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1. The article or Data you use should be a recent one. (From 2017 to 2021)

2. Do not copy-paste and make the  Pai chart or bar graph. It should be hand-made by own. It should be on percent or per thousand. Should be clearly written.

3. Proper intext citation

4. Proper references should be there.

Follow the attached outline and do from there

THE MAIN RESOURCES FOR THIS PAPER IS FROM THE CDC( CENTER DISEASES OF CONTROL ANd PREVENTION)

Abstract

Part I. Overview of Sexual assault among college students

1. What is Sexual assault? How dangerous and big is it? Discuss the impact of sexual assault among college students.

2. Sexual assault causation

I. Define sexual assault as a major cause among college students

A. Risk Factors

i. Individual behavior

Alcohol use, early sexual initiation, delinquency, forceful sexual fantasies, lower age, and academic year ( Needed any kind of graph, or chart) Explain in 5 to 6 sentences.

ii. Environmental factors

Witnessing family violence, exposure to sexually explicit media, late night weekend party

B. Determinants of sexual assault

i. Education

ii. Sociodemographic factors

a. Poor social status

b. Racial discrimination

c. Lack of social support

II. Sexual assault diagnosis (Forensic exam, history, investigation)

3.Why is sexual assault a problem? Allocation graphs and data to show the variation in rates.

I. Prevalence rates (Describing in a short paragraph to explain the difference of prevalence rates in each level and ( show in Chart, or bar)graph

i. National

ii.State, ( Texas)

iii.County (local) Dallas County

II. Incidence rates (Describing in a short paragraph to explain the difference of incidence rates in each level)

i. National- The united states

ii. State, and ( Texas)

iii.County(local) (Dallas)

III.Morbidity and Mortality rates (Describing in a short paragraph to explain the difference of morbidity and mortality rates in each level)

i. National, United states

ii. State, and (Texas)

iii.County(local) Dallas County

4.Sexual assault distribution (representing charts and graphs to show differences in each subgroup)

I. Demographic variation (Comparing visual data in a paragraph, which variable has the highest and lowest rate)

i. Age

ii. Gender

iii. Race/ethnicity

iv. Socioeconomic status

II.Geographic variation (Comparing visual data in a paragraph, which variable has the highest and lowest rate) Exaplain in small paragraph

i. National ( United State)

ii. State, and ( Texas)

iii.County(local) (Dallas)

III.Temporal variation

i. Secular trend (showing gradual changes in frequency of Sexual Assault)

Part II: Intervention Opportunities

5. Literature review –

A. Sexual assault is a Public Health Issue

B. Prevention and Management of Sexual assault

The most helpful way to prevent and manage sexual assault is to teach everyone you know about the myths and realities of sexual violence.

I. Education

i. Practice through educational sessions was used. 

II. Discreet screening

i. Forensic examination

III. Targeted Intervention Strategies

i. Programs promoting to recognize that sexual violence will not end until men become part of the solution.

ii. Bring awareness to the youth about sexual violence

iii. The willingness to be able to know that silence does not equal consent.

6. Public Health Practice –two strategies that target the youth

I. One policy intervention strategy – national level

II. One health education strategies – at the local level

III. Target Population and why – Young Adults

Part III: Implications

  

7.Implications  

I. Describe how the public health players can tackle this issue in the school.  

i. Health educator at School (Public health professionals) 

ii. Student groups (Community Organizations)  

 

8.Conclusion and Implications  

II. Each part I and II will be summarized in this section in a one-paragraph each. 

III. Summarizing why we must act for sexual assault, what are the future steps to reduce it, who can help to reduce sexual assault.

9. References

10.Appendix

Helpful Resources

A Primer for Lone Ranger Epidemiologist in Texas Counties

DSHS Reporting Forms: www.dshs.state.tx.us/idcu/investigation/forms/

 Guidelines for Investigation & Control of Invasive, Respiratory, Foodborne, and Vaccine‐Preventable Diseases: http://www.dshs.state.tx.us/IDCU/health/infection_control/Investigation‐Guidance/

 VPD Investigation Forms: www.dshs.state.tx.us/idcu/health/vaccine_preventable_diseases/forms/

 Other Investigation Forms: www.dshs.state.tx.us/idcu/investigation/#

 Notifiable Conditions List: www.dshs.state.tx.us/idcu/investigation/conditions/

 Epi Case Criteria Guide (Rev 2015):

http://www.dshs.state.tx.us/workarea/linkit.aspx?linkidentifier=id&itemid=8589995012

 Laboratory Submission Guide: www.dshs.state.tx.us/lab/MRS_labtests_toc.shtm

NORS Outbreak Reporting Form: http://www.cdc.gov/nors/forms.html

 CDC Legionellosis Hypothesis‐Generating Form:

http://www.cdc.gov/legionella/downloads/hypothesis‐generating‐questionnaire.pdf

 CDC Environmental Assessment Form:

http://www.cdc.gov/legionella/downloads/environ‐assess‐instrument.pdf

 Texas Influenza Surveillance Handbook:

http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589946469

 Vaccine Information Sheets: http://www.dshs.state.tx.us/immunize/literature/litlist.shtm

 Communicable Disease Chart and Notes for Schools and Child‐Care Centers (Stock #6‐30)

CDC Vaccines and Preventable Diseases: www.cdc.gov/vaccines/vpd‐vac/default.htm

 Manual for the Surveillance of Vaccine Preventable Diseases: www.cdc.gov/vaccines/pubs/survmanual/index.html

 Morbidity and Mortality Weekly Report (MMWR): www.cdc.gov/mmwr/

 Epidemiology and Prevention of Vaccine Preventable Disease (Pink Book):

http://www.cdc.gov/vaccines/pubs/pinkbook/index.html

 Recommendations of the Advisory Committee on Immunization Practices (ACIP) Influenza Prevention and Control Recommendations: www.cdc.gov/flu/professionals/acip/index.htm

 Centers for Disease Control and Prevention Pneumococcal Disease information:

http://www.cdc.gov/pneumococcal/clinicians/clinical‐features.html

 Centers for Disease Control and Prevention Group A Streptococcal Disease (GAS) information:

http://www.cdc.gov/groupAstrep/resources.html

Local Mental Health Authorities ‐ http://www.dshs.state.tx.us/mhcommunity/LPND/LMHAs/

Emergency Preparedness and Response ‐ http://www.dshs.state.tx.us/commprep/about.aspx

Public Health Emergency Preparedness Branch ‐ http://www.dshs.state.tx.us/commprep/phep/program/

Performance Standards:

· Healthy People 2020 Goals

· Ten Essential Public Health Services

· CDC Environmental Public Health Performance Standards

· Public Health Accreditation Board

· County Health and Rankings ‐ http://www.countyhealthrankings.org/app#/home

Data systems, Software, and Organizations

· Public Health Information Network ‐ https://www.txphin.org/sign_in

· LabWare ‐ https://results‐web.dshs.state.tx.us:8443/index.jsp

· CIDRAP ‐ http://www.cidrap.umn.edu

· EpiX ‐ http://www.cdc.gov/epix

· ProMed ‐ http://www.promedmail.org/

· APIC ‐ https://apic.org/Member‐Services/Join

· Texas Environmental Health Association (TEHA) ‐ http://www.myteha.org/Home

· Texas Public Health Association (TPHA) https://www.texaspha.org/

· Council of State and Territorial Epidemiologists
https://www.cste.org

· National Association of County and City Health Officials (NACCHO)

· Dallas County Public Health Advisory Board (quarterly meetings)


Local health departments play a central role in providing essential public health services in communities that fall into the following ten categories:

1. Monitor health status to identify and solve community health problems.

2. Diagnose and investigate health problems and health hazards in the community.

3. Inform, educate, and empower people about health issues.

4. Mobilize community partnerships and action to identify and solve health problems.

5. Develop policies and plans that support individual and community health efforts.

6. Enforce laws and regulations that protect health and ensure safety.

7. Link people to needed personal health services and assure the provision of healthcare when otherwise unavailable.

8. Assure competent public and personal healthcare workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

10. Research for new insights and innovative solutions to health problems.


http://www.phf.org/corecompetencies

HEPATITIS B & C DESCRIPTIVE EPIDEMIOLOGY 1

City of Garland Hepatitis B & C Descriptive Epidemiology Report

Students

HHPH 416: Epidemiology

December 2, 2018

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 2

TABLE OF CONTENTS

Part 1: Overview of Hepatitis B & C………..…………………………………………………….3

Part 2: Insight About Selected Health Problem…………………………………….……………10

Part 3: Proposed Solutions……….………………………………………………………………12

Model Programs…………………………………………………………….……………14

Program Proposal…………………………………………………………………………18

Policies and Statutes………………….………………………………………………….19

Conclusion……………………………………………………………………………………….20

References………………………………………………………………………………………..22

Appendices…………………………………………………………………………….…………26

A. Hepatitis C Incidence Rates by State…………………………………………………….26

B. Incidence of Acute Hepatitis C by Race/Ethnicity ………………………………………28

C. Program outline for B Positive Program…………………………………………………30

D. Map of States with Hep B Mandates ……………………………………………………32

E. Infographic ………………………………………………………………………………34

F. List of Helpful Resources…………………………………………………………………36

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 3

Part 1: Overview of Hepatitis B and C

There currently is not any local data on the city of Garland for Hepatitis B and C.

Whereas, Hepatitis B and C were not mentioned in the Garland 2017 Community Health

Assessment, or in the 2018 Key Findings of the Community Health Assessment. For the purpose

of this paper, data was extracted from the county, state, and national levels and were applied, and

framed to be relevant for the Garland Public Health Department.

Currently Dallas County has a Hepatitis B (HBV) vaccination rate of 98% amongst

children according to the Dallas County 2016 Community Needs Assessment. This is a relatively

high rate compared to the national average of 90% (CDC, 2016a). While these rates may be high,

the problem lies within keeping the rates at this level. Whereas, with growing controversy

towards vaccines and more parents opting out from vaccinating their children, this rate may

begin to dwindle amongst children and adults. There currently is not any data on adult

vaccination rates in Dallas County or Garland however, Hepatitis B vaccination rates amongst

adults greater than 18 are problematic, as the national vaccination rate is currently at 25% (CDC,

2018b). As the nation struggles with Hepatitis B vaccination rates it is safe to assume that

Garland has similar percentages. A large contributor for these low rates is due to low vaccination

of high-risk adults as a result of the difficulty of identifying high risk candidates (CDC, 2017).

Increasing adult Hepatitis B vaccination rates amongst at-risk groups should be a priority for all

health departments within the United States.

Hepatitis C (HCV) rates in Texas vary amongst counties and are larger in counties with

major cities and counties located near the Texas – Mexican Border. Dallas county, where the city

of Garland is located, is a county that has higher rates of Hepatitis C at approximately 2%

(Yalamanchili, Saadeh, Lepe, & Davis, 2017) This number is significant as Hepatitis C is the

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 4

most common indicator for liver transplantation (Yalamanchili, Saadeh, Lepe, & Davis, 2017)

Therefore, Hepatitis C puts a burden more so on transplant and health care facilities in areas

where Hepatitis C is prevalent such as Dallas County. Therefore, with stakes as high as these, it

is imperative for all health entities to contribute and work together to help reduce Hepatitis C

incidence rates.

Hepatitis B and C are diseases that adversely affect the liver. There are acute and chronic

infections of Hepatitis B and C. Acute infection symptoms for both illnesses range from

asymptomatic to mild disease lasting anywhere from a few weeks up to six months. Compared to

chronic infections that lead to cirrhosis, liver cancer, hepatocellular carcinoma. Nearly 50% of

children who are infected with Hepatitis B will develop chronic HBV and the individual will

most likely deal with the infection the rest of their life. Whereas, 95% adults who are infected

with Hepatitis B infection completely recover and do not progress to the chronic stages of the

illness. One out of every four children diagnosed with chronic HBV will die prematurely

compared to 1 out of every 7 adults who die prematurely as a result of chronic HBV. Hepatitis C

will develop into chronic HCV in approximately 3 out of every 4 people diagnosed with HCV.

Out of those who develop chronic HCV 10 to 20 percent of cases will eventually develop

cirrhosis.

Hepatitis B is a sexually transmitted infection that can also be spread through various

different avenues. Whereas both diseases may be transmitted through infectious blood, HBV

may also be transmitted through other fluids such as semen or other bodily fluids. Those who are

at a higher risk of contracting Hepatitis B are; men who have sex with men, sex partners of

infected person, injection drug users, healthcare and public safety workers. (CDC, 2018a) Those

who are at a higher risk of contracting Hepatitis C are; injection drug users, recipients of donor

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 5

blood, people with HIV infection, babies born to an HCV-infected mother, prisoners or someone

who has ever been in prison, those who received tattoos from an unsterile environment, and

anyone who used a clotting factor concentrate before 1987 (CDC, 2018b; Mayo Clinic, 2018) .

Lack of vaccination and/or engaging in risky behaviors increases the morbidity and

mortality rates of Hepatitis B & C. The World Health Organization (2018) analyzed that around

600,000 people worldwide died of Hepatitis B associated diseases, such as acute and chronic

liver disease. Advanced chronic Hepatitis B & C virus infections may lead to mortality. In the

United States alone, 3,000 to 4,000 people die of Hepatitis B and these are just cases related to

cirrhosis, this does not include cases of mortality from other complications (CDC, 2017b). An

additional 1,000 to 1,500 people die a year in the United States from cancer due to Hepatitis B

(CDC, 2017b).

Different types of determinants contribute to Hep B & C, such as age, sex, and marital

status. For example, in terms of age the group that has the greatest risk of contracting Hepatitis B

include newborn babies and toddlers, this means the carrier risk decreases as people get older

(CDC, 2018c). Figure 1 illustrates the risk associated with children under five contracting

Hepatitis B.

Figure 1

Risk of Chronic HBV Carriage by Age of Infection from 1978-2012

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 6

Although children can get the Hepatitis B virus relatively easier compared to adults,

adults account for the age group that has the most cases of Hepatitis B and C in both acute

infections and chronic infections. Following adults, adolescents make up for the majority of

cases regarding acute infections, in the chronic infection cases the perinatal age group makes the

majority as well. Lastly, children and adults make up the smallest share of acute infections while

chronic infections have adolescents and children making up the smallest share. It is important to

categorize the types of infections among Hepatitis B and C because they affect different age

groups. The distribution of acute and chronic infections of Hepatitis B is illustrated in Figure 2.

Figure 2

Distribution of Chronic and Acute Hepatitis B infections

Note. Data for HBV carriage by age

is provided by (CDC, 2017b).

