ADD RES l NG THE MENTAL HE LTH OF WOM N THE ROL E OF FOLLOW-U P FTER SEXUAL A SAULT: RE by Li sa B c , KwantJ en reelman niver ity C li ege, 2005 FNP PROJECT SUBMITTED IN PARTIAL FULFILLM NT OF THE REQUIREMENTS FOR THE D GREE OF MASTER OF SCI NCE IN NURSING : FAMILY NURS E PRACTITIONER UNIV RSITY OF NORTHERN BRITI H COLUMBIA November 20 15 © Li a reelman, 20 15 2 b tract exual a ault i a ociated with d bilitating mental h alth cons qu nee , uch a p stre di order (PT D) and depre ion, yet a ignificant gap the care needed to addre the e con equences. t-traumatic i t within the literature around a re ult, thi proj ect eek to an wer the que tion: In adult women of childbearing age wh have experienced a rec nt exual a ault, can acce s to po t-a ault foll w-up care within two we k of the a ault deer ase the prevalence and everity of PT D and depre ion? ligi bility criteria D r thi literature rev iew includ ed re earch data publi hed in 2004 or later regarding mental hea lth follow-up care D r adult wom n of childbearing age who have ex perienced ex ual a ault. The majority of parti cipants within the e primary tudie included adult women of childbearing age from large urbanized area . This review utilized an ecological framework that id entifi ed individual, per onal relationship, community and ocietal influences that impact the mental health of women after sex ual assault while highlighting multi-level strategies aimed at decreasing the emotional distress experi enced by women. Utilizing a trauma infonned approach to care that encompasses thorough asses ment and action orientated care planning, preferably within two weeks of a sex ual assault, was suggested to be important for coping with emotional and psychological trauma . Limitations of this project include the retrospective nature of the studies reviewed and their reliance on participant recall or provi der documentation practices. Further research i needed to develop multi-level strategies that improve the mental health of women after sexual assault. 3 Acknowl edgement I would like to acknowl dge and expre P(c) and m y in ere gratitud e t my up erv1 ela Zimmer Ph , who e p rti ry com1nittee, , p atience and incredible upp rt helped m e to c mpl t thi pr j ect. I would al o like to thank m y fa mil y and fri nd [! r the unwavering upp rt they provided m e tlu·oughout m y gradu ate tud i . pecifica ll y I want to ackn owledge m y husband, teve and my childr n, Brady and fi ni bed thi the i . ddi on , without who e 1 e, enc uragem nt and upp ort, I w uld not have 4 Table of ontent Ab tract Acknowl edgem nt HAPT R N E Introdu cti on Background Hi t rica! P r pectiv Health on qu ence P t-traumatic tre di sord er Depr Initial xual are M anagem ent Follow- p ar N ur Practition r co pe of practice Barri ers to oll ow-up Care Provid er time con traints Documentation Provid er com fo rt lev 1 Geographical con ideration P ychological and ociological con ideration Theoretical Fram ework CHAPTER TWO Integrative R eview M ethod Literature Search M ethods Inclusion and Exclu ion Criteria Literature Search One Literature Search Two CHAPTER THREE Findings Clinical Practice Guidelines AG REE II Individual Level of Influ ence P ersonal Relationships Level of Influ ence C01rununity Level of Influ ence Societal Level of Influence Summary of Findings HAPT R OUR Discu sion Optimal Intervals fo r Follow- up Care Individual Levels of lnflu nee Fac tors imp acting fo ll ow- up car 2 3 6 8 8 9 10 11 12 13 13 14 15 15 16 16 16 17 17 22 22 22 23 23 26 26 30 31 40 46 52 55 58 58 60 60 5 60 Demographic charact ri ti cs Pa t hi tory of xual a sault Pre-exi ting m ental health di ord er A ault characteri tic Per onal Relation hip Le el of Influ nee ommunity and ocietal Lev 1 of Influenc CoiTI111unity etting Provider comfm1le el Provider d cumentation practice ocial and cultural norm Language The Role of ur e Practiti oner in F llow-up are 67 67 CHAPTER FIVE Recommendations for urse Practiti oner Recommendation for Optimal Follow-up Care Recommendations Targeting Individual Levels of Influ ence Approach t care M ental health fo llow-up care components Ongo ing care planning Recommendation Targeting Per onal Relationships RecoiTI111endation Targeting Community Levels of Influence Strategies for providers Strategies for organi za ti ons Recommendations Targeting Societal Levels of Influ ence Language Education and Aw areness Developing Partnerships fo r Change Conclusion 69 69 70 70 72 73 74 75 76 77 77 