also excluded. Thus, the sample comprised 37 women. The largest proportion (n =16) was 23 to 30 years old, 9 were less than 23 years old, and 11 were over 30 years old. One respondent did not report her age.
The majority of participants (n=21, 57%) indicated they had access to a computer. When asked if they would feel comfortable using the Internet to access information after a sexual assault although many women answered yes, the majority answered unsure (see Figure 1).
When asked if they would be willing to answer research questions on-line intended to learn more about the needs of victims, the majority answered yes, but once again, many answered unsure (see Figure 2). Two women who were unsure commented about their concerns for confidentiality when using the Web.
In response to questions about the type of information they would find beneficial on the Internet after a sexual assault, the participants indicated interest in all forms of health information (Figure 3).
Medical Information Counseling Information
1 – medication 7 – rape crisis centers
2 – sexually transmitted infections 8 – group counseling
3 – area health providers 9 – area counselors
Substance abuse services
4 – alcoholics anonymous
5 – narcotics anonymous
6 – area programs
The majority of sexual assault victims surveyed responded that they do have access to computers and would access health information offered via the Internet. Many also would participate in Web-based research. Victims concerns about confidentiality represent the biggest challenge to nurse educators and to nurse researchers who plan to use the Internet to study sexual assault victims.
The results of this study demonstrate that the majority of women who have been sexually assaulted and seek services at women’s shelters have access to the Internet, and many are receptive to obtaining health information and participating in research via this method of communication. The number of participants in this study with Internet access (57%) was less than the total number of adult Americans reported to have access (70%) (Zickuhr, 2010). Nonetheless, the findings of this study indicate that the Internet has potential to reach a significant proportion of this elusive population after a sexual assault. This is especially important when considering that current follow-up care through in-person appointments remains unacceptably low.
The Internet has potential to engage vulnerable populations in nursing research. Forty-six percent of participants were willing to answer research questions on-line. The study findings are similar to previous research findings that the Internet is an effective tool to reach vulnerable population (Bowker & Tuffin, 2004; Miller & Sonderlund, 2010). If researchers are able to assure participant confidentiality, this number could rise significantly.
The women who were unsure about using the Internet to access health information or to answer research questions are of greatest concern to the future of Internet education and research in this area. To successfully launch any Web-based information site or Internet research with this population, victims must be assured of their virtual anonymity.
The Internet provides a promising means to provide accessible knowledge to victims of sexual assault, thus improving healthcare outcomes after sexual assault. Traditional methods of follow-up with sexual-assault victims have proven ineffective. Nurses should seek alternative ways to provide this important health care by embracing existing technology to provide accurate, timely health information to patients in an accessible venue.
Nurses who plan to use the Web as a tool to reach sexual-assault victims must address victims’ concerns for confidentiality. One strategy to address this concern is to provide victims with information about anonymity when browsing the Web and accessing informational Web sites. In addition, researchers should provide secure password-protected access when conducting research with this population (P. G. Miller & Sønderlund, 2010). Experts in Internet security are important to any Web-based research study and can significantly affect budgets (Cotton, 2003). Information technology experts provide online computer and network security measures that define and control access to the educational information and data in order to ensure confidentiality, availability, and integrity of the health information and research (Cotton, 2003)
Nurses considering Web-based research must consider issues of anonymity and confidentiality when making decisions about research design. Web based surveys that request no identifying information, are able to provide anonymity, whereas e-mail group discussions, for example, cannot offer anonymity. Researchers using methods that can not provide anonymity, must emphasize confidentiality in communications with research participants and must limit access to the server as well as any electronic copies of data (Im & Chee, 2003)
This feasibility survey was kept simple to obtain the information about Internet access from this vulnerable population of women while insuring their anonymity. However, this simplicity presents limitations due to a lack of specifics about each participant’s age and racial/ethnic characteristics. Furthermore, the women surveyed in this northeastern state may differ from other victims across the country with regard to socioeconomic status, culture, and ethnicity, resulting in differences with regard to use and comfort with the Web. The researchers attempted to minimize this limitation by choosing women’s centers that served diverse cultural populations.
The survey included questions about access to a computer, and comfort with the Internet. With the rapid changes in information technology the Internet is becoming accessible to more people using devices other than computers. One third (35%) of American adults own smartphones and similar Internet accessible mobile devices and 87% of these smartphone users report accessing the Internet via these devices (Smith, 2011). This new technology has been more readily adopted by persons under the age of 45, the financial well-off and well-educated, as well as by African-Americans and Latinos (Smith, 2011). This shift in Internet access to hand held devices could significantly change the results of future feasibility studies in this area. This recent increase in Internet availability supports the use of the Web to provide victims of sexual assault with health information and to conduct research designed to improve health care outcomes for victims.
The risk of health sequelae after a sexual assault supports the need for victims to receive timely follow-up care. Despite these risks, however, most victims do not follow recommendations. Innovative approaches are needed to reach victims with specific information regarding medication regimes, recommended STI screening, and advised mental-health counseling. The results of this feasibility study suggest that victims of sexual assault who attend women’s centers have access to computers, would be willing to receive health information via the Internet, and would participate in Web-based nursing research. The next step in this research is to pilot a health focused web site for victims. This pilot Web site would permit an investigation of its use and solicit comments and suggestions from victims for improving the web site.
The feasibility study revealed a need to assure this vulnerable population of Internet anonymity and security. These findings support the use of the Internet to reach this vulnerable population for healthcare follow-up and research. Nurses are in an ideal position to effectively facilitate and guide Internet health education and to successfully conduct research with victims of sexual assault.
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Karen A. Kalmakis, PhD, MPH, FNP-BC
Karen A. Kalmakis, PhD, MPH, FNP-BC has experience in various areas of nursing including acute care, community health, women’s health, college health, and forensics. Dr Kalmakis obtained her BSN from Elms College. She attended graduate school at the University of Massachusetts Amherst where she obtained a MSN in primary care nursing, a MPH in public health policy and management, and a PhD in nursing. Her research focuses on the health effects of victimization. Dr Kalmakis currently teaches in the undergraduate and graduate nursing programs at the University of Massachusetts Amherst.
Lori J. Banning, MSN, RN
Lori J. Banning, MSN, RN has experience in many areas of nursing including critical care, community health, discharge planning and forensics. She worked as a Sexual Assault Nurse Examiner (SANE) for nearly 10 years, including seven years as a regional coordinator for the Massachusetts SANE Program. She remains dedicated to improving follow-up care for victims of sexual assault. Ms. Banning obtained her BSN from Saint Joseph’s College in Standish, Maine and her MSN from the University of Massachusetts Dartmouth. She currently teaches at Signature-Healthcare Brockton Hospital School of Nursing in Brockton, Massachusetts.