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 7

There are major risk factors when it comes to contracting Hepatitis B and C. The

likelihood of contracting these viruses increases along with number of years that a person

engages in high-risk behavior (CDC, 2017b). This is illustrated in Figure 3. In this example when

comparing IV drug users and homosexual men along years of risk, the results show that IV drug

users have almost twice the risk of getting infected with the Hepatitis B virus compared to men

who have sex with men. When having another comparison group, health care workers (HCW’s)

and heterosexual individuals, the data shows how low their infection percentages are. The

highest percentage for HCW’s and heterosexual individuals only peaked at 20% compared to

homosexual men who peaked at 50% and IV drug users who peaked at 70%

Figure 3

Hepatitis B Infection by duration of high-risk behavior

Note. This figure is provided

by (CDC, 2017b)

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 8

When these high-risk behaviors are broken down to see who is most at risk, the results

point to heterosexuals who have multiple sexual partners accounting for 39% of Hepatitis B and

C cases. The second largest share comes from men who have sex with men (MSM), the third

largest share comes from injecting drug users (IDU), the fourth largest share comes from high-

risk behaviors classified as “other”, and lastly there are unknown risk factors that contribute to

these cases (CDC, 2017b). These risk factors are summarized in Figure 4.

Figure 4

Risk Factors for Hepatitis B and C

Note. This figure is provided by (CDC,

2017b)

Note. This figure was provided by (CDC, 2017b)

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 9

Geographical areas, social and economic factors such an income, occupation, and

education are all also important at determining people at risk for Hepatitis B and C. These

contribute to an understanding of vaccination rates. When taking a look at geographical

populations about 45% of the global population live in places that have a high prevalence of

chronic HPV infections, compared to 12% of the population that lives in low prevalence areas

(CDC, 2017b). High prevalence areas include: Amazon Basin, most Pacific Islands, most of

Africa, parts of the Middle East, Southeast Asia, and China. On the other hand, Australia, United

States, and Western Europe are the places that make part of the lowest prevalence areas (CDC,

2017b).

Geographical exposures contribute to Hepatitis B and C, along with social exposures.

These can be healthcare-related, dealing with households, based on occupation, travel, lifestyle,

environment, and many more and they are significant because they account for 5% of incidence

rates. Even though they account for such a low number this number is said to be an rough

estimate since nearly 16% of individuals deny that a certain social exposure was the risk factor

for their infection (CDC, 2017b). It’s important to realize that HBV infection is highly prevalent

in specific groups even if it’s uncommon among adults in the broad populations judging that the

lifetime risk is less than 20% for infection (CDC, 2017b). When highly prevalent specific groups

are being targeted it’s important to pinpoint who they are. The three major risk groups include

men who have sex with men, people in contact with infected persons or heterosexuals with

multiple sexual partners, and injection-drug users. The reason why these groups account for high

prevalent groups is because, health educators have trouble gaining access to them (CDC, 2017b).

This leads to a lack of awareness of risks and consequences that can lead to this disease among

the different groups. In addition, many public health programs are not effective even when they

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 10

target these groups (CDC, 2017b). However, vaccine cost and healthcare accessibility also play a

role Hepatitis B and C rates in these specific population (include the Garland stats on vaccines).

Hepatitis B and C incubation period ranges anywhere from 45 to 160 days with the

average being 120 days. This disease is in a secular trend in the United States. Surprisingly in the

mid-1980’s Hepatitis B reached the highest it has ever been with about 26,000 cases each year.

With the help of more prevention programs, vaccines, and tests to help with Hepatitis B cases

declined and fell below 10,000 cases in 1996 (CDC, 2017b). The major decline came during the

end of the 1980’s and the early 1990’s when high risk groups such as injection-drug users and

men who have sex with men saw reduction in transmissions as a result of HIV prevention efforts.

As the years kept going (1990-2004) incidence of acute Hepatitis B in the U.S decreased by 75%

(CDC, 2017b). This is vital because around 79% people who have been newly infected with

Hepatitis B are engaged in risky health behaviors such as having unprotected sex and injection

drug use. The group that had the best declining rates were children and adolescents, their

incidence rates decreased by 94% due to the increase of Hepatitis B vaccine. As of 2012, in the

United States a total of 2,895 cases were reported which shows the importance of how important

prevention strategies and vaccines are to reduce the number of incidence rates. It’s important to

keep the vaccination rates up even if vaccines have increased the rate of prevention because

before childhood Hepatitis B vaccination was recommended about 80% of HBV infections

happened among adults (CDC, 2017b). For example, in 2015 adults ages 25-45 in the United

States had the highest incidence of acute Hepatitis B (CDC, 2017b).

Part II: Insight about Selected Health Problem

One of the most prevalent key social determinants of Hepatitis B and C are people who

come from foreign countries and people who have HIV. According to the World Health

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 11

Organization(2018), there is an HIV-HBV coinfection of 2.7 million people, those infected with

HBV are most likely to be living with HIV. Those coming from foreign Hepatitis endemic

countries, many times do not have the financial means or accessibility to go to the doctor when

they have symptoms. Spanish-speaking people are also less likely to report HBV (Greene,

Duffus, Xing, King, 2017). There are many factors as to which people contract Hepatitis B or C.

Many people live or are born into environments where Hepatitis is prevalent. Where people are

born into place or society, where they work, where they live, according to age all have risks of

becoming a victim to Hepatitis. HBV and HCV can be transmitted from mother to baby.

Socioeconomic status has much to do with the contraction of Hepatitis as it determines the

quality of life a person may live. People who live with HBV, HCV, and or HIV are more likely

to have experienced homelessness, unemployment, substance abuse, and incarceration. When

related to HIV, Hepatitis C is mainly spread through recipients of blood and substance injections

(Rourke, Sobota, Tucker, Bekele, Gibson, Greene, Bacon, 2011). People can also be uneducated

about HBV or HCV, therefore do not take the precautions to prevent it, such as vaccinations.

Both Hepatitis B and C are mainly spread through bodily fluids, the most prevalent being blood,

but not limited to saliva, vaginal discharge, menstrual blood, breast milk, and semen

(Zuckerman, 1996). HBV, HCV is more common among drug abusers, homosexuals, and

prostitutes. In countries where prostitution is not illegal, the distribution of HBV and HCV is

more prevalent, as it is spread through sexual contact.

Hepatitis both B and C have challenges when it comes to lowering their rates around the

world, specifically acute Hepatitis C among the United States which has continued to gradually

increase between 2012-2016 (CDC, 2016). In 2012 the rate was 0.6 and in 2016 the rate

increased to 1.0 according to the CDC, Acute Hepatitis B rates between 2012-2016 have

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 12

remained steady according to the available data showing the 2015 rate at 1.1 and the 2016 rate at

1.0 according to the CDC website, meaning that the issue with Hepatitis B prevention may be at

a standstill in the United States. With the creation of high approved oral therapies that have the

opportunity to help cure some of the infected population of Hepatitis B and C these numbers

were predicted to have decreased over the years but there seems to be a variety of issues

preventing this from being accomplished. A major issue of Hepatitis B and C is the limited

amount of data, for example Appendix A shows that there are a total of 9 states that have

unavailable data on acute Hepatitis C incidence rates (CDC, 2016). Another distribution gap

within Hepatitis is the low awareness and low perceived risk among the public. This leads to a

missed opportunity of prevention methods. The public is not alone when it comes to low

awareness there are also many gaps of knowledge within health care providers. The lack of

awareness amongst healthcare providers lead to low vaccination rates as well as low testing and

diagnosis rates(Department of Health & Human Service, 2018) Lack of investments within

public health and the health system in addressing Hepatitis results in very little services of

prevention, identification and treatments of the virus B and C. The stigma and discrimination of

Hepatitis is another gap issue when it comes to trying to lower Hepatitis rates around the world.

Appendix B shows that Acute Hepatitis C incident rates are the highest among the American

Indian/ Alaska Native in which surpassed other ethnicities by nearly 2.5 by 100,000 population

this is a key gap among this ethnicity(CDC, 2016 ;Rempel, Uhanova, 2012) With consistent high

rates of Hep C within the American Indian/ Alaska Native community there needs to be a focus

on finding the determinants and reaching this community to minimize this spike in Hep C rates.

Part III: Proposed Solutions

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 13

In most cases, health is affected at home, communities, schools, or workplaces. Most

individuals know that it is good to get checkups and to not engage in risky behaviors. However,

there a lot of health key issues that are prevalent as a result of people still engaging in risky

behavior and not doing routine checkups. In addition, health is determined by the various

economic and social opportunities within an community. To be specific, many social

determinants associated with low coverage of Hepatitis B vaccines are a stem from a lack of

access to health care services, economic opportunities, education, and job opportunities. While at

the same time language barriers, literacy rates, low quality and training among “experts”, diverse

social norms, and socioeconomic conditions also play a role in low Hepatitis B vaccination rates

(Social Determinants of Health, n.d). Experts who work on health education/promotion can

address these social determinants by creating, updating, and using health assessments for their

communities, the state, or even the nation. They can also provide health classes or screenings to

the community so that the community can be knowledgeable about the resources offered to them.

For example, Garland TX currently offers children Hepatitis B vaccines at a low cost or even

free of cost (City of Garland Public Health Department, n.d). Garland also has their own health

assessment that is up to date so that they can keep track of what health issues are within the

community. The nurses also provide health education to the entire community, they offer back-

to-school clinics, flu vaccine clinics, and clinical services at different community events,

locations, and schools (Public Health Clinic, n.d). A current example of the metro area trying to

combat low Hepatitis B vaccines as well as Hepatitis C is displayed through The Dallas-Fort

Worth Hepatitis B Free Project (DFW HEPB Free) (Hep B, n.d). They are hosting two “Hepatitis

B & C Screenings”, one on November 10th, 2018, and the other one on December 8th, 2018. In

addition to their health screening event if a person tests positive for either Hepatitis they are

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 14

referred to a liver doctor in the DFW area which provides additional resources for the individuals

in the community.

Model Programs

The program ENCORE by Rhode Island public health department is a successful

program that has limited the spread of Hepatitis C (HCV). The purpose of the ENCORE program

is to reduce HCV and HIV rates for people who inject drugs (PWID). The term ENCORE stands

for the 5 components of the program; Educate, Needle Exchange, Counseling, Outreach, and

Referrals. As of 2005, ENCORE is Rhode Island’s only free needle exchange program. Evidence

shows that needle exchange programs are effective in reducing incidences of HIV, however,

there is limited evidence showing the effectiveness needle exchange programs have on reducing

new cases of HCV (Joseph, Kofman, Larney, & Fitzgerald, 2014). Joseph et al. (2014) asserts

that a needle exchange component of a HCV reduction program is an integral part of the

intervention.

Initially during the implementation of the program there was public opposition towards a

pilot needle exchange program within Rhode Island. In order to get around public opposition the

Rhode Island Department of Health (RIDH) teamed up with community-based AIDS

organization to coordinate with. By doing so, the RIDH attached the problem of AIDS to their

cause, in order to receive public support for their project.

Participants for the program were recruited via referrals from substance abuse treatment

facilities, the street outreach, or by word of mouth (Joseph et al., 2014). The program currently

has three main facilities and street-based exchange units and operates in over five cities, cities

that are comparable to Garland. Services are only provided to clients over the age of 18 and are

provided anonymously. According to Joseph et al. (2014), tools that are supplied to clients

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 15

include: new syringes, cookers, cotton swabs, sterile water, tourniquets, biohazard sharp

containers, and antibiotic ointments. Training that is provided to employees included; Harm

Reduction 101 provided by the Drug Policy Alliance, safety guidelines in handling and disposing

used syringes, HIV and HCV basics and preventions, and cultural competency training. Other

Services that are provided by ENCORE include free HCV and HIV testing, free male and female

condoms, and hygiene packs.

Garland Public Health Department can benefit from this program in a variety of ways.

First would be to notice the key takeaways from this program, as according to the pre-enrollment

interview of clients, one of the largest contributing factors to the spread of HCV was related to

lack of HCV testing as more than half of the ENCORE clients reported prior exposure to HCV.

Meaning, that if Garland Public Health Department does not have the means or the desire to

implement the entirety of this program, they may have some success in implementing a program

that increasing accessibility to HCV testing. However, if GPH does wish to implement this

program, they may be able to adopt the same methods in jump starting the program by pairing up

with a local AIDS organization in order to gain public support. GPH may also be able to adopt or

adapt the employee educational components of training employees on how to handle used

needles, while also taking advantage of the general cultural competency training for those who

interacted with people who inject drugs.

Although Hepatitis B is not experiencing a drastic up rise in the U.S and has remained

steady, there is plenty of room to lower rates especially since Hep. B is preventable, and in most

cases treatable. The “B Positive” intervention, a multi-pronged and economic modeling

intervention put together by “Cancer Council New South Wales”, a local cancer charity in

Australia in order to reduce the incidence of Hep. B liver cancer (Robotin, Kansil, Porwal,

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 16

Penman, & George, 2014). The goals of the “B Positive” program is to reduce Hepatitis B-

related health disparities specifically among the migrant population by completing a community-

based screening, providing community to care of Hep. B, increasing knowledge and awareness

and surveillance. The program stakeholders included: local practitioners, Cancer Council New

South, Divisions of General Practice, Millennium Institute in Westmead, New South Cancer

Institut, New South Wales Department, Storr Liver Unit, Sydney Medical Foundation of

University of Sydney, National Health and Medical Research Council of Australia. All

contributed to the programs implementation or contributed to the funding of the program.

This three-phase program began in 2007 and took place in Sydney Australia. Phase 1

used economic-modeling to investigate the possible success of the program, the screening and

treatment algorithm for Hep B was put together, along with the desired data that needed to be

collected from the program. Phase 2, stakeholders were confirmed and education testing,

prevention, and treatment of Hep B for local practitioners and the community were provided.

Phase 3 included the changing of the monitoring and evaluation tools after consultation from the

stakeholders. The “B Positive” program involved stakeholders as well as community members

when creating and evaluating the program. Practitioners that were involved were given

incentives to increase participation. The program included a screening and treatment algorithm

that was used to categorize the participant’s severity by low-risk, intermediate, and high risk

which is demonstrated in Appendix C. At enrollment, participants were screened, if they did not

have the virus they were given the vaccination. Those who were positive were separated by

severity with all of the …

Research Article

Testing a Model of How a Sexual Assault
Resistance Education Program for
Women Reduces Sexual Assaults

Charlene Y. Senn
1,2

, Misha Eliasziw
3
, Karen L. Hobden

1
, Paula C. Barata

4
,

H. Lorraine Radtke
5
, Wilfreda E. Thurston

6
, and Ian R. Newby-Clark

4

Abstract
The Enhanced Assess, Acknowledge, Act (EAAA) program has been shown to reduce sexual assaults experienced by university
students who identify as women. Prevention researchers emphasize testing theory-based mechanisms once positive outcomes
related to effectiveness are established. We assessed the process by which EAAA’s positive outcomes are achieved in a sample of
857 first year university students. EAAA’s goals are to increase risk detection in social interactions, decrease obstacles to risk
detection or resistance with known men, and increase women’s use of effective self-defense. We used chained multiple mediator
modeling to assess the combined effects of the primary mediators (risk detection, direct resistance, and self-defense self-efficacy)
while simultaneously assessing the interrelationships among the secondary mediators (perception of personal risk, belief in the
myth of female precipitation, and general rape myth acceptance). The hypothesized multiple mediation model with three primary
mediators met the criterion for full mediation of the intervention effects. Together, the mediators accounted for 95% and 76% of
the reductions in completed and attempted rape, respectively, demonstrating full mediation. The hypothesized secondary
mediators were important in achieving improvements in personal and situational risk detection. The findings strongly support the
benefit of cognitive ecological theory and the Assess, Acknowledge, Act conceptualization underlying EAAA. This evidence can
be used by administrators and staff responsible for prevention policy and practice on campuses to defend the implementation of
theoretically grounded, evidence-based prevention programs. Online slides for instructors who want to use this article for teaching are
available on PWQ’s website at http://journals.sagepub.com/doi/suppl/10.1177/0361684320962561

Keywords
sexual assault, sexual violence, prevention, resistance, women

For at least 40 years, people and communities affiliated with

feminist, health, and educational organizations and institu-

tions have been working to prevent sexual assault (e.g.,

Morrison et al., 2004; Women Against Rape, 1980), and since

the early 2000s, there has been increased interest in

evidence-based program development and evaluation to rig-

orously assess interventions’ successes and failures. Much of

this work has been accomplished on university campuses.