78 78 78 80 References Appendix A : Post-Assault Care Recolllinendations Appendix B: Literature Search One Major Concepts and Similar Tern1s Appendix C : AGREE II Assessment of Clinical Practi ce Guidelines Appendix D : Definition of Terms Appendix E: Sulllinat-y of Recommendations fo r Mental Health Follow-up Care Appendix F: Mental Health Screening Tools Appendix G: Online Resources for Patients Appendix H: Resources for Care Provider 61 61 62 63 63 64 65 65 66 82 89 90 91 94 95 97 98 99 6 H PT R Introduction ex ual violen e i a gl bal i u that plague e ery c mmunity and thr at n the health, well-being and quality f life f all who inhabit th a p r on i [! reed r c e c mmuniti e . e ual viol nee occurs when reed int any typ e f e ual activity aga in t hi victim i unabl t c n ent r r fu (Talb t, r her will or when th e eill , & Rankin, 201 0) . ex ual a ault i a typ e of exual viol ence defin ed by Pen ault and Brennan (20 10) a a .G reed r an attempt at forced exual contact including " unwanted e ual touchin g, grabbin g, ki in g r fondlin g'' (Penault & Brennan, 2010, para . 7) . The te1m exual a ault w ill be u ed throughout thi s proj ect a it encompa se both attempted and compl eted unwa nted ex ual act , regardl e of fo rce or pen etration. Thi tenn will b examined ep arately from dome tic/i nterp er onal v iolence a exual as ault may or may not be includ ed within this type of violence. Stati tics anada (2 01 3) reported 21,900 reports of sexual a sault in 20 12 demon trating a decline in police-reported sexual as ault in compari son to previous years. The mo t recent statistic ava ilable comparing the rate of poli ce reported exual assaults by gend er demon trated that 92% percent of sexual a aults were experi enced by fem ales demon tratin g a preva lence rate ten times greater than th ose reported by m ales (Stati stics anada, 201 0) . Whil e exual a sault can affect both men and wom en, stati stics refl ect a grea ter prevalence am ong women. T hu for the purpose of this proj ect, only women who have experi enced sexual as ault will be examined . It is difficult to know the preva lence or the effect of exual as ault on women and th ir fa mili es, a sex ual assault are unden·epo1ied with le than one in ten ex ual a ault reported to poli ce (Brennan & T aylor-Butt , 2008) . Roughl y on in fiv wo men wi ll e peri nee c ual as ault within their lifetim (Na ti onal enter for Inj ury Prevention and Control & enter for 7 Di a e ntTol and Pr venti n, 2011 ). It an ha p n t w men f ev ry age, ra background , etlmicity, oci - con mic tatu and famil y tru tur . e ual a ault i n 1 ng r perceived a ju t a ocial probl m but i al c n id r d a public health pr blem a it affect the health f many people in a p pul ati n (Talb t t al. 201 0). Th phy ica l and p ych 1 gi al f} ct a ault can b far r aching and in uffered by me women wh expen enc xual me ca e p rm anent r life- threatening. he e wom en arc at gr aterri k[i racut and chr nic h alth chall nge (W ad worth phy ical injuri e , chr nic pain c ndition , Van rd er,201 2) uch a xuall y tran mitted infecti n ( T1 ), pregn ancy and gynecological complication , m ntal h alth and behavioural problem , uicid al id eation and wor ening of exi ting chr nic h alth c nditi on (Padd n, 2008) . Th e complica ti n can be hort or long-tenn re ulting in proD und effect n w m n, their famili and oci ty a a whole. The direct co ts of exual a ault in Canada are estim ated at more than 546 milli on doll ar per year and thi figure rise ignificantl y to more than 1.9 billi on if the costs a soc iated w ith the ongoing pain and suffering experi enced by these wo men are factored in (Mcinturff, 20 13 ). As a Forensic Nurse Examiner, I have conducted many m edico-legal examinati on of women who have reported exual assault. The care I provided included addre ing the n egative p ychological and physical consequences of the as ault, and providing the pati ent with various resources to assist in their recovery process. In addition, I also provid ed p atient w ith information about primary care practices that were ava il able t provid e po t-a sau lt fo llow-up care. The info rm ation I have rece ived from these practices and our ocial work department revealed that many patients do not fo llow through with the e po t-a sault appointment . Thi appear to be consi tent with the literatu re ugges ting le care appointments (Ackerman, uga r, Fine, & than 30% of patient attend follow -up ckert, 2006). a