A number of qualitative and quantitative review articles and

meta-analyses have summarized the state of the field and

made recommendations for promising directions for aca-

demics and practitioners (Basile et al., 2016; DeGue et al.,

2012; DeGue et al., 2014; Ellsberg et al., 2015; Gidycz et al.,

2002; Lonsway et al., 2009; Schewe, 2002). As well, promi-

nent researchers have called for resources to be focused on

evidence-based, theory-driven, effective programs within a

comprehensive approach to sexual violence prevention

(e.g., Banyard, 2013; Banyard & Potter, 2017; Orchowski

et al., 2010; Orchowski et al., 2018). This approach includes,

and extends beyond, student programming to changing entire

campuses and communities. Included in current recommen-

dations by a consortium of independent sexual violence pre-

vention researchers and the Centers for Disease Control are

bystander-based interventions for students of all genders,

resistance education for female students, and continued

development of programming for male students related to a

1 Department of Psychology, University of Windsor, Ontario, Canada
2 Women’s and Gender Studies Program, University of Windsor, Ontario,

Canada
3
Department of Public Health and Community Medicine, Tufts University,

Boston, MA, USA
4 Department of Psychology, University of Guelph, Ontario, Canada
5
Department of Psychology, University of Calgary, Alberta, Canada

6
Department of Community Health Sciences, University of Calgary, Alberta,

Canada

Corresponding Author:

Charlene Y. Senn, Department of Psychology, University of Windsor,

401 Sunset Avenue, Windsor, Ontario, Canada N9B 3P4.

Email: [email protected]

Psychology of Women Quarterly
2021, Vol. 45(1) 20–36
ª The Author(s) 2020

Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0361684320962561
journals.sagepub.com/home/pwq

bystander and social norms education (Basile et al., 2016;

Orchowski et al., 2018).

These opinions are strongly supported by the prevention

science literature (e.g., Nation et al., 2003), where it has long

been recommended that all prevention work be comprehen-

sive in having multiple interventions targeted for different

audiences within a system and use prevention best practices

(e.g., include opportunities for active interaction and appli-

cation of skills). Researchers in academia and public health

have also recommended improvements to evaluation research

in order to answer more precise questions about what

works and why (Banyard et al., 2014; DeGue et al., 2014;

Orchowski et al., 2018). Published standards for reporting

randomized and nonrandomized evaluation trials (Des Jarlais

et al., 2004; Schulz et al., 2010) and calls for better reporting

of interventions so that they can be understood and imple-

mented with findings replicated and improved upon by others

(e.g., Hoffmann et al., 2014; Pinnock et al., 2017) have also

emerged. Specifically, within the sexual violence prevention

field, researchers have argued for more rigorous studies that

would allow the testing of theory-based mechanisms once

positive outcomes related to their effectiveness are estab-

lished (e.g., Norris et al., 2018).

Salazar et al.’s (2019) recent analysis of the mechanisms

for change in the RealConsent program for university men is

a good example of such an analysis. While high attrition in

the follow-up period and the short duration of the positive

outcomes make the authors’ conclusions tentative, it is an

important first attempt to understand how a theory-based

sexual assault program works. To our knowledge, no studies

of sexual assault resistance education programs for university

women have assessed the process by which positive out-

comes are achieved (Senn et al., 2018), despite increasing

calls for such analyses (Hollander, 2018; Norris et al.,

2018). This is our goal.

The current article focuses on the first author’s

Enhanced Assess, Acknowledge, Act (EAAA) sexual

assault resistance education program, which is also known

as the Flip the Script
TM

program. EAAA is the only pro-

gram that in a randomized controlled trial (RCT) has been

shown to substantially reduce the sexual assaults that

women university students experienced over the subsequent

year (i.e., 50% reduction in attempted and completed
rape as well as reductions in other forms of sexual assault;

Senn et al., 2015). In fact, positive outcomes occur for at

least 2 years (Senn et al., 2017). A few empowerment

self-defense or risk reduction programs for women have

also demonstrated positive sexual assault outcomes. Specif-

ically, assessment of a 30-hour empowerment self-defense

program using a quasi-experimental design indicated signif-

icant reductions in sexual victimization for college women

for at least 1 year after participating in the program

(Hollander, 2014). A shorter, 7.5-hour risk reduction pro-

gram, evaluated using an experimental design, also led to

significant reductions in sexual victimization for subsets of

college women who participated in the program for a few

months (e.g., Gidycz et al., 2006; for a review of theory and

evidence for the type of program more generally, see

Orchowski & Gidycz, 2018). Thus, the benefits of under-

standing how these types of programs work extend beyond

a single program.

We were ideally situated to provide answers to this ques-

tion for many reasons. EAAA was evaluated in a multi-site

RCT with a large sample of 893 women students. There were

prospective data for women who did and did not take the

program, which included information about their back-

grounds and baseline scores on key variables. Further, we

followed them with assessments across more than a year with

high retention. Data collection included measurement of

potential mediators (mechanisms) 1-week post-intervention

and sexual assaults in the 12 months following that assess-

ment, which allowed for prospective temporal conclusions

regarding the mediators’ influence on post-program sexual

assault outcomes. As such, we were able to go beyond the

goal of finding out whether a program works to decrease

sexual victimization to how and why the program works. This

article describes a chained multiple mediation analysis,

which allowed us to assess the joint processes that produced

treatment outcomes. Through this analysis, we tested the

model of theoretically postulated mechanisms that drove the

development of the sexual assault resistance education pro-

gram. This is important for scientific and practical reasons

and has not previously been reported.

Theoretical and Empirical Foundation of EAAA

The EAAA program’s name acknowledges that it is based in

large part on the recommendations of Rozee and Koss (2001),

who synthesized decades of theory and rape research to sug-

gest a theoretically driven, evidence-based approach for sex-

ual violence prevention programming for young women.
1

They named this conceptualization “Assess, Acknowledge,

Act (AAA).” AAA was conceived on a bedrock of theory and

feminist research, particularly the cognitive ecological theory

proposed by Norris and Nurius (e.g., Norris et al., 1996;

Nurius & Norris, 1996) and the evidence of effective sexual

assault resistance strategies provided by Ullman (1997, 1998)

as well as a long tradition of feminist grassroots activism,

advocacy, theory, and self-defense practice (e.g., Bateman,

1978; Rozee et al., 1991; Wen-Do Women’s Self Defence,

n.d.; Women Against Rape, 1980). These underpinnings are

described in more detail elsewhere (Rozee et al., 1991; Rozee

& Koss, 2001; Senn et al., 2015; Senn et al., 2017). Rozee and

Koss’s proposed approach challenged past practices that were

not theory- or evidence-based, tended to focus primarily on

stranger sexual assault, and were largely ineffective (see

Morrison et al., 2004, for review of research evaluations of

programs conducted prior to this period). They argued that,

given the continuing alarming rates of sexual violence expe-

rienced by young women, the complete lack of success in

Senn et al. 21

reducing perpetration, and the substantial evidence base

available, providing women with knowledge and skills to

prepare them to detect risk, overcome emotional obstacles

to acknowledging the danger, and to resist sexual coercion

or sexual assault by men they know was imperative.

In response to this call, the first author designed a resis-

tance program curriculum to bring the conceptualized pro-

gram into reality. The term “resistance” is used in its broadest

sense to represent any attitudes women hold or actions they

take to refuse to accept or comply with social norms or expec-

tations that (a) support woman-blaming explanations for sex-

ual violence, (b) undergird societal tolerance of rape culture,

and/or (c) undermine women’s sexual autonomy. Resistance

includes defensive actions women take to protect their

boundaries, their body, and sexual integrity in interactions

with others. For survivors, resistance also includes the refusal

to accept sexual violence perpetrators’ views of them and

what occurred. EAAA reduces the sexual victimization

women experience while holding perpetrators entirely

responsible for their actions (Senn et al., 2015; Senn et al.,

2017) and interrupts messages often perpetuated in a rape

culture (Radtke et al., 2020). The program has a gendered

framing, focusing on sexual assaults perpetrated by men who

are known to young women (i.e., it uses a broad definition of

acquaintances that includes family members, intimate part-

ners, classmates, neighbors, and other men they know).

EAAA is designed and implemented to recognize the diver-

sity of experiences of participants who self-identify as

women in terms of prior sexual victimization history (i.e.,

that there will always be survivors in the room), demo-

graphics (e.g., race, class, religion), abilities (e.g., physical

ability, ability to be loud), sexual identity (i.e., explicitly

acknowledges heterosexual, bisexual, lesbian, and asexual

identities), and relationship and sexual experience.

The goals of the program are to (a) increase the likelihood

that empirically supported risk cues in social contexts (e.g.,

isolation, alcohol) and revealed in men’s behavior (e.g., per-

sistence, sexual entitlement) will be detected by women as

early as possible in social interactions, (b) decrease women’s

emotional or cognitive obstacles to risk detection or resistance

in situations involving known men, and (c) increase the like-

lihood that women will use defensive actions (e.g., leaving

when possible, forceful verbal and physical self defense) that

are most likely to lead to better outcomes (i.e., reduced severity

of the sexual assault, interruption of rape; Tark & Kleck, 2014;

Ullman, 1997) when threats are detected.

To accomplish these goals, the curriculum has four 3-hour

units. Unit 1, Assess, is designed to help women identify

situations and behaviors that signal a higher risk for sexual

violence. Unit 2, Acknowledge, was created to assist women

to overcome emotional barriers to acknowledging the threat

from men they know and provides practice in identifying and

resisting verbal coercion. Unit 3, Act, provides empowerment

verbal and physical self-defense training (based on Wen-Do

Women’s Self Defence) focused on effective strategies for

resisting common acquaintance tactics. Unit 4, Relationships

and Sexuality, adapted from the Our Whole Lives curriculum

(Goldfarb & Casparian, 2000; Kimball & Frediani, 2000),

offers high quality sexual information and a context for

exploring and talking about their own sexual desires and

relationship values. In other words, EAAA gives women

evidence-based information, skills, and practice within a pos-

itive sexuality framework to empower them to more quickly

identify a sexually coercive situation involving a male

acquaintance as dangerous and get out or use forceful resis-

tance if necessary. More detail on the program content is

provided elsewhere (Radtke et al., 2020; Senn et al., 2013).

The key findings for the registered, multisite (three uni-

versities), RCT (SARE Trial) evaluating EAAA have been

published elsewhere (Senn et al., 2015; Senn et al., 2017) but

are briefly summarized here. The reductions in sexual vio-

lence for young women who were assigned to the EAAA

program (Senn et al., 2015) were accompanied by positive

program effects on a number of other important outcomes

(Senn et al., 2017) measured 1 week after participation and,

for most, at 6 and 12 months (and up to 24 months). We

measured these additional outcomes because they were

hypothesized mediators; that is, they encompassed most of

the theoretical mechanisms targeted by the AAA approach to

increase women’s safety without limiting their freedom. In

this study, we go beyond our previous analysis of the pro-

gram’s positive effects on these outcomes to test whether,

together, they are mediators of the reductions in the sexual

assault across time. In other words, do improved scores on

these outcomes at post-test (1-week after participation) com-

bine to account for the reductions in sexual assault experi-

enced from that point until the 12-month follow-up?

In the following section, we explain the hypothesized mul-

tiple mediation model (Figure 1) and, specifically, the theory

behind our expectations that the possible mediators would

combine to lead to reductions in sexual assault. Given that

the model was built based on the best evidence available,

there are no competing theoretical models to be tested; rather,

we are assessing whether the model works as a whole and

whether the relationships for any hypothesized elements are

not supported. Any variable that is hypothesized to explain a

portion of the EAAA program’s effect on sexual assault vic-

timization through a direct link to the outcome, we refer to as

a “primary mediator.” These are the primary elements of the

AAA model. Any variable that is hypothesized to have an

indirect link to the outcome through its influence on a pri-

mary mediator, we refer to as a “secondary mediator.”

Mediators of Reductions in Sexual Assault

Risk detection is a key element of the primary appraisal pro-

cess outlined in Nurius and Norris’s (1996) cognitive ecolo-

gical model and hence also the theoretical underpinning of

the first unit (Assess). The program is designed to undermine

socialization processes about “stranger risk” that direct

22 Psychology of Women Quarterly 45(1)

women to use a wide range of precautionary strategies

involving restrictions on their freedom without protecting

them from sexual violence (e.g., not walking alone at night;

Gordon & Riger, 1989; Stanko, 1990). The curriculum pro-

vides information and practice in identifying empirically sup-

ported risk factors for acquaintance sexual assault and

encourages women to trust their own instincts and judgments

when they identify risk cues in social situations. Based on

past research (e.g., Marx et al., 2001) and theory, better risk

detection (i.e., more accurate, earlier) at post-test, which was

a positive outcome of participation in EAAA (Senn et al., 2017),

should be directly linked to reductions in sexual victimization

in the subsequent 12 months and hence a primary mediator.

The EAAA program also addresses obstacles women

encounter at secondary appraisal stages (i.e., after risk has

been detected and when they are making “determinations of

coping resources, options, and outcomes”; Nurius & Norris,

1996, p. 130) in interactions with coercive men. Content and

activities in the second unit of the EAAA program focus on

strengthening women’s belief in their own sexual and rela-

tionship rights and undermine the belief that relationships

must be preserved at all costs. Young women are provided

with a context in which they can practice asserting their needs

and confronting common verbal and physical acquaintance

perpetrator tactics. In the third unit, facilitators present

evidence that direct forceful verbal and physical resistance

strategies and leaving lead to better outcomes in sexual

assault situations. In any given situation, participants are then

able to select their own toolbox of effective strategies from

among the many techniques taught. Nurius and Norris (1996)

summarize the goal of intervention to improve the situation

for women as follows:

Thus, the extent to which a woman is prepared to see assertive

behavior as a reasonable resistance stance and is assisted to gain

assertiveness skills and habits may have an indirect effect

mediated through a woman’s cognitive structures operating at

the time of the coercion. (p. 122, emphasis added)

Thus, both increases in self-defense self-efficacy, that is,

confidence that she could assert and defend herself across a

range of situations, and the ability and willingness to use more

direct resistance strategies in a hypothetical situation should be

related to one another and be primary mediators of the EAAA

program’s effects on sexual assault. Notably, in our previously

published analysis, we found both variables to be positively

impacted by program participation (Senn et al., 2017).

Based on the research evidence (e.g., Vitek et al., 2018),

risk detection was a primary mediator expected to be influ-

enced by secondary mediators (i.e., other specific attitudes

Figure 1. Hypothesized Multiple Mediation Model.

Note. Primary mediators are variables that are hypothesized to explain a portion of the Enhanced Assess, Acknowledge, Act program’s
(Group) effect on sexual assault victimization and have a direct link to the outcome (Sexual Assault). Secondary mediators are variables
that are hypothesized not to have a direct link to the outcome themselves but rather are expected to influence the primary mediators.
OwnRisk ¼ perceived risk of acquaintance rape; FPrecip ¼ belief in female precipitation of rape; RapeMyth ¼ rape myth acceptance;
RiskDet ¼ risk detection; DResist ¼ direct resistance; SDSE ¼ self-defense self-efficacy.

Senn et al. 23

and beliefs directly affected by the EAAA program). Three

hypothesized secondary mediators that were included in the

RCT were (a) women’s perceptions of their own general risk

of sexual assault, (b) acceptance of rape myths, and (c) the

belief that women play a causal role in sexual assault. All

were affected in the desired direction by program participa-

tion at the post-test, and these effects were maintained for at

least 2 years (Senn et al., 2017). These attitudes and behaviors

were not expected to have direct effects on sexual victimiza-

tion (i.e., changes in attitudes and beliefs alone have never

been sufficient to reduce the incidence of sexual assault;

Morrison et al., 2004). Instead, they were included in the trial

precisely because any improvements in these attitudes and

beliefs were hypothesized to facilitate risk detection. Thus,

we hypothesized that in combination these three factors

would be related to each other and would lead to better out-

comes in sexual assault through their relationships with risk

detection. Each is described in more detail below.

An optimism bias, which is the belief that while others are

at risk of experiencing a particular negative outcome, we are

not ourselves at risk, can in some circumstances be protective

(e.g., against depression; Conversano et al., 2010). However,

“unrealistic optimism” (Nurius & Norris, 1996) is an obstacle

to detecting acquaintance sexual assault risk (Norris et al.,

1996). Unsurprisingly, an optimism bias is present in women’s

estimates of their sexual assault risk (Gidycz et al., 2006). The

problematic piece of this perception is not the judgment of risk

for other women who are similar to us—this tends to be rela-

tively accurate (i.e., there is a possibility the bad event could

occur)—but rather judgment for one’s self (i.e., it is unlikely to

occur to me). The RCT analyses showed that the EAAA pro-

gram increased women’s perceptions of their own general risk

of sexual assault (Senn et al., 2017).
2

We hypothesized that this

should be related to women’s risk detection in specific situa-

tions by making “danger cues” relevant and worthy of attention

as they arose in those situations.

Similarly and relatedly, commonly held myths about the

characteristics of rape, rape perpetrators, and rape victims

(e.g., that rape is most likely to be perpetrated by strangers)

may be psychologically self-protective (e.g., “only women

who do X, wear Y, or go to Z are raped and I would never

do those things”) but may also have negative consequences,

such as impairing perceptions of one’s own risk of sexual

assault (e.g., Bohner et al., 2009; Yeater et al., 2010).

Victim-blaming beliefs are thought to be particularly perni-

cious in this regard. We therefore hypothesized that the pro-

gram’s positive effects in reducing rape myths in general and

the specific incorrect belief that women cause rape by their

own actions (Senn et al., 2017) would be related to improved

risk perception. Further, we expected that reducing the belief

that women cause rape by their own actions, a belief that

when applied to the self can give one false sense of security

(e.g., If I don’t go there or do that, then it can’t happen to me),

would be related to increases in women’s perceptions of their

own personal risk because reducing these beliefs makes sali-

ent that any woman is potentially at risk.

The theory and evidence upon which EAAA was built

emerges from many different, primarily correlational studies

often focused on a single domain (e.g., risk perception or

self-defense strategies) that were related to positive outcomes

(Norris et al., 2018; Tark & Kleck, 2014; Vitek et al., 2018).

Although changes in individual domains can occur and can be

important in their own right (e.g., more high-quality informa-

tion about a phenomenon or more skill is usually better than

less), our focus is on how the combined domains of the whole

model are implicated in achieving the reductions in attempted

and completed rape
3

affected through participation in the

EAAA program.

We focused on the 1-year data from the SARE Trial RCT,

because a drop in effect sizes after 1 year and a decrease in

the sample size across 2 years reduced our ability to test these

relationships beyond this period.
4

We assessed mediation

prospectively using participants’ scores on the hypothesized

primary and secondary mediators that were measured 1-week

post-program and their experience of sexual assault in the

subsequent 12 months after the post-test. Given our large

sample size, we were able to test the mediation effects for

completed and attempted rape separately. It should be noted

that rape is broadly and behaviorally defined to include oral,

vaginal, and anal penetration by a man without the woman’s

consent through a range of perpetrator tactics including

threats, force, and taking advantage of or inducing women’s

incapacitation from drugs or alcohol (Koss et al., 2007).

Method

Participants

Eight hundred and ninety-three first-year undergraduate stu-

dents who identified as women were recruited at three uni-

versities and enrolled in the SARE RCT. The full trial

protocol has been published (Senn et al., 2013), as have the

1- and 2-year primary and secondary outcomes (Senn et al.,

2015; Senn et al., 2017). The prospective analysis in the

present study required valid responses on potential mediators

measured post-intervention at a 1-week post-test and sexual

assault outcomes measured beyond that point. A total of 871

(97.5%) women completed the 1-week post-program survey.
Among these, 857 (98.4%) completed one or both of the
6- and 12-month follow-up surveys (i.e., not lost to

follow-up) and were included in this study. The 36 partici-

pants who were excluded were not characteristically different

from the 857 who were retained in the present study (all ps

ns). The average age of the included women was approxi-

mately 19 years, almost all were heterosexual or bisexual,

one-quarter were women of color, one-half lived in a univer-

sity residence, one-third had previous self-defense training,

and approximately one-quarter had experienced the previous

victimization (see Table 1).

24 Psychology of Women Quarterly 45(1)

Intervention

EAAA. This small group (�20 participants) intervention was
led by pairs of highly trained, slightly older peer (<30 years)

women facilitators. Women attended an average of 3.62 (SD

¼ 0.82) of four sessions, with most (91%) attending three or
four sessions. Curriculum fidelity was high (average 94%) as
measured by the assessment of randomly selected audio

recordings.

Control. To match the standard of care common to all univer-
sity campuses at the time, brochures on sexual assault were

available for participants to take and read, with a friendly and

knowledgeable person available to answer any questions that

arose about sexual assault or available resources from the

group of participants. Brochures chosen were specific to the

campuses but had common elements, including the provision

of general sexual assault information, date rape drug facts,

legal and medical information for survivors, and local

resources.

Procedure

The detailed RCT protocol and procedures are published else-

where (Senn et al., 2013), but we provide a brief overview

here. Participants were recruited through a variety of means,

including posters, emails, tabling, and advertising in research

participant pools. Interested students made contact by phone or

email, were screened by a research assistant and given a

detailed explanation of the purpose of the study, the longitu-

dinal survey process and timing, and the randomization pro-

cedure. They then chose the timing of the baseline and EAAA

intervention sessions that matched their schedule without yet

knowing to which condition they would be randomly assigned.

All participants attended a baseline session to complete sur-

veys in a computer lab, were …

MAJOR ARTICLE

Facial emotion identification and sexual assault risk detection among college
student sexual assault victims and nonvictims

Alexander J. Melkonian, MAa, Lindsay S. Ham, PhDa, Ana J. Bridges, PhDa, and Jessica L. Fugitt, PhDb

aDepartment of Psychological Science, University of Arkansas, Fayetteville, Arkansas, USA; bG.V. (Sonny) Montgomery VA Medical Center,
Jackson, Mississippi, USA

ARTICLE HISTORY
Received 10 June 2016
Revised 7 March 2017
Accepted 19 April 2017

ABSTRACT
Objective: High rates of sexual victimization among college students necessitate further study of
factors associated with sexual assault risk detection. The present study examined how social
information processing relates to sexual assault risk detection as a function of sexual assault
victimization history. Participants: 225 undergraduates (Mage D 19.12, SD D 1.44; 66% women).
Methods: Participants completed an online questionnaire assessing victimization history, an
emotion identification task, and a sexual assault risk detection task between June 2013 and May
2014. Results: Emotion identification moderated the association between victimization history and
risk detection such that sexual assault survivors with lower emotion identification accuracy also
reported the least risk in a sexual assault vignette. Conclusions: Findings suggest that differences in
social information processing, specifically recognition of others’ emotions, are associated with
sexual assault risk detection. College prevention programs could incorporate emotional awareness
strategies, particularly for men and women who are sexual assault survivors.

KEYWORDS
Emotion recognition; risk
detection; sexual assault
prevention; social
information processing

Sexual assault in college presents a major public health
concern. Although many college sexual assault prevention
programs have been developed and implemented, college
sexual assault rates have remained consistently high.1

Sexual assault is defined as unwanted sexual contact
including but not limited to attempted and completed
rape, incapacitated sexual contact obtained through
alcohol or drugs, and sexual contact obtained through
physical force or coercion. Studies suggest rates of sexual
assault for undergraduates while enrolled in college range
between 19% and 35% for women (as many as 43% may
experience sexual victimization in their lifetime), and 5%
and 15% (23% lifetime rates) for men.2–5 Sexual victimiza-
tion is associated with many negative outcomes, including
elevated rates of depression, anxiety, alcohol use disorders,
post-traumatic stress disorder, and revictimization com-
pared to nonvictims.6–8 Among college student survivors
of sexual assault, 11% changed their residence, 8%
dropped classes, and 3% changed universities following
the assault.9 Although the blame for sexual assault lies
solely on the perpetrator and therefore prevention efforts
should target perpetrators’ behaviors, targeting bystanders
and potential victims could also help reduce incidence
rates of sexual assault. Research to identify relevant factors
that contribute to risk for sexual assault can be used to
empirically inform prevention efforts for potential victims

or bystanders who may have the opportunity to intervene
in a sexual assault.

Studies that empirically examine individual factors
relating to risk for sexual assault frequently use vignette
methodology, in which participants read or listen to a
scenario describing a social interaction and then respond
to questions assessing the identification and interpreta-
tion of risk in potentially hazardous social scenarios.10–12

Such methodology is based on the premise that reduced
identification of risk in a hypothetical scenario is associ-
ated with greater risk for an unwanted sexual experience
based on the lack of recognition of potential harm to
oneself or others. This methodology is supported by pro-
spective studies that have found a relationship between
lower risk detection and future sexual assault experien-
ces: participants who were delayed in their recognition of
sexual assault risk in a vignette were significantly more
likely to experience a new instance of sexual assault at a
follow-up compared to participants who recognized risk
more quickly.13,14 However, social situations are highly
complex and social reactions may not be fully captured
by a written or audio vignette.

According to social information processing theory,15

in order to respond effectively in a situation such as a
potential sexual assault scenario, one must first notice
and accurately interpret relevant social and situational

CONTACT Alexander J. Melkonian, MA [email protected] University of Arkansas, Fayetteville, AR 72701, USA.
© 2017 Taylor & Francis

JOURNAL OF AMERICAN COLLEGE HEALTH
2017, VOL. 65, NO. 7, 466–473
https://doi.org/10.1080/07448481.2017.1341897

cues, which may include direct verbal conversation or
nonverbal communication. Social information process-
ing theory provides a helpful framework for how an indi-
vidual’s or a bystander’s ability to identify relevant social
cues, such as emotional expressions in others, could con-
tribute to recognition of risk in a potential sexual assault
situation. Given the importance of noticing and inter-
preting situational cues as dangerous is an important
step of the bystander intervention process,16 the identifi-
cation of additional factors related to how potential vic-
tims or bystanders interpret social information in risky
scenarios may help to enhance our understanding of risk
for sexual assault.

Emotion identification

Many researchers study perceptions of social scenarios
using written or audio recorded descriptions of situa-
tions; however, these studies may not capture all relevant
components of communication. Human communication
is a complex process with important pieces of informa-
tion conveyed through verbal and nonverbal cues, such
as facial expressions. Nonverbal communication makes
up a critical component of meaning in human interac-
tion.17 Specifically in sexual interactions, important
information related to consent is likely to be communi-
cated nonverbally.18 Thus, studying how individuals
uniquely interpret nonverbal expression and the implica-
tions of misinterpretation of cues in a sexual situation is
a critical component of understanding risk perception,
relevant for potential victims or bystanders.

Not everyone interprets cues in the same way, as vari-
ation in emotion recognition is biologically based and
refined in early childhood.19 Accurate understanding of
visual emotional expression is critical to interpersonal
relationships.20 Indeed, researchers find that difficulties
in facial emotion recognition are related to difficulties
with accurate interpretation of social communication
and increased problems in social relationships.21,22

Though no known published studies have directly
examined the association between nonverbal emotional
cue recognition and sexual assault risk perception,
Walsh, DiLillo, and Messman-Moore23 examined the
role of emotion dysregulation (ie, lack of awareness of
one’s emotions, lack of acceptance of one’s emotions,
and limited emotion regulation strategies) in sexual
assault risk perception among college women. Results
suggest that self-reported difficulties with awareness and
differentiation of one’s own emotions were significantly
related to reduced risk detection in a sexual assault
vignette. Given the observed connection between identi-
fying one’s own emotions and sexual assault risk detec-
tion,23 it is possible that impairment in identifying the

emotions of others may also relate to difficulty detecting
sexual assault risk.

Victimization history

Sexual victimization is associated with subsequent vic-
timization.8 However, results of studies examining the
association between sexual assault victimization history
and sexual assault risk detection have been mixed. Marx
and Soler-Baillo11 and Soler-Baillo et al24 found college
women who had experienced sexual assault displayed
differences in responding to a sexual assault vignette,
taking longer to identify risk compared to nonvictims.
However, other researchers have found no such differen-
ces in sexual assault risk perception based on victimiza-
tion history.25,26

There is evidence that emotion-related variables could
play a role in the association between sexual victimiza-
tion history and sexual assault risk detection. In the pre-
viously mentioned study by Walsh and colleagues,23 the
researchers found several facets of emotion dysregula-
tion, including identification of one’s own emotions, to
be related to sexual assault victimization history and sex-
ual assault risk detection in a vignette. However, no
known research has examined whether accuracy in
detecting and differentiating others’ emotional expres-
sions relates to sexual assault risk detection. Sexual
assault survivors may be less accurate at gauging risk in
social situations if they are less accurate in processing
emotions in others. Social situations, including those
which involve sexual assault risk detection, represent a
complex interplay of environmental, psychological, and
sociocultural considerations that may not be fully cap-
tured in a controlled laboratory study. Thus, the present
study represents a first step in understanding the rela-
tionship between victimization history, risk detection,
and a facet of social information processing. The current
study aims to contribute to the literature on the preven-
tion of sexual assault by incorporating facial emotion
recognition as a moderator between victimization history
and risk detection.