Regi tered Nur ' working in a 8 bu y em rgency d partment, I ha a au1 t ft n car d ~ r w m n with pr vi u hi t ri eking c are ~ r p ych 1 gi al r phy i 1 gica1 c n ern . Th mu1 tip l em rg ncy i it ~ r care f th exp ri nc , I ha e witne e w m en ften ha v arne c nditi n , which in id entifi d a n gati e c n qu nee r u1ting fr m pa t m e ca e , have been ual a ault d b th the h rt and 1 ng t rm effect of exua l p ri nces. Thu in my ual a ault can have on w m n. A a r ult, I ~ 1 it i imp rtant t inve tiga t th r 1e th r ugh D llow-up care mi ght have in d crea ing the n ega ti ve health c n equ nee experienced by thi vulnerabl p pu1 ati on. A menti ned exual a ault can ha e a ignifi ant nega tive impact n th 1 ng- tenn health of wom n but it i le cl ear whether the role f fl 11 w up care can help le sen the impact or prevalence of the e health chall enge . Th ere~ re the purp e of thi paper is to inve ti gate, in the re earch literature, the qu e tion: In adult women f childbearing age who have ex peri enced a recent exual a ault, can acce to po t-a ault fo llow- up care within two weeks of the as ault decrea e the prevalence and severity of po t-traum ati c stre s di ord er (PT D ) and depres ion? This proj ect introduces the topi c of exual as ault fo llow-up care, provides fu rth er background information, and discusses the purpose of thi review as well as the theoretical fram ework used to synthesize it findings. The literature rev iew m ethod and earch trategy will be examined and the findings ynthesized u ing th e theoretical fra mework with analy i and discus ion of the data collected specific to fo llow- up care of wom en after exua1 a ault. R econunendations will be provided for furth er research, practice, edu cation, and policy. Background Hi storical Perspective ex ual as ault i perva ive and entrench d tlu·o ughout hi tory, and con ider d by ome to be a growing epidemic. However, the tenn e ual a ault it elf wa only introduc d within 9 anada o er th la t thirty y ar . Th riminal th t nn "rape r :D rring only t a au lt and ducati n oun il f 111 anada [ I de f anada prior to 1 1 ing aginal r anal pen trati n ( ex In£1 rmati n ], 20 11 ) . The intr du cti n of the t 1111 exual ual act ran ging fr m unwanted a ault allowed :(1 r a br ad r definition of n n-c n n ual ki ing and touching to penetrati e nly rec gmz d 20 11 ). H w ver d pite thi change, 1 than 10% of exual a ault are r p rt d t p lice (Brennan & ayl r-Butt , 2008) . Health Con equ ence exual a ault again t w m en i n t nl y und errep rt d, but m r imp rtantl y, it victim areal o medi cally under erv d. '· iol ence take a t II on the health of an individual , re ulting in risk-taking behavior health probl em throughout their adult lifetim e and for many, re ulting in death " (Fergu on & p ck, 20 I 0, p. 153). xual a ault remains a compl ex i sue and whil e its long term impact are not completely understood, there ulting negative health con equences can have a detrimental effect on the quality of life of women. They can al o fu11her hind er recovery and perpetuate the cycle of pain and uffering. Negative p ychological health effect may include anxiety, avo idance coping, decrea ed elf-es teem, PTSD , depress ion, substance use and suicid al ideation (Padden, 2008; Wadsworth & Van Ord er, 20 12). Phys ica l health effect may include heada ches, facial and back pain, immune system suppression, gastrointestinal problems, and gynecological/reproductive health is ues (Ray & McEneaney, 20 14 ). These negative phy ical health effects often occur as a result of physiological tre reaction a ociated with the development of PT D and depres ion (Padden, 2008). Therefore, it is the purpo e of thi paper to address the follow-up care needs of women who have ex perienced e ual a ault in the hope of decreasing the prevalence and everit y of PT D and depre ion and their as o iated n gative hea lth con equ ence . 10 Po t-traumatic tre conditi n that ccur after p ychol gica l tr di ord er. P t-traumati po ure to a traumati c tre di rd r 1 a typ f m ntal health ent, u ch a e ual a ault au mg ev re gica l, p ych logical and reacti n r ulting inn ga ti con equ en e ( hiver -Wil n, 200 ). 