Current study

To inform prevention efforts to reduce sexual assault
incidence, we aimed to enhance our understanding of
risk for sexual assault by incorporating facial emotion
interpretation as an aspect of social information
processing ability, which could relate to risk detection
for both male and female college students. While sev-
eral studies have examined the relationship of prior
sexual victimization and risk perception (see Gidycz
et al1 for review) and Walsh et al23 examined emotion

JOURNAL OF AMERICAN COLLEGE HEALTH 467

dysregulation (one’s own emotions), victimization his-
tory, and sexual assault risk perception, no known
study to date has also examined additional facets of
nonverbal social communication ability. Previous
mixed findings related to sexual victimization history
and sexual assault risk detection could be related to a
failure to consider how one processes others’ emo-
tions.27 Therefore, the current study focuses on whether
emotion recognition moderates the relationship
between sexual assault victimization history and risk
detection. First, we expected that ratings of risk detec-
tion in a hypothetical sexual assault scenario would be
lower for those who have been a victim of sexual assault
(since age 14) compared to nonvictims. Further, it was
hypothesized that the association between victimization
history and risk detection would be moderated by facial
emotional expression recognition such that those who
had experienced previous victimization and were less
accurate in identifying others’ emotions would have the
most difficulty detecting risk in the sexual assault sce-
nario. Though most previous work focused on women,
men are also victimized and both men and women may
be in a position to intervene as a bystander in a sexual
assault scenario.28 As such, this study adds to the litera-
ture by examining both men and women.

Methods

Participants and general procedures

Participants were 225 college students aged 18–28 years
(Mage D 19.12, SD D 1.44; 66% women; 86% Caucasian)
recruited from a large southern university’s undergradu-
ate psychology courses in 2013–2014. See Table 1 for a
demographic summary. Participants provided anony-
mous responses on an online study administered
through Qualtrics for course credit. Participants were
presented with informed consent electronically. Upon
providing an electronic signature to indicate informed
consent, participants completed self-report question-
naires, an emotion identification task (ie, identify one of
five emotions depicted in facial images), and a sexual
assault vignette task (ie, reading a vignette ending in sex-
ual assault followed by providing ratings of their inter-
pretation of the behavior in the scenario) in randomized
order. Participants were provided with debriefing infor-
mation online. All procedures were approved by the Uni-
versity’s Institutional Review Board.

Measures and stimuli

Demographics
Participants reported age, gender, race, and ethnicity.

Sexual victimization history
Sexual victimization history was assessed using the Sex-
ual Experiences Survey—Short Form Victimization
(SES-SFV29). The SES-SFV is a commonly used brief
measure that includes items related to the occurrence
and frequency of multiple types of unwanted sexual
experiences since the age of 14 years. Previous versions
of the SES have displayed good reliability and validity.30

Participants were included in the victimization history
group based on scoring recommendations of the SES-
SFV if previous unwanted sexual contact was reported as
a result of force or coercion [n D 56 (25% of sample;
31% of women, 14% of men)] and were included in the
nonvictimization history group (n D 169) if no sexual
contact as a result of force or coercion was reported.

Emotion identification
Emotion recognition was assessed with a series of images
of male and female portrayals of one of four facial emo-
tions (anger, happiness, sadness, and disgust) or no emo-
tion. Although surprise and fear are also outlined as
universally identifiable emotions, we chose to exclude
these emotions as past research shows poor reliability in
identifying these expressions.31,32 Each image shown to
participants was a composite image based on Ekman and
Friesen’s33 facial stimuli created by combining multiple
images of varying strength of expression (ie, a face dis-
playing 50% emotion expression strength is a composite
image exactly halfway between no emotion being shown,
and 100% expression). Strength of expression was varied
to include 10 images each shown at 30%, 50%, and 70%
strength of expression to simulate the variability of emo-
tion expression in a social situation.31 Participants were
shown 30 total digital images (one male and one female
portrayal of 5 different expressions, shown at the three
strengths of expression) and asked to identify the emo-
tion being depicted in each by selecting their choice from
a list of possible responses (ie, angry, happy, sad, dis-
gusted, neutral). Overall accuracy scores were computed
based on the total number of correct identifications of
each emotion image (M D 21.11, SD D 3.34).

Sexual assault risk detection
Participants read a brief vignette used in prior research35

that portrays a situation involving unwanted sexual con-
tact between a male perpetrator and female victim. The
story follows a college-aged woman being introduced to
a man by a mutual friend with whom she gets along well.
As the gathering concludes, the woman agrees to return
to the man’s house to continue talking and have a drink.
The woman begins to kiss the man for a short time
period before deciding she would like to end the interac-
tion and asks the man to stop. The man ignores her

468 A. J. MELKONIAN ET AL.

request, and instead begins to engage in increasing levels
of sexual acts despite the lack of consent. Items were
selected based on previous vignette research to assess
participant perceptions regarding the scenario, including
responsibility of the man (reverse coded) and woman,34

approval of the man’s behavior (reverse coded),35 degree
of consent provided, the woman’s desire for sex,35 and
the degree to which the scenario could be considered a
rape.35 Each item was rated on a 7-point Likert-type
scale. A sum score was calculated to create an overall
index of risk perception, with higher scores reflecting
greater detection of risk (possible range D 6–42,
M D 30.36, SD D 4.8, Cronbach’s alpha D .68). Items
used were based on related research examining risk
detection in a sexual assault scenario26 and situational
rating25 scores to high degrees of reliability.

Results

Preliminary analyses

Data were examined for violations of assumptions for the
analyses conducted. There were no missing data (all par-
ticipants completed all study measures, despite having
the option to skip over items) and no violations of nor-
mality. Results of independent samples t-tests indicated
that there were no gender differences in vignette risk
detection rating sum scores [Mmen D 30.28, SD D 5.23;
Mwomen D 30.40, SD D 4.6; t(223) D 0.17, p D .87] or
emotion identification scores [Mmen D 20.63, SD D 3.41;
Mwomen D 21.35, SD D 3.30; t(223) D 1.50, p D .14]. As
shown in Table 1, victimization history groups did not
significantly differ in race and ethnicity, emotion identi-
fication scores, or sexual assault vignette rating scores.
Victimization groups differed by gender, with women
more likely to be victimized than men. Finally, emotion
identification scores and sexual assault vignette risk
detection ratings were significantly positively correlated,
r D .20, p < .01.

Moderation

The Hayes PROCESS macro36 was used to test emotion
identification as a moderator of the association between
victimization history and sexual assault risk detection.
The overall model including victimization history, emo-
tion identification, and their interaction accounted for a
significant amount of the variance in risk detection
scores, R2 D .063, F (3,222) D 4.96, p < .01. Main effects
of victimization history {B D 0.67 [95% confidence inter-
val (CI) D ¡0.77, 2.10], t D 0.91, p D .36} and emotion
identification score [B D 0.16 (95% CI D ¡0.61, 0.38),
t D 1.42, p D .16] on risk detection score were nonsignif-
icant. The victimization history X emotion identification
interaction [B D 0.47 (95% CI D 0.06, 0.89, t D 2.25,
p D .03)] accounted for significant variance in sexual
assault risk detection [DR2 D .022, p D .03]. As shown in
Figure 1, emotion identification moderated the associa-
tion between victimization history and sexual assault risk
detection such that individuals with a history of victimi-
zation showed a significant positive relationship between

Table 1. Demographic summary.

Total sample (N D 225) Victimization history (n D 56) No victimization history (n D 169)
Gender x2 (1, N D 225) D 8.45, p D 0.01
Male 76 (33.8%) 10 (17.9%) 66 (39.1%)
Female 149 (66.2%) 46 (82.1%) 103 (60.9%)

Race and ethnicity x2 (5, N D 225) D 5.37, p D 0.37
Caucasian (non-Hispanic) 194 (85.8%) 49 (87.5%) 144 (85.2%)
African American 5 (2.2%) 2 (3.6%) 3 (1.7%)
Hispanic/Latino 10 (4.4%) 0 (0%) 10 (5.9%)
Asian 6 (2.7%) 1 (1.8%) 5 (3.0%)
American Indian 5 (2.2%) 2 (3.6%) 3 (1.7%)
Other/not reported 5 (2.2%) 2 (3.6%) 4 (2.4%)

Age 19.12 (SD D 1.44) 19.14 (SD D 1.57) 19.12 (SD D 1.41) t(224) D ¡0.11, p D 0.91
Emotion identification score 21.11 (SD D 3.34) 20.80 (SD D 3.54) 21.21 (SD D 3.27) t(224) D 0.79, p D 0.43
Risk detection score 30.36 (SD D 4.83) 30.71 (SD D 5.51) 30.25 (SD D 4.60) t(224) D ¡0.62, p D 0.53

Figure 1. Sexual assault risk detection score by emotion identifi-
cation score and victimization group.

JOURNAL OF AMERICAN COLLEGE HEALTH 469

emotion identification and risk detection [B D 0.63 (95%
CI D 0.28, 0.99), t D 3.52, p < .01], whereas emotion
identification was not related to sexual assault risk detec-
tion in nonvictims [B D 0.16 (95% CI D ¡0.61, 0.38),
t D 1.42, p D .16]. Furthermore, this association was not
significantly moderated by gender [B D .74 (95%
CI D ¡0.26, 1.74), t D 1.42, p D .15].

Comment

The current study examined the role of nonverbal social
communication abilities in the association between sex-
ual victimization history and sexual assault risk detection
among college students, a population with high rates of
sexual assault.5 Results revealed that the association
between sexual victimization history and situational risk
detection was moderated by emotion identification accu-
racy for both men and women. Ability to identify emo-
tional expressions in others was positively related to
sexual assault risk detection for those with a victimiza-
tion history, but emotion identification accuracy was
unrelated to sexual assault risk detection for those with
no victimization history. Due to previously mixed find-
ings regarding the effects of victimization history on risk
detection,1 the present findings suggest an important
new avenue of study further examining the connection
between visual emotion processing and social situation
interpretation to better explain conditions under which
victimization history may be related to risk detection.
Extending previous work connecting emotion identifica-
tion related to one’s self and detection of sexual assault
risk,23 the present results suggest that identification of
others’ emotions may also be an important factor related
to risk detection.

Discussion

The results of the current study suggest that sexual
assault risk detection did not differ based on victimiza-
tion history alone. Although some researchers have
found a significant relationship between victimization
history and situational risk recognition,13,14,24 others
have not found support for differences by victimization
history.14,26 The present study revealed those who experi-
enced victimization and showed less accuracy in identify-
ing facial emotions also rated lower levels of risk in the
sexual assault scenario, suggesting that social informa-
tion processing may be an important variable related to
further understanding differences in detecting sexual
assault risk. Sexual assault survivors who are less accu-
rate in decoding nonverbal cues may also be more likely
to misidentify potential risk in social situations. Con-
versely, sexual assault survivors who are more accurate

may be more attuned to risk cues and therefore have
reduced risk for revictimization and a greater likelihood
of intervening as a bystander to prevent to stop a sexual
assault. These findings may be explained by variable
levels of hyperarousal among victims. Previous research
has found increased reported levels of posttraumatic
stress disorder-related arousal, such as hypervigilance,
increased startle response, and irritability, among sexual
assault victims was related to increased risk detection
compared to victims with lower levels of reported arousal
symptoms.37 Thus, while some survivors may experience
a higher threshold for risk recognition, others may expe-
rience enhanced attention to risk and social information
processing. Future research examining how and why sex-
ual assault survivors might have differential responses to
risk cues and social information cues, as well as how
these differential responses are related to meaningful
health and behavioral outcomes, is warranted.

Furthermore, results suggesting differences in sexual
assault risk detection and social information processing
for those with a history of victimization are relevant for
practice settings as well as experimental research to
improve intervention and prevention efforts. Emotion
recognition accuracy may be considered a relatively sta-
ble yet malleable factor; research supports that with spe-
cific training, emotional awareness can be improved.38

Thus, practitioners could consider assessing emotional
awareness in survivors of sexual assault to understand
how they process social information and embed emo-
tional awareness of others into interventions focusing on
empowering survivors. Further understanding of the
implications of these social processing differences can
also be used to enhance bystander behavior to reduce
sexual assault incidence. Recent evidence supports the
efficacy of bystander intervention programs targeting
reduction in victimization, reduction in perpetration,
and increase in bystander intervention.39 Adding a com-
ponent of training in nonverbal communication recogni-
tion may further increase the likelihood of identifying a
situation in need of intervention to enhance program
effectiveness on college campuses. Other programs have
targeted increasing empathy to enhance bystander inter-
vention behavior.40 Given emotional awareness has been
connected to empathic responding,41 enhancing emo-
tional awareness of bystanders through direct training
may provide an added benefit to empathy-based
bystander intervention training to prevent sexual assault.
Accuracy of facial emotion identification has been found
to be enhanced through training, which includes feed-
back on emotional expressions displayed.38 Thus, practi-
tioners or bystander interventions aiming to increase
empathic responding may include an emotional expres-
sion feedback training.

470 A. J. MELKONIAN ET AL.

Limitations

A primary limitation of the current study is that it was
correlational; thus, no assumptions regarding causality
can be implied. Additionally, it is possible that the
lack of a significant relationship between victimization
history and risk ratings could be due to the methodol-
ogy employed. There are numerous approaches to
studying the assessment of a nonconsensual situation,
all of which may reveal differences in findings; Gidycz
et al1 discuss the potential for differences as a result of
varying vignette items and individual sexual assault
experiences. Thus, it is possible different results may
be found based on individual victimization experiences
(the setting, context, and relationship to perpetrator),
the situation detailed in the vignette used (how similar
or dissimilar is it to the victimization experience), and
the way in which risk detection is measured (eg, rat-
ings versus behavioral response). Of note, the internal
consistency of our risk detection measure (a D .68)
fell just below the conventional cutoff of acceptability.
However, measures with this Cronbach’s alpha may be
considered moderately reliable, and acceptable for use
in preliminary research such as the current study.42,43

Furthermore, victimization history was only measured
from the age of 14 years, and perpetration history was
not measured. Given the scope of the study, childhood
sexual assault experiences were not examined; there-
fore, it remains unknown how childhood victimization
may influence the relationships examined in the pres-
ent study. Additionally, though a strength of the study
was the inclusion of both men and women, it is possi-
ble that the lack of gender moderation was due to low
power to detect the effect. Future studies should con-
tinue to examine the role of gender in the relationship
between social information processing and risk detec-
tion. Follow-up studies may also consider use of
vignettes that vary the depiction of the gender of the
perpetrator and victim.

Additionally, given that in nearly 50% of all college
sexual assault situations alcohol is present in either the
perpetrator or the victim, future research should con-
sider examining this relationship within the context of
alcohol intoxication.44 Research suggests intoxication is
related to impaired risk detection,10 and thus future
research should consider the impact of intoxication on
emotional awareness as well. Finally, all emotions dis-
played in a social interaction such as events leading to
sexual assault may not always be authentic or clearly dis-
played. Given these limitations, the current study repre-
sents the first step in a line of research further
understanding the role of emotional awareness under
controlled conditions. Future research should next target

the more nuanced display of emotions in a complex
social situation.

Conclusions

This study incorporated emotion recognition, a compo-
nent of social information processing, into the current
understanding of sexual assault risk detection and sexual
victimization history. Results provide evidence for differ-
ences in processing of social information and risk detec-
tion between victims and nonvictims of sexual assault,
with the least successful sexual assault risk detection
being observed among survivors of sexual assault and
less accuracy in emotion recognition. The present results,
if replicated, have implications for improving prevention
programs by incorporating emotional awareness strate-
gies, particularly for men and women who are sexual
assault survivors. However, future research is needed to
further study unique differences in risk for victimization
based on history and social information processing.

Conflict of interest disclosure

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

Funding

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

References

1. Gidycz CA, McNamara JR, Edwards KM. Women’s
risk perception and sexual victimization: A review of
the literature. Aggress Violent Behav. 2006;11(5):441–
456. doi:10.1016/j.avb.2006.01.004

2. Turchik JA. Sexual victimization among male college stu-
dents: Assault severity, sexual functioning, and health risk
behaviors. Psychol Men Masculin. 2012;13(3):243–255.
doi:10.1037/a0024605

3. Coker …

MAJOR ARTICLE

An application of the theory of normative social behavior to bystander
intervention for sexual assault

Tobias Reynolds-Tylus, PhDa�, Kaylee M. Lukacena, MAb, and Brian L. Quick, PhDc,d
aSchool of Communication Studies, James Madison University, Harrisonburg, Virginia, USA; bDepartment of Communication, University
of Kentucky, Lexington, Kentucky, USA; cDepartment of Communication, University of Illinois at Urbana-Champaign, Champaign,
Illinois, USA; dCollege of Medicine, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA

ABSTRACT
Objective: Given the high prevalence of sexual assault on U.S. college campuses, the cur-
rent study examines predictors of college students’ intentions to intervene to prevent sexual
assault through the lens of the theory of normative social behavior (TNSB). Participants:
One hundred eighty-six undergraduate students age 18–25 were recruited from an introduc-
tory course at a large Midwestern university. Methods: Data were collected through an
online survey during the 2015–2016 academic year. Results: Results indicated that descrip-
tive norms, injunctive norms, and outcome expectations had direct positive effects on
behavioral intention. However, no direct effect of group identity on intention was found. In
addition to these main effects, an interaction between descriptive and injunctive norms was
also observed. Conclusions: The results of the current study speak to theoretical questions
surrounding the nature of TNSB variables, as well as several practical implications for coordi-
nated efforts to promote bystander intervention on college campuses.

ARTICLE HISTORY
Received 21 July 2017
Revised 18 May 2018
Accepted 9 July 2018

KEYWORDS
Bystander intervention;
descriptive norms;
injunctive norms; sexual
assault; theory of normative
social behavior

An estimated 300,000 people in the United States are
sexually assaulted each year.1 Among this population,
young adults attending postsecondary educational
institutions are at an increased risk for sexual victim-
ization. While pursuing their degree at a college or
university, it is estimated that one in five females and
one in 16 males will be sexually assaulted.2 Of note,
between the years of 1995 and 2013, women age
18–24 had the highest rate of sexual assault compared
to any other age group.3 The consequences of sexual
assault are severe, as survivors of sexual violence are
at increased risk for a variety of harmful physical,
social, and mental health outcomes.4 Given both the
prevalence of sexual assault on college campuses and
the severity of the consequences for survivors, a crit-
ical area of inquiry is identifying effective communica-
tion strategies for sexual assault prevention efforts.

The current investigation stands to move the litera-
ture forward in two primary ways. First, by examining
college students’ beliefs towards bystander intervention
for sexual assault through the theoretical lens of the
theory of normative social behavior (TNSB),5 this
investigation holds the potential to shed light on
effective message strategies for promoting bystander

intervention among college student populations. In
short, bystander intervention programs focus on
reframing sexual assault as a community issue, empow-
ering community members to be active bystanders who
stand up to prevent sexual assault, and seek to change
social norms that contribute to the prevalence of sexual
violence.6 Second, the current study seeks to move the
scholarly literature forward by applying the TNSB5 in
an underexamined context. To date, the TNSB has
principally been applied within the context of college
student drinking.7 In their call for future work on the
theory, Rimal and Lapinski7 have challenged scholars
to extend the TNSB literature by examining additional
behavioral contexts and to continue gathering empirical
data to test the propositional logical of the theory.
The current study seeks to answer this call. We begin
with an overview of the problem of sexual assault on
college campuses

Sexual assault on college campuses

The United States Department of Justice2 defines sexual
assault as “any type of sexual contact or behavior
occurring without the explicit consent of the recipient.”

CONTACT Tobias Reynolds-Tylus [email protected] School of Communication Studies, James Madison University, 800 S Main St, Harrisonburg,
VA 22807, USA.
� 2018 Taylor & Francis Group, LLC

JOURNAL OF AMERICAN COLLEGE HEALTH
2019, VOL. 67, NO. 6, 551–559
https://doi.org/10.1080/07448481.2018.1499648

This definition includes any sexual coercive contact or
behavior including fondling, incest, sexual intercourse,
and attempted rape. Central to this definition of sexual
assault is the concept of consent. At its most basic
meaning, consent is an agreement between individuals
to engage in sexual activity.8 In order to provide con-
sent, however, an individual needs to be cognizant of
the situation, know what he or she desires to do, and
have the ability to communicate this desire.9 Situations
in which an individual is incapable of giving consent
include, but are not limited to: (1) instances in
which an individual is threatened, forced, coerced, or
manipulated into a sexual act against his or her will,
(2) situations where an individual is unable to provide
consent (ie, incapacitated due to drugs or alcohol),
(3) circumstances where the individual does not have
the mental capacity to give consent (ie, due to illness
or disability), and (4) all cases where the individual is
legally a minor.9

Given that college students are at a heightened risk
for sexual victimization,3 identifying strategies for
reducing rates of sexual assault on college campuses is
critical considering the unwarranted health and social
consequences arising from incidents of sexual assault.
These include, but are not limited to physical, social,
and mental health concerns.4 Physical health issues
resulting from sexual assault include unintended preg-
nancy and gynecological trauma, increased risk for
sexually transmitted infections (STIs), including HIV,
as well as an increase in high risk behaviors such as
drug and alcohol use following the assault.4,10 In add-
ition to these behavioral health consequences, there are
also many serious consequences for survivors’ mental
health. A recent meta-analysis11 of 40 years of research
on the relationship between sexual assault and psycho-
pathology found that survivors of sexual assault have
significantly worse psychopathology than people who
have not been assaulted. In particular, sexual assault
survivors face an increased risk for obsessive-compul-
sive conditions, suicidality, trauma- and stressor-related
conditions, bipolar conditions, depression, anxiety, dis-
ordered eating, and substance abuse/dependence.11 In
respect to negative social outcomes, sexual violence
negatively affects survivors’ relationships with their
friends, family, coworkers, and romantic partners.12

For instance, many survivors often must endure victim
blaming from their peers.13 Given the serious conse-
quences of sexual assault for survivors, their friends,
family, and society, identifying strategies for preventing
sexual assault is an issue of national importance.2

As a strategy for reducing the alarming rates of
sexual assault, many U.S. colleges and universities are

implementing bystander intervention programs.6

Federal law14 requires that all educational institutions
receiving Title IX funding must educate students, fac-
ulty, and staff on sexual assault, sexual violence, and
rape prevention. Bystander intervention programs aim
to reduce rates of sexual assault by fostering a sense
of shared responsibility within the campus community
for the prevention of sexual assault and dating vio-
lence, and seek to change social norms that help to
perpetuate sexual violence.6 Central to bystander
intervention programs is the idea that everyone has
the potential to be an active bystander to ensure all
members of the community are safe, and it is critical
to speak out or take action when one witnesses a
harmful situation.15 Though sexual assault is com-
monly associated with private settings, research shows
that nearly one-third of sexually violent situations
occur within the presence of bystanders.16 Thus, given
the strong focus of bystander intervention programs
on changing campus norms, we now turn to the
TNSB to help elucidate concepts critical for informing
bystander intervention efforts on college campuses.

The theory of normative social behavior

The TNSB5 was developed to better delineate the con-
ditions under which social norms impact individuals’
behavior. Building off the work of Cialdini et al,17 the
TNSB distinguishes between descriptive norms, which
represent an individual’s perceptions about what is
commonly done by others, and injunctive norms,
which represent an individual’s perceptions of what
is commonly approved of or disapproved of by
others.5,17 The TNSB also specifies the underlying
cognitive mechanisms believed to moderate the influ-
ence of descriptive norms on individuals’ intentions
and behavior.5 Therefore, the TNSB proposes that the
effect of descriptive norms on behavior must be
understood in the context of meaningful moderators.
The core of the TNSB is the relationship between
descriptive norms and three variables hypothesized to
moderate this relationship: (1) injunctive norms, (2)
outcome expectations, and (3) group identity. The
current study extends TNSB work by testing its pre-
dictions in the context of bystander intervention for
sexual assault. As previous work has been somewhat
inconsistent in supporting TNSB predictions,7 the cur-
rent investigation provides an opportunity to critically
evaluate the central propositions of the TNSB in a
novel context. Below, we introduce the major theoret-
ical constructs of the TNSB and critically discuss
empirical work supporting TNSB predictions.

552 T. REYNOLDS-TYLUS ET AL.

Descriptive norms

Descriptive norms are conceptualized as individuals’
perceptions about the prevalence of a behavior among
members of a referent group.17,18 Descriptive norms are
thought to influence individuals’ behavior by providing
information about what is adaptive for a particular situ-
ation, as well as by serving as a decisional shortcut or
heuristic cue for action.17,18 Empirical investigations
across a wide range of health contexts5,19–21 have shown
that descriptive norms are positively associated with
greater behavioral intentions. Therefore,

H1: Descriptive norms will be positively associated with
intention to intervene to prevent a sexual assault.

Injunctive norms

Injunctive norms represent individuals’ perceptions of
what constitutes socially appropriate behavior in a par-
ticular context.17,18 In contrast to descriptive norms,
injunctive norms are thought to influence individuals’
behavior by providing social approval for compliance
with the norm, and social sanctions for noncompli-
ance.17,18 According to the TNSB, injunctive norms are
thought to have both a direct positive effect on inten-
tion, as well as an interactive effect on intention.5,18

Specifically, perceiving that many others engage in a
behavior (ie, high descriptive norm) is more likely to
motivate individuals to engage in the behavior if they
also believe there is strong social pressure to conform
(ie, high injunctive norm). Conversely, if both descrip-
tive and injunctive norms are low, individuals are
hypothesized to be less likely to engage in the behavior
than if the two norms are divergent.5,18 However,
empirical evidence in support of the hypothesized inter-
active effect of injunctive and descriptive norms on
behavior has been mixed. Some work has supported this
interaction,22–24 whereas other work has found only dir-
ect effects of injunctive norms on intention.5,25

Therefore, given remaining questions about the role of
injunctive norms within the TNSB,

H2: Injunctive norms will be positively associated with
intention to intervene to prevent a sexual assault.

H3: Injunctive norms will interact with descriptive
norms such that behavioral intention will be strongest
when both are high, and weakest when both are low.

Group identity

Group identity, a concept grounded in the social
identity perspective,26 refers to feelings of affinity or

connectedness towards a particular social group.5 Studies
have long shown the strong role that individuals’ social
networks play in initiating and reinforcing negative27 and
positive28 health behaviors. Furthermore, stronger identi-
fication with a social group has been shown to enhance
the likelihood that one will be influenced by ingroup
members’ behavior.29 Accordingly, the TNSB proposes
both a direct positive effect of group identity on inten-
tion, as well as an interactive effect between descriptive
norms and group identity.5,18,19 The hypothesized inter-
action is such that when individuals perceive the preva-
lence of a behavior among a referent group to be
widespread, and they see themselves as similar to the
members of the referent group, they are more likely to
engage in the behavior themselves. In the absence of a
strong identity with the referent group, however, there is
no reason to expect that a strong descriptive norm should
influence an individual’s behavior.5,22 Empirical support
for the moderating role of group identity as specified by
the TNSB has been found across various health con-
texts.5,19,22,23 However, other work has failed to support
this hypothesized interaction,20,21 and in general these
findings have consistently been rather weak, often adding
less than a 1% increase in additional variance explained
to the model.22 Therefore, the current study seeks to
revisit the role of group identity within the TNSB,

H4: Group identity will be positively associated with
intention to intervene to prevent a sexual assault.

H5: Group identity will interact with descriptive norms
such that when both group identity and descriptive
norms are high, individuals will have the strongest
behavioral intention.

Outcome expectations

Outcome expectations refer to individuals’ assessments
of the benefits of taking action relative to the costs associ-
ated with the action.30,31 Quite simply, individuals are
more likely to engage in behaviors they believe will result
in desirable outcomes for themselves.5 Therefore, accord-
ing to the TNSB outcome expectations are expected to
have a direct positive effect on intention, and are also
hypothesized to moderate the relationship between
descriptive norms and intention such that when a high
descriptive norm is accompanied by beliefs that the
behavior results in significant benefits (ie, high outcome
expectations), individuals are more likely to engage in the
behavior.5,18 Empirical work has broadly supported a dir-
ect effect of outcome expectations on behavioral inten-
tion,5,22 though empirical support for the moderating
role of outcome expectations as proposed by the TNSB

JOURNAL OF AMERICAN COLLEGE HEALTH 553

has been somewhat mixed. Some work has fully support-
ing the predicted interaction,19,22 whereas other work has
found mixed support20,32 or no support for this predic-
tion.5 Therefore, given remaining questions about the
role of outcome expectations within the TNSB,

H6: Outcome expectations will be positively associated
with intention to intervene to prevent a sexual assault.

H7: Outcome expectations will interact with descriptive
norms such that when both outcome expectations and
descriptive norms are high, individuals will have the
strongest behavioral intention.