1agn f intru i n ympt m ti all y ignificant m anife tation r rec ll cti n a ci 1 gical f PT D idanc b h avi ur , negative in lud th pr n c gniti e or m d alterati n , and hyp r-ar u a! m ani .D tati n related to the traumati c v nt experi enc d with ympt m Ia tin g gr ater than ne m nth ( m eri can P ychi atri c ual a ault are am ng th [APA] 201 3). W orn n wh e pen enc e at greate t ri k D r the dev lopment of PT D with e timati n of 30% t 50% devel ping the di 2006; Ray & Me neaney, 20 14 ). Whil e r perp etuate mani.D tation c iati n rd er ( hiver -Wils n, arch allud e t bi 1 gical di turb ance that m ay een in the pr ence of P D (Bun eviciu , Le erman, & irdl e, 20 12), greater empha is is pl aced on the p ychologica l and ociological factor that contribute to women' ri sk for PT 0 deve lopm ent. egati ve elf- percepti on, shame and elf- bl ame have detrim enta l effects on a woman' p ychological health (Chivers-Wilson, 2006). Thi s negative impact i furth er perp etu ated by societal influ ences such a attitud es that promote victim bl aming and rape-m yth acceptance (Chivers-Wilson, 2006). xampl es of prevalent rape-m yths includ e beliefs that wo men often li e about being exuall y assaulted (Chiver -Wil on, 2006), that women who dress provocatively ask to be sexually assaulted or that wo men onl y ex peri ence exual assault if th ey were assaulted by a stranger in a dark all ey (W om en ga in t Violence gain t W omen, 2014). These victim-bl aming attitude can have a detrim ental impact on th emotional and psychological well-being of wom en after sexu al a ault. Psychological di stre a sociated with PT 0 also ca n produ ce phy io logica l m anifestation that furth r impac t the hea lth of wo men after e ual a au it. Police report that 11 xual a aul t data dem n trat r ughly 60% f femal d n t u tain any phy ical inj urie at the time of a ault, with 24% r p tiing min r injurie n t requiring m edical int rventi n (Vaillan ourt, 201 0). H wever de pit the ab ence fa ute phy ical injury rep rted by 4% of women (Vaillanc urt, 201 0), long- tetm negati vari ance in v rity (Ray Me nea ney, 2014 ). health ympt m I gy ar not uncomm n with an exampl e, (2006) po it that w men with rape and abu e hi t n e ar pelvic pain th an th e without a hi t ry f abu e. handler, iccone and Raphael ight time m ore likely to xp n ence ther phy ica l manife tation may includ e abdominal pain, dige tive pr blem , headache , back pain and immune uppre ion second ary to tre reaction (Ray & Me neaney, 20 14 ). The e potenti al hea lth con equ ence hi ghli ght the importance of inve ti gating whether earl y interventi n can h lp decrea e the preval nee and everity of PT D and prom ote recovery in wo rn n aft er exual a ault. Depression. It i well e tabli hed within the literature that wom en are at ri k fo r developing depression after sexual assa ult. Chandl er et al. (2006) fo und the pre ence of major depressive di sord er (MDD) to be ignificantl y associated with self- reports of sex ual assault. W omen with depre sion are two times m ore likely to report having been ab u ed in their life and also more likely to have experi enced phy ical or exual violence over the precedin g year (L vine et al. , 2008). Whil e the causative fac tors for depression are similar to those de crib ed previou ly fo r the development of PTSD , negative di closure re pon e and negati ve self-cognitions are beli eved to be significant chara cteristics used in the predi ction of depre ion developm ent ( ampbe11 , Dworkin, & abral, 2009). Depre ion ca n have a detrimental impact on the health of wo men after ex ual assa ult, affecting not onl y their mood but their quality of liD . Tho e with deprc io n o ften report ignifi ca nt impairments in the area of m ntal hea lth, ro le and , ocial fun ctio nin g a well a bodil y pain (Levine ct a!. , 200 ). Levine et al. fou nd in their tudy that 12 h alth care utilization rat w re higher in w men wh rep 11 d abu ho pitalizati n than tho with ut an ab u e hi t ry. related to th InJUn chronic r and a ft n h with m re frequent pitalizati n ar n t dir ctly u tain d a a r ult f th a ault but in t ad ar rna tic c ndition (Le ine et al. 200 ). Th effect uch highli ght th tmp t1an f depr f i n are far r aching, f inve ti gating whether id entifyin g trat g1e t better care for worn n after exual a auit can aid in decrea ing the prevalence and Initial ft n xac rbation v rity of depr n. ex ual A ault Care M ana gem ent nly 27% to 40% of women wh ha v experienced exual a ault eek m edical care immediately after the a ault (Tavara, 2006). f th who do eek care, it is e timated that only 10%-31 % eek follow-up care after thei r initial care managem ent (Ackerman t al. , 2006) . Wad worth and Van rder (20 12) as ert that