Methods

Participants and procedures

Following IRB approval, undergraduates (N ¼ 186)
were recruited through an introductory undergraduate
class at a large Midwestern university to complete an
online survey for extra credit. Participants ranged in
age from 18 to 25 (M ¼ 20.24, SD ¼ 1.40). The major-
ity of the participants who completed the survey were
female (n ¼ 134, 72.04%). In respect to race/ethnicity,
most participants identified as White/Caucasian
(n ¼ 93, 50.00%), followed by Asian (n ¼ 49, 26.34%),
Black/African American (n ¼ 26, 13.98%), and
Hispanic/Latino (n ¼ 19, 10.21%). Seven participants
(3.76%) identified as some other race or ethnicity. In
terms of the representativeness of the university at
large, our sample closely mirrored the university in
terms of racial/ethnic representation1, but was under-
represented in terms of males.2 Participants were
nearly evenly split by grade level (Freshman [n ¼ 45,
24.19%], Sophomore [n ¼ 55, 29.67%], Junior [n ¼ 47,
25.27%], Senior [n ¼ 38, 20.43%]). Approximately half
of the participants (n ¼ 83, 44.62%) reported being
involved in a Greek-letter fraternity or sorority.
Fourteen participants (7.53%) reported that they were
members of a campus collegiate sports team. In
respect to knowledge about sexual assault, the vast
majority of participants (n ¼ 171, 91.94%) indicated
they had attended at least one education course on
sexual assault and rape. Approximately half of the
participants (n ¼ 95, 51.08%) reported personally
knowing someone who was a survivor of sexual
assault or rape. Approximately 12% of participants
(n ¼ 22) reported they themselves had personally
experienced sexual assault or rape. Nearly 16%

(n ¼ 29) of participants reported they had previously
intervened at one point in order to prevent a sexual
assault from occurring.

Measures

All items for the current study were measured on a 5-
point Likert scale (1 ¼ strongly disagree to 5 ¼ strongly
agree). All scales were computed by averaging the
items. See Table 1 for a zero-order correlation matrix
of study variables, means and standard deviations. See
Appendix for the wording of all survey items.

Descriptive norms were assessed with three items33

(eg, “Most [university name] students would intervene
to prevent sexual assault,” M ¼ 3.77, SD ¼ 0.73,
a ¼ .77). Injunctive norms were assessed with five
items33 (eg, “Most of my [university name] friends
think that I should intervene to prevent sexual
assault,” M ¼ 3.70, SD ¼ 0.71, a ¼ .84). Group identity
was assessed with four items5 (eg, “I want to be like
other [university name] students,” M ¼ 3.02,
SD ¼ 0.82, a ¼ .82). Outcome expectations were
assessed with five items5 (eg, “Intervening to prevent
sexual assault could stop someone from getting hurt,”
M ¼ 4.40, SD ¼ 0.66, a ¼ .92). Intention to intervene
to prevent a sexual assault served as the primary
dependent measure for this investigation. Behavioral
intention was measured with four items34 (eg, “I
intend to intervene in the future if I see a sexual
assault, M ¼ 4.27, SD ¼ 0.64, a ¼ .94).

Results

To examine study hypotheses, a hierarchical regres-
sion analysis was employed with biological sex, race,
Greek-letter organization affiliation, collegiate sports
affiliation, previous sexual assault and rape education
experience, personally knowing a survivor of a sexual
assault, being a victim of sexual assault, and previ-
ously intervening to prevent a sexual assault initially
included in the regression as covariates. As none of
the demographic variables were significant predictors
of intention, F (9, 174) ¼ 1.04, p > .05, R2 ¼ .00, these

Table 1. Zero-order correlation of study variables, means and
standard deviations.
Variables 1 2 3 4 5

1. Descriptive norms —
2. Injunctive norms .48�� —
3. Group identity .14 .30�� —
4. Outcome expectations .39�� .39�� .08 —
5. Intention .45�� .46�� .03 .61�� —
Mean 3.77 3.70 3.02 4.40 4.27
SD 0.73 0.71 0.82 0.66 0.64

Note. �p < .05, ��p < .01.

1The university population where data were collected is approximately
53.8% White/Caucasian, 21.7% Asian, 13.5% Hispanic/Latino, 7.1% Black/
African American, and 3.7% multiracial.
2The university population is 54.6% male and 45.4% female.

554 T. REYNOLDS-TYLUS ET AL.

variables were dropped from further analyses. See
Table 2 for the full results of the hierarch-
ical regression.

H1 predicted that descriptive norms would be posi-
tively associated with intention to intervene to prevent
a sexual assault. To test H1, descriptive norms were
entered into block 1 of the hierarchical regression.
Consistent with our expectations, descriptive norms
(b ¼ 0.45, p < .001) were positively associated with
intention, F (1, 184) ¼ 45.69, p < .001, R2 ¼ .20. H2,
H4, and H6 examined the direct effect of injunctive
norms, group identity, and outcome expectations on
intention. Specifically, injunctive norms (H2), group
identity (H4), and outcome expectations (H6) were
hypothesized to be positively associated with inten-
tion. To test H2, H4, and H6, injunctive norms, group
identity, and outcome expectations were entered into
block 2 of the hierarchical regression. In block 2,
injunctive norms (b ¼ .22, p< .001) and outcome
expectations (b ¼ .46, p< .001) were positively associated
with intention, F (4, 180)¼ 37.49, p< .001, R2 ¼ .44.
Group identity3 was not associated with intention.

H3, H5, and H7 examined interactions consistent
with the predictions of the TNSB.5 Specifically, H3
proposed that descriptive norms and injunctive would
interact such that when both were concordant, their
strength on intention would be maximized. H5 pro-
posed that the effect of a high descriptive norm would
be maximized when paired with a strong group iden-
tity. H7 proposed that when outcome expectations
and descriptive norms were both high, behavioral
intention would be strengthened. In line with recom-
mendations from Aiken and West,35 all predictor vari-
ables were centered prior to moderation analysis.
After centering the predictors, interaction terms were
calculated by taking the product of both variables. In
block 3, controlling for the main effects of all predic-
tors, only the interaction between injunctive norms
and descriptive norms (b ¼ �.13, p < .05) arose as a

significant interaction term, F (7, 177) ¼ 22.19,
p < .001, R2 ¼ .45. As can be seen in Figure 1, a
decomposition of this interaction demonstrates that
when both injunctive norms and descriptive norms
were low (�1 SD), participants had the lowest inten-
tion overall.

Comment

Given that college students are at a heightened risk
for sexual victimization,3 a broader theoretical under-
standing of the antecedents to bystander intervention
is critical for informing campaigns aimed at reducing
the number of sexual assaults on college campuses.
Two major objectives guided the current study. First,
by examining predictors of college students’ bystander
intervention intentions by utilizing the theoretical
constructs of the TNSB,5 we sought to provide prag-
matic evidence of use for coordinated efforts to pro-
mote bystander intervention among college student
populations. Our second major objective was to
extend the literature on the TNSB by examining cen-
tral questions about the role of TNSB constructs and
behavioral intention more broadly. In doing so, we
met the call of TNSB scholars who have advocated for
more empirical work examining the propositional
logic of the theory.7,22 In discussing our findings, we
focus on the practical and theoretical contributions of
the current study.

Overall, we found broad support for the utility of
the TNSB in predicting bystander intervention inten-
tions among college students. In particular, the inclu-
sion of the TNSB variables into the regression model
was able to explain approximately 47% of the variance
in intention. The large variance explained by these
variables lends support to the utility of the TNSB in
the context of bystander intervention, and suggests
the important of strategically emphasizing these con-
structs in promotional efforts. In particular, our
results revealed that descriptive norms (b ¼ .45) and
outcome expectations (b ¼ .46) were quite strongly
related to behavioral intention (see Table 2). From a
practical standpoint, campaign designers may benefit
by strategically emphasizing these constructs in cam-
paign messages and materials aimed at promoting
bystander intervention. For instance, promotional
messages targeting descriptive norms may emphasize
the large number of students who have intervened to
help a peer, or the number of who have formally
pledged to prevent sexual assault on their campus (see
www.itsonus.org). Likewise, campaign messages
emphasizing the positive outcomes associated with

3Based on the suggestion of one reviewer, we conducted subgroup
analyses examining the role of Greek life identity on study outcomes.
Specifically, given that we had a sizeable number of Greek life-affiliated
students in our sample (44.6%, n ¼ 86), we conducted separate
hierarchical regressions for Greek life and non-Greek life affiliated
students. Our results showed a similar pattern of findings in respect to
main effects among each sub-group, with some subtle differences.
Overall, both regressions explained approximately the same amount of
variance (R2 ¼ .48 for non-Greeks; R2 ¼ .52 for Greeks). For both Greek
and non-Greek students, group identity was not associated with
intention. For Greek students, outcome expectations were most strongly
associated with intention (b ¼ .58, p < .001), followed by descriptive
norms (b ¼ .40, p < .001). Interestingly, among Greek students, injunctive
norm was not associated with intention. For non-Greek students,
descriptive norms were the strongest predictor of intention (b ¼ .50,
p < .001), followed by outcome expectations (b ¼ .34, p < .001), and
injunctive norms (b ¼ .33, p < .001).

JOURNAL OF AMERICAN COLLEGE HEALTH 555

bystander intervention (such as personal profiles of
university students describing the benefits of
bystander intervention) provide just one instance of
how campaigns can strategically emphasize outcome
expectations within their outreach efforts.

Another finding with both theoretical and practical
implications was the observed interaction between
descriptive and injunctive norms. A decomposition of
this interaction (see Figure 1) demonstrated that when
injunctive norms and descriptive norms were both
low (�1 SD), individuals had the lowest intention to
intervene to prevent sexual assault. This finding is
consistent with what would be predicted by the
TNSB,5 thus lending further empirical support for the
hypothesized interaction between injunctive norms
and descriptive norms.5,18 Beyond the theoretical
implications of this finding, this interaction between
descriptive and injunctive norms seems likely to be of
particular interest to campaign efforts. From a prac-
tical standpoint, these findings suggest that injunctive
norms may be a critical construct for targeting within
campaign messages. Namely, the results from the cur-
rent investigation revealed that when both injunctive
and descriptive norms were low, individuals’ inten-
tions were the lowest overall. Therefore, these findings
suggest that strategic efforts to strengthen injunctive
norms, in addition to descriptive norms, may be par-
ticularly consequential in this context.

In line with previous work,5,36 we found direct
effects of both injunctive norms and outcome expecta-
tions on intention (see Table 2). In contrast to previ-
ous work,19,22 however, our results did not support
the hypothesized interaction between outcome expect-
ations and descriptive norms. Though the original
formulation of the TNSB5 proposed an interactive
effect of outcome expectations and descriptive norms,

previous work has failed to consistently support this
finding.5,20,32 This has led some scholars to suggest a
reconsideration of the role outcome expectations play
within the TNSB.18,22 Our findings provide further
evidence that outcome expectations may influence
intentions in a direct, rather than moderated, manner.

Interestingly, we found that group identity was
completely unrelated to intention (see Tables 1 and
2). Though some previous work has found a direct
effect of group identity on intention,20 our results did
not support this finding. Nor did we find an inter-
active effect between descriptive norms and group
identity as would be predicted by the TNSB.5

Considering these findings, a discussion of referent
groups seems relevant. In the current study, the refer-
ent group utilized was the general student population
at the university where the data were collected (eg,
“other [university name] students”). A growing body
of evidence suggests that norms emanating from more
proximal referent groups (eg, same-race, same-sex)
hold a stronger influence on behavior than those
norms emanating from more distal referent groups
(eg, a “typical” student on campus).18,25,36 A boundary
condition of the hypothesized interactive effect of
group identity and descriptive norm within the pur-
view of the TNSB is that individuals must have a
strong identity with the referent group in order for
the descriptive norms of that group to influence their
behavior. In the current study, group identification
with …

1054 © 2013 Springer Publishing Company
http://dx.doi.org/10.1891/0886-6708.VV-D-12-00113

Violence and Victims, Volume 28, Number 6, 2013

Bystander Education Training for
Campus Sexual Assault Prevention:

An Initial Meta-Analysis

Jennifer Katz, PhD
SUNY College at Geneseo

Jessica Moore, PhD
University of Rochester Medical Center

The present meta-analysis evaluated the effectiveness of bystander education programs
for preventing sexual assault in college communities. Undergraduates trained in bystander
education for sexual assault were expected to report more favorable attitudes, behavioral
proclivities, and actual behaviors relative to untrained controls. Data from 12 studies of
college students (N 5 2,926) were used to calculate 32 effect sizes. Results suggested
moderate effects of bystander education on both bystander efficacy and intentions to
help others at risk. Smaller but significant effects were observed regarding self-reported
bystander helping behaviors, (lower) rape-supportive attitudes, and (lower) rape proclivity,
but not perpetration. These results provide initial support for the effectiveness of in-person
bystander education training. Nonetheless, future longitudinal research evaluating behav-
ioral outcomes and sexual assault incidence is needed.

Keywords: bystander education; sexual assault; rape; prevention

S
exual assault is a common problem on college campuses in North America. Many
researchers define sexual assault as involving attempted or completed sexual pen-
etration in the absence of affirmative consent. Between 20% and 25% of women are

estimated to experience a sexual assault during college (Fisher, Cullen, & Turner, 2000).
College men also experience sexual assaults. According to a report commissioned by the
National Institutes of Justice (NIJ), 19% of women and 6% of men reported experiencing
attempted or completed rape specifically since starting college (Krebs, Lindquist, Warner,
Fisher, & Martin, 2007).

Institutions of higher education are challenged in their attempts to prevent campus
sexual assault. Traditionally, educators have sought to reduce women’s risk for assaults by
providing education and self-defense training (rape avoidance or risk reduction programs).
In a narrative review of the rape avoidance literature, Ullman (2007) concluded that partic-
ipating in self-defense and other rape avoidance programs inconsistently led to decreased
rates of victimization. Although helpful, risk reduction programs alone are insufficient to
end campus sexual assault (Gidycz et al., in press). Other educators have sought to reduce
men’s rape-supportive attitudes and perpetration behaviors. Unfortunately, there have

Bystander Education Meta-Analysis 1055

been relatively few evaluations of such programs, and the available results are inconsis-
tent (Lonsway et al., 2009). Even more concerning, among men identified as “high risk,”
sexual assault education may actually predict increased perpetration (Stephens & George,
2009), perhaps because of a backlash effect.

Increasingly, community-based prevention efforts involving bystander education are
recommended in the primary prevention of sexual violence (e.g., American College Health
Association [ACHA], 2011). Bystanders are third party witnesses to the problem of sexual
assault; they are neither perpetrators nor victims. Those third parties who intervene in
response to risk for harm are responsive bystanders. The bystander education approach to
sexual assault prevention encourages responsive bystander behaviors to “spread” respon-
sibility for safety to members of the broader community.

Multiple in-person bystander education programs for sexual assault and interpersonal
violence prevention have emerged over the past few decades. A partial list includes Bringing
in the Bystander (Banyard, Plante, & Moynihan, 2004), InterACT (Rich, 2010), SCREAM
peer education (McMahon, Postmus, Warrener, & Koenick, in press), and the Mentors in
Violence Prevention (MVP) Program (Katz, Heisterkamp, & Fleming, 2011). Programs
aimed specifically at either men or women include the Men’s Project (Gidycz, Orchowski, &
Berkowitz, 2011), the Men’s Program, and the Women’s Program (Foubert, 2011).

Although specific components and audiences of these bystander education programs
vary, they share common methods and goals. In terms of methods, participants are
approached as potential allies or helpers, which may reduce defensiveness or backlash.
In addition, bystander programs typically involve single-sex groups facilitated by trained
peers who serve as positive role models. In terms of goals, bystander programs seek
to promote prosocial attitudes and behaviors related to both sexual assault and helping
others. Participants are educated about prevalence rates, indicators of high risk situations,
and how they, as bystanders, can promote safety. Sexual assault awareness may engage
community members by challenging the acceptability of sexual assault and helping par-
ticipants to notice high risk situations and respond constructively. Such programs may
also empower participants as capable of helping others and meaningfully contributing to
creating an inclusive, safe community. In addition to promoting awareness and empower-
ment, bystander programs teach participants how to remain safe while also promoting
safety more generally. For example, in response to either actual or potential risk, program
attendees are encouraged to interrupt the situation in some way to prevent a completed
assault. Likewise, after hearing sexually degrading comments or victim disclosures, pro-
gram attendees are encouraged to express support for victims and people as humans who
deserve respect. Awareness, empowerment, and skills imparted by educational programs
have the potential to help specific victims while also promoting norms for community
safety more generally.

The goal of the present meta-analysis was to evaluate the existing literature on
bystander education programs for campus sexual assault prevention. To what degree do
these bystander programs specifically benefit participants and promote campus safety?
In what ways are these programs successful, and in what ways are they not? To date, no
systematic or meta-analytic evaluations of the effects of bystander education programs
for sexual assault prevention exist. The effectiveness of these programs across campuses,
programs, and researchers merits evaluation. Furthermore, this initial evaluation also may
help identify important directions for program development and future research.

Previous meta-analyses have examined outcomes associated with general (not
bystander-based) sexual assault education programs for college students. For example,

1056 Katz and Moore

Flores and Harlaub (1998) analyzed 15 effect sizes from 11 studies of education for
college men; the authors concluded that various programs yield positive but short term
changes in rape-supportive attitudes. Subsequently, Brecklin and Forde (2001) analyzed
153 effect sizes from 22 published and 23 unpublished studies with either pre–post or
treatment-control comparisons of rape-supportive attitudes. These authors concluded
that, overall, education fosters prosocial attitudes about rape. However, effect sizes were
negatively associated with the length of time between the training and the posttraining
assessment, and men in mixed-gender groups reported less attitude change than men in
same-gender groups.

A more recent meta-analysis of sexual assault education programs provides more
refined and rigorous information about how college students are affected by general sexual
assault education. Anderson and Whiston (2005) separately analyzed seven different out-
comes across 69 studies: (a) rape-supportive attitudes, (b) rape empathy, (c) rape-related
attitudes (e.g., gender stereotypes), (d) rape knowledge, (e) behavioral intent to rape,
(f) awareness behavior (e.g., interest in rape activism), and (g) sexual assault incidence.
These authors employed more rigorous inclusion criteria than in past meta-analyses,
including a requirement for a control condition to avoid potential biases associated with
precomparisons to postcomparisons. This analysis provided strong evidence for the use
of sexual assault education. On average, five of the seven outcomes (all but rape empathy
and awareness behavior) showed significant effects. Several moderator variables also
were identified: for example, more focused, longer programs had a greater effect on
rape-supportive attitudes and rape-related attitudes and professional educators were more
effective than peers.

The current meta-analysis focused specifically on bystander education programs for
college students. Guided by Anderson and Whiston (2005), we restricted our analysis to
effect sizes based on comparisons of treatment versus control conditions and we exam-
ined multiple outcomes separately. Outcomes evaluated in the present meta-analysis were
selected based on both conceptual and pragmatic considerations. Conceptually, bystander
education for sexual assault attempts to teach students about bystander behavior and about
sexual assault, and so both bystander-related and rape-related outcomes were evaluated.
Pragmatically, we could only analyze outcomes assessed in multiple previous evaluations
of bystander education. In essence, six different meta-analyses were conducted, one for
each different outcome.

The first outcome was bystander efficacy, defined as one’s perceived competence in help-
fully responding to sexual assault risk. For example, participants might be asked how confi-
dent they are that they would be able to “Walk a friend who has had too much to drink home
from a party” (Banyard, 2008, p. 90). The second outcome was rape-supportive attitudes such
as acceptance of rape myths: common but generally false attitudes and beliefs that deny, min-
imize, or justify men’s use of sexual aggression against women. A sample rape myth is “If a
woman doesn’t physically fight back, you can’t really say that it was rape” (Payne, Lonsway, &
Fitzgerald, 1999, p. 49). The third outcome was intent to help as a bystander. For example,
participants might be asked how willing they would be or how likely they would be in the
future to “think through the pros and cons of different ways I might help if I see an instance
of sexual violence” (Banyard & Moynihan, 2011, p. 300). The fourth outcome was rape pro-
clivity, assessed by asking how reinforcing sexual aggression is or by how likely one would
be to rape someone if they knew they wouldn’t be caught or punished (Malamuth, 1991). The
fifth outcome was actual bystander helping behaviors enacted since the training. Examples
include “I stopped and checked in with my friend who looked very intoxicated when being

Bystander Education Meta-Analysis 1057

taken upstairs at a party” and “said something when I heard someone say ‘she deserved to be
raped’” (Banyard & Moynihan, 2011, p. 300). The final outcome was perpetration behaviors
since the training, typically assessed by asking male participants about their use of behavior-
ally specific acts adapted from the Sexual Experiences Survey (Koss & Oros, 1982).

The primary aim of the present research was to estimate the degree to which bystander
education programs promote favorable outcomes among trained relative to untrained
participants. We expected students who attended bystander education training sessions
would report more prosocial attitudes, behavioral proclivities, and actual behaviors as
compared to controls. A secondary aim was to examine the magnitude of training effects
on various outcomes, both bystander-related (efficacy, intent to help others, and bystander
helping behavior) and rape-related (rape-supportive attitudes, rape proclivity, and perpetra-
tion behavior). We expected to find stronger effects on bystander-related outcomes overall
as compared to rape-related outcomes. Finally, we explored possible moderators of the
effects of bystander education programs on these outcomes.

METHOD

We adopted strategies suggested by Cooper (2010) to systematically search the avail-
able research literature on bystander education programs for sexual assault prevention.
Initially, we conducted computerized literature searches of the following databases
using multiple combinations of various search terms including “bystander” or “wit-
ness,” “prevention” or “training,” and “sexual assault” or “rape”: (a) PsycInfo, (b) ERIC
(Educational Resources Information Center), (c) Dissertation Abstracts Online, (d)
Sociological Abstracts, and (e) MEDLINE. Descriptions of program content were exam-
ined for explicit focus on approaching participants as allies and who could help others
at risk for or following sexual assault. Next, we examined the reference sections of rel-
evant articles to identify and locate other studies that might be appropriate for inclusion.
General internet searches were conducted to identify unpublished electronically available
reports on the internet; search terms included researcher’s names as well as the names
of programs (e.g., MVP program, Step Up!). We also contacted study authors to request
copies of unpublished or in press work not yet available online. In the case of dissertation
studies, we conducted online searches to locate individuals and request copies. Finally,
we searched by hand through important journals in community psychology, prevention,
and interpersonal violence.

A bystander education program for sexual assault prevention was defined as involving
an in-person training session in which participants are approached as allies in prevention.
At least part of the education explicitly focused on ways in which participants could help
reduce others’ risk for sexual assault and/or respond to others who may be or who were
victims. Studies eligible for inclusion in the meta-analysis involved those in which North
American college students (a) attended a bystander education program for sexual assault
prevention, (b) provided quantitative data on at least one of our six study outcome vari-
ables both pretraining and posttraining (i.e., qualitative studies, studies with posttraining
data only, or both were excluded), and (c) whose participation in the program could be
compared to control students not trained in bystander education.

Out of a possible 41 identified studies, 12 studies (one unpublished) met our inclusion
criteria. Studies were excluded for one or more of the following reasons: participants were
not in college, bystander education took the form of a speech or a poster, no quantitative

1058 Katz and Moore

pretraining and posttraining data were available, there was no control or comparison
group, or the study analyzed data from a sample already included in the meta-analysis.
Because not all studies included assessments of all outcomes, different numbers of studies
were included for each potential outcome variable. In all, 32 effect sizes were evaluated.
Only one study (Banyard, Moynihan, & Plante, 2007) employed a multiple training ses-
sion condition. Accordingly, the present meta-analysis examines only the effects of a
single training session based on pre- and post-scores. Most studies assessed outcomes at
a single time point. When multiple outcome assessments were conducted, only the first
outcome was coded. The following study characteristics were coded as potential modera-
tor variables: year of the study, sample characteristics (average age, percent male, Greek
affiliation), program presenters (professional or peer), length of the training program
(in minutes), and length of time between training and outcome assessment (in days).

RESULTS

Studies included in the meta-analysis are listed in Table 1. There were 1,452 college stu-
dents trained in bystander education, and 1,474 served as untrained controls. On average,
study participants were 19.34 years old (SD 5 0.56, range 18.50–20.33). Across the stud-
ies, 53.8% of participants were in their first year of college, and 66.7% of the participants
in the studies were men. Peers conducted the trainings in 86.0% of the studies. Every study
reported that bystander education was conducted in same-sex groups. Only three studies
included mixed sex samples. On average, attitudes and behavioral intention outcomes
were assessed 20 days after the training; behaviors were assessed at 2 or more months
(M 5 112 days, SD 5 68.58, range 56–224). Only nine programs provided information
about the length of the training; on average, trainings were 140 min long (SD 5 122.78,
range 60–420 min). Studies were conducted from 1997 to 2011, with an average of 2006.71
(SD 5 4.84 years).

Comprehensive Meta-Analysis Version 2.0 (CMA) Software was used to calculate
standardized mean differences between the posttraining education group and the control
group. Within each study, separate effect sizes were calculated for each of the six different
outcome variables available. Next, using CMA Software, a random effects meta-analysis
was calculated for each outcome. A random effects meta-analysis is used when the studies
differ in terms of participant characteristics as well as the content and implementation of
the training programs. Each study outcome was weighted by an estimate of its precision;
outcomes were then combined to create a summary effect size: a standardized mean dif-
ference. The summary effect is an estimate of the mean of the true effects of training in
bystander education, with a null hypothesis that the standardized mean difference between
participants in training versus control groups is zero (Borenstein, Hedges, Higgins, &
Rothstein, 2009).

Results are reported in Table 2. As can be seen, effect sizes ranged from .579 for
measures of intent to help others to 2.167 for intent to perpetrate. The null hypothesis
of a true effect of zero was rejected for five of the six outcome variables. Compared to
controls, students who attended bystander education programs reported more bystander
efficacy, intent to help others, and actual bystander behaviors, and less rape myth accep-
tance and rape proclivity. In contrast, trained students were no less likely to report per-
petration behaviors.

Bystander Education Meta-Analysis 1059

Orwin’s fail safe N statistic for each significant outcome is reported in Table 2. This
statistic is an index of publication bias; it shows the number of additional studies with
trivial effects needed to reduce the effect size enough to accept the null hypothesis of no
significant training effect (Borenstein et al., 2009). The criterion for a “trivial” standard
difference in means was set at .05. As shown in Table 2, 44, 50, and 54 studies would be
needed to nullify the significant effects of bystander education programs on participants’
bystander efficacy, rape- supportive attitudes, or intent to help as a bystander, respectively.
Publication bias may be more likely for the other study outcomes; 11 studies with trivial
effects would nullify the observed significant education effects on bystander helping
behavior, and only 10 studies with trivial effects would nullify observed effects on reduced
rape proclivity.

Based on Cohen’s reference values, a standardized mean difference of about .50 is con-
sidered a moderate effect size, and a standardized mean difference of about .20 is small
(Cooper, 2010). Using these guidelines, moderate effect sizes were obtained regarding
measures of bystander efficacy (.49, 95% CI 5 .31 to .66) and intent to help others as a
bystander (.58, 95% CI 5 .38 to .78). In contrast, smaller effect sizes were obtained for
rape myth acceptance (2.28, 95% CI 5 2.20 to 2.36), rape proclivity (2.17, 95% CI 5
2.03 to 2.30), and for actual bystander behavior (.23, 95% CI 5 .04 to .41). Overall, the
available evidence suggests that bystander education programs may be more effective in
promoting bystander efficacy and intent to help others than in promoting actual bystander
helping behavior. Furthermore, bystander programs exert moderate effects on bystander-
related attitudes and behavioral intentions (bystander efficacy, intent to help) but small
effects on rape-related attitudes and behavioral intentions (rape-supportive attitudes, rape
proclivity).

Tests of homogeneity of the summary effects are also reported in Table 2. The Q sta-
tistic addresses the null hypothesis; the true dispersion of effects is zero. As can be seen,
none of the Q tests reached statistical significance, although a p 5 .05 trend emerged
for bystander efficacy. Unlike Q, Tau2 and I2 are not sensitive to the number of avail-
able studies. Tau2 reflects an absolute amount of true (rather than random) heterogeneity
across studies, whereas I2 reflects the proportion of true, potentially explainable variance
(Borenstein et al., 2009). Only bystander efficacy, intent to help as a bystander, and actual
perpetration showed both (a) nonzero values for Tau2 and (b) values of I2 indicating that
variability might be explained by different characteristics of the studies, participants, or
interventions. However, there were only few studies for each outcome, particularly for per-
petration. As such, exploratory moderator analyses were conducted for bystander efficacy
and intent to help as a bystander, although these analyses must be viewed as preliminary
given the small number of studies available.

Separate subgroup and meta-regression analyses were conducted to identify predictors
of posttraining bystander efficacy and intent to help. Meta-regression results suggested
that the average age of participants was negatively associated with program effects on
bystander efficacy. More specifically, bystander programs offered to younger participants
showed stronger effect sizes (B 5 2.392, SE 5 .146, Z 5 22.69, p 5 .007), although the
total model only approached significance, Q(5) 5 11.03, p 5 .051. Meta-regression results
also showed that the percentage of male participants was positively related to intent to help
others (B 5 .005, SE 5 .002, Z 5 2.35, p 5 .018), although again, the total model did not
reach statistical significance, Q(4) 5 6.72, p 5 .15. No other moderator variables were sig-
nificantly associated with effect sizes for either bystander efficacy or intent to help others.

1060 Katz and Moore

T
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Bystander Education Meta-Analysis 1061

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1062 Katz and Moore

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Bystander Education Meta-Analysis 1063

DISCUSSION

The primary aim of this meta-analysis was to examine the effectiveness of in-person bystander
education for campus sexual assault prevention. We expected that students who attended
bystander education programs would report more prosocial attitudes, behavioral proclivities,
and behaviors compared to untrained controls. Six separate quantitative outcomes were evalu-
ated, and favorable results were observed for five of these outcomes. Across studies, students
trained in bystander education reported increased bystander efficacy, intent to help others,
and …