th e initia l managem ent of women who experi ence sexual a ault is critical a recovery begin with an empatheti c and uppot1i ve respon e wherea care provided with insensiti vity and incompetence can further exacerbate a woman' feeling of guilt, shame and powerle sne . The e nega tive experiences can affect a woman' wi II in gne s to seek follow-up care for the assault. Many primary care provider (P P ) do not routinely provide care immediately following exual a ault in more urbanized area a many women eek care throu gh loca l em ergency depat1ments or are refened, when available, to speciali zed se ual assault or forensic nurse examiner programs for these examinations. However, it i e entia! that P Ps have an und erstanding of the initial care provid ed a they will often ee these same patient for follow -up and routine longitudinal care (Ray & Me neaney, 20 14 ). Furthennore, it i imp rative that P P working in rural area b aware of the initial managemen t of women who have been sex ually a saulted as sp cialized ervice that provide care in the acute aftem1ath of as ault may not be readil y ava ilabl e in these tting . 13 Follow-up are Whil th lit ratur [! r acut m di al [! r n i e aminati n f ual a ault appear to be robu t th availability f rec mm nd ati n [! r primary health car [! 11 w-up 1 Availabl e guid line pr vid r c mm nd ati n on the immedi ate p carce. t-a auit care [! r w m en, but provide limit d guid ance[! r care to help w m n c m e t term w ith th em ti nal a pect of being a ault d. Thi i an area that m any primary car provid er need to inc rporat in their care ofw men who have been exuall y a ault d, h w ver cunent guid eline are vagu ab ut what thi care entail . T here are two re urc ava il able that prov id e recommend ation to po t- exuai as auit fo llow-up care within a prim ary health care ttin g. They include the Guidelin e fo rM dico-1 a/ are for Victim of Sexua l Vio lence and Sexual Violence: A guide for p rimary care P . p ecific arin for Survivors of tabl e comparing and contrastin g recorrunendation for follo w-up care has been compil ed to demonstrate vari ance in the care provided to women po t- exual a ault. ee Appendi x A : Po t-A ault are Recommend ati on This table provide a quick glance at recomm endati ons for fo llow-up care after sexual as ault and easil y identifies gaps in the m ental hea lth and emoti onal care recomm end ation fo r the e women . Further in-depth analysis and di cus ion of these document will be provided within Chapter Three. Nurse Practitioners T he impmiance of comprehensive follow-up care is applica ble to all health care profess ionals who provid e care to wom n after sexual assault, includ ing nur e practitioner (N P ). Nurse practiti oners are hea lth care pro fe ionals who autonomou ly deli ver vital hea lth ervices utili z ing " the ir in -depth kn w ledge of advanced nur ing practice and theory, hea lth management, hea lth pro m ti n, di ca e/i njury prev ntion, and other r I vant biomedi cal and 14 p ychoso ia l th on to pro id c mpr h n i 2010, p. 5) . Within rimary h alth car tting h a lth P ma y pr vid .G 11 w-up care D r a recent xual a ault r in t ad may pr vid e care r lated t a and di clo d during a r utine vi it Ray ual a au lt that ccuned previou ly M e n an ey, 20 14; utherland 2014) . iven the prevalence f exual a ault lv ont n t, & Fanta ia, P will likely encounter w m en who hav xperienced thi vi lent crime. There.G re it i imperati ve that familiari ze them ciati n, r 1ce ' ( anadian Nur P and th r P P alike, with the care needed D r thi p pul ati n. cope of practice. It i within the P c pe f prac ti ce t independ ntly di agno e and manage the care f women po t- xual a ault, includin g th e nega ti ve emotional and psychological equela e that may develop ( oll ege of Regi tered [CRNB ], 20 15 ). Po t-traumatic tr ur of Briti h olumbi a di ord er i th e onl y m ental health conditi on requiring some level of phy ician con ultation for dia gno i confinnation or m anagem ent pl anning (CRNB , 20 15). However, furth er specialized theoretical and clinical experi ence are important components for profes ional development and competency in caring fo r women after exual assa ult. Forensic nur e examiner courses provide training to nurses and other hea lth care professionals in the provision of comprehensive and en itive medico- legal examination for all persons after sexual assa ult. M ore recently, the British Columbia In titute of Technology (20 15) began offering thi s training to health care professional as a means to stand ardi ze the car provided to person after sexual assault. Recommended courses includ e the Forensic Nur e xaminer Theoretical and Practi cal Applicati on course . The e cour es provide compr hen ive training in the medical and for nsic care need of patient after exual a sa ul t. Whil the majority of these cour es focus on the initial care management after e ual as ault, compon nt of the training al o includ e the importan e of und erstanding and responding to the long-tem1 15 p ycho ocial and p ychol gical con equence a ociated with xual a ault. The kn wl dge and competency exhibited by health care profe ional can hav d trimental effects or conv rsely can tart the recovery proc (2009) tre for women who experience exual a ault. Lane and Dubowitz the imp rtance of increa ed experi ntial know ledge and the profound effect it ha on provider confid nc and comfort in caring for tho e who have experi enced sexual a ault. Nurse practitioner can better prepare th em elve for thi role by taking specialized continuing edu cation cour e and e king out opportunitie to prov id e care [! r this specialized population. The Fra er Health uth01ity within Briti h N urse Practitioners for British olumbi a rec ntl y received fundin g from the olumbi a program (NP4B ) to develop and implement a clinic that provides follow -up care to person who have experienced exual violence. The mbrace Clinic is led by two P who provide regional mobile-outreach health services to per on after sexual violence using " a trauma-inform ed approach that recogni ze the impact of traum atic experi ences on an individual' s phys ical, emoti onal, psychosoci a l and spiritual well -being" (Fraser Health Authority, 2015 , para. 4). Telephone contact is made wi thin 72 hours of a refenal to their clinic and care intervals are determined based on the needs of the patient . The e NPs work in close partnership with various organizations to meet the physical, medical, psychological and emotional safety needs of persons within their care. Fmihermore, they are actively involved in program development, collaborative partnership building as well as advocacy for education, awareness and policy changes aimed at improving the health of persons after sexual violence. Barriers to Follow-Up Care Provid er time constraints. Time constraints are often seen a a barrier to compr hensive care of the complexiti e a, sociated with sexual assault. Multipl e competing demand , brief appointment blocks, and the unpredictabi lity of th emotiona l need of women pre enting for 16 ar aft r ua l a ault pr e nt a ca re ( uth erl and et al. , 20 14) . T h an al furt her a hall e nge t ap r id r' ab il it t d liv r compr h n 1ve e c n traint n t nly impa t the care d livered to women, but r at w m n' e m ti na l di tr a they m ay ft n ~ el ru hed, ummp rtant run upp rt d . Documentation. Th rou gh d cum ntati n f hi t ry, a e m ent and ca r pla nning allow £ r c ntinuity f are am ng t mu ltidi ciplinary t am m emb er inv lved in the care f worn n aft r ual a ault. It al o dec rea e th e ri k f re- traum atiza ti n that ca n b a with repeated di clo ure to new pr cia ted id r . T im c n traint are cited a a maj r barri r tha t limit the time P P have to thoroughl y d cum nt th eir a e m ent and plan fi r care ( utherlan d et al. , 2014 ). Docum entation ma y al have ig nifi ca nt impli ca tion for lega l proceeding . Improp r r inc mpl ete docum entati on m ay no t accurately de cribe th e characteri tic of the di clo ed a ault or the impact it has on th e wom e n w ho experi enc d it. Provider comfort level. Comfort with prov iding fo ll ow-up ca re to wom en after ex ual assault reduce the ri sk for re- traumati za ti on and aids worn n in th eir recovery . Lack of com fo rt can occur fo r m any rea on uch a lack of fa miliarity w ith th e fi llow-up ca re needed by wo men after exual assault, lack of exp eri ence in carin g for thi p opul ati o n, personal di com f011 in providing the care and a lack of availabl e re ources (1 akubec, a1ier- nell , fr im , & kanderup, 20 13 ). Decreased exposure and decrea ed co ntinuing m edi ca l educa ti n m ay be re pon ible for low level of co mfort and compe tency w hen pr v idin g follow-up care to wom n after e ua l assa ult (Jakub ec et al. , 20 13). Geographi ca l con sid erations. tati ti p pul ati n In anada (20 I I ) report that roughly 20° o f th an ada re id e w ithin rural co mmuniti e . eographical i lation reprc cnL a hea lth eli parity th at a f~ t wom en w h have e peri need c ual assault from recci\ mg 17 equitable care that i acce ible to women living within urbanized area . Lack f available re ource and acce to em rg ncy or p cialized care rvices, tran potiation limitations, and fear of retaliation or repri al fr m the of~ nd r or the community it elf r pre ent barrier to women acce ing care (Averill, Padilla, & lem nt , 2007) . In addition, there are often greater conce111s for confid ntiality found within maller rural communiti e (Padden, 2008) . While there are many barrier to follow -up care for all wom en, g ographical i lation and socia l functioning repre ent an additional chall nge for tho e li ving within mailer communities. Psychological and ociological con sideration . elf-blame, hame and embarras ment are strong negative emotion that can prevent women from seeking ~ llow-up care after exual a sault (Padden, 2008). Fmihermore, fear of not being believed and concerns about breach of confidentiality can also impede women from eeking care (Jakubec et al. , 2013 ; Padd en, 2008) . Negative social reactions from friends and fami ly and the societal perpetuation of rap e-myth are strong social factors that can cause emotional and psycholo gical distress to women after sexual assault. "The trauma of [sexua l assault] extend s far beyond the actual assault, and soci ety's response to thi s crime canal o affect women ' well-being'' (Campb ell et al. , 2009, p . 226). Fear of secondary victimization and judgment can act as a barrier to follow -up care for these women. Theoretica l Fra mework An ecological framework was utilized to synthesize the literature findin gs examined within this proj ect. It is well known that the experience of sexual assault can have detrim ental effects on women 's emotional and mental health , however, the eti o logy and strateg ie to decrease the severity of th ese con equence are less clear (Campbell et al. , 2009) . fram ework i ground ed in the belief that no one factor can n eco logical plain th e nega tive hea lth effect ex peri enced by women after sexual assault (Viol n e Prev ntion Alli ance, 20 15) . The negative 18 equelae of xual a ault in tead ne d to be con ide red from th e perspective of varyin g level of influence and th e interaction that occur between the e level (Dubo c taL 201 2; Violence Prevention Allianc , 2015 ). "The utility of an ecol gical fram ework is that it can ugge t multipl e trategies, at multipl lev 1 of analy i , for all eviatin g the p yc hological harm caused by xual a sault" ( ampbell et al., 2009, p. 226) Thi s proj ect will therefore e amine the eco log ical co mponent that influence th e mental health of women after sex ual a ault. It i c mpri ed of fo ur eparate lev Is of influence: the indi vidual leveL per onal relati on hip leve l, co mmunity I ve l and oc ietall eve l (Campbell et aL 2009 ; Violence Pr v nti on Alliance, 20 15). e Figure 1: Eco log ical Framewo rk . Within each leveL the ecolog ical approach examines the interacti on between a vari ety of factors such as bi ologicaL economic , cultural and the soc io-politi cal con tructs (Henry & Powe ll, 20 14 ). lt is the interactions that occur between women and th ese level of influ ence that impact hovv a woman perceives her experi ence and her role in its occ urrence (Campbell et a l. , 2009). Figure 1: Eco logical Framework (Quadara & Wall, 20 12). Individual The indi v idual leve l of influence examines the biologicaL psychological and social characteri stics of wo men who experie nce sex ual as ault and the impact it has on their reco\ cr) process (Campbell et al. , 2009). Age, pre-ex istin g mental health conditions and se'\ual assault characteri sti cs such as the usc of a wea pon arc examples or individual levels or inlluencc that 19 may negatively impact the p ych logical well -being fa w man after e ual a au lt ( ampb 11 et al., 2009) . Examinati nat thi lev 1 all w for a b tt r und r tanding f the "ch 1ce and pro pen iti "of wom n wh e peri en e e ua l a au lt and int raction and f~ ct e n within the higher level ften erv a the ba i ~ r f inOu enc ( ampbell et al. , 2009, p. 228). Th per nal relation hip le el o f inOu nee e am111e " th e impact f di c lo ur in-D nnal ourc f uppo rt ( .g., fami ly and friend ) on victim ' p to ta ault p ychological di tre " ( ampbell et al., 2009, p. 22 ). There i a grea t dea l of empha i within the literature ab ut the impact p itive and nega tive rea ction fr m fri end and fami ly have on the emotional and mental h alth of women after exual as ault. ega tive reactions, such a blaming attitudes and di belief can further traumatize w m en thu increa in g their psycholo gical di stre s (Padden, 2008), whereas positive reaction and upportive relation hips ca n he lp promote recovery (Hellman, 2014). Examination at this level is imperative to und erstandin g the per anal relationship risk factors or recovery upport available to women after sexual a ault. The c01rununity level of influence examine disclosures and interaction within more formal sources of support such as community resource services, sexual assault serv ices, as well as m edical and legal systems (Campbell et al., 2009). The negative experi ences at thi level are not only a significant barrier to disclosure but also serve to reinforce negati ve elf-perception, shame and self-blame thus increasing the psychological di tre experienced by the e women (Kelleher & Me illoway, 2009). Furthermore, geographi cal isolation can further impact the emotional distress experi enced by women . A an exampl e, women in remote communitie may not have access to health care servi ces, may b co ncerned with the confidentiality of their care or receive ca re by provi ders with no e peri ence or trai ning in the care of women after e. ual 20 a ault. A thi can hav a detrim ntal impact, xamination at thi 1 vel can help inf01m trategie to d cr a e the di tr Th ciat d with th ocietall vel of influ nee xamine the cultural nonn e nega tive interaction . CI ultural fa ctor uch a cia l and rape-myth acceptance and gend r tere typing that attrib ute re. p n ibility D r exual a au lt nt the women who xperience it ( ampbell et al., 2009) . Thi r inforces the negative elf-percepti n , self- blame and ham their p ychological di tr xperi enced by mew m en thus increa ing and pr pen ity forth devel pment f PT D . For exampl e, the widely h ld beli ef that if w m n dre s provoca ti vely, they are a king to be exually a saulted may alter women's percepti on of th ir role in the a ault leadin g t cognition and emotional di tress. elf-blam e, negative elf- xamination at the oci tal level i important to help inform trategies aimed at changing pre-ex isting ocietal belief: and va lu e . The ecological framework places equ al importance on each level with the beli ef that a dynamic interplay among the levels exi t which influences the factor of each level (Kell y, 20 11 ; Violence Prevention Alliance, 20 15). As an exampl e, Campbell et al. (2009) discuss the concept of self-blame, arguing that it tran cend any one level of influ ence a se lf- blame terns fro m the individual, personal relationship , community and societal interaction experienced by women after sexual assa ult. This highlights the impOiiance of examining the mental health impact of sexual assault throu gh an ecological perspective as only then can the ignificance of a multi-level primary care response be und er tood and approached . An ecolo gical approach to synthesis and analy i f the literature, focusing on the individual, their per onal relationships, community and societal factor a socia t d with e ual a sault and its impact ha been undertaken. Within th litera ture r view, you will note that ome tudi e w ill b reviewed in one contc t r level, but may b r levant within other level a well. 21 This i becau e exual a ault d e n t occur in i olati n but in tead c ntain factor that are dynainic and pertain to more than one 1 vel. 22 H PT R W Integrati ve R eview Method Th purp e of thi int grative literature r vi ew i t d tennine wh ther acce a ault follow -up car within tw w k fr m th time f to exual ual a ault can re ult in a decrea e in th preval nee and ev rity of PT D and d pre i n in adult w men f childbearing ag . In rder to an w r thi qu e ti n, the literature follow -up care in both urban and rural ar h invo lved examining any urce pertaining to tting . Thi int grative literatur re iew wa c nducted utili zing th m ethod a et forth by Whittemore and Knafl (2 005 ). Thi m ethod wa appr pri ate for thi review a it incorporate data obtained from vari u tud y typ e uch a qu antitati ve, qualitati ve and literature review s. Whittemore and Knafl ' method con i t of fi ve tages: probl em id entifi cati on, literature search, data evaluation, data analy i , and presentation. Literature Search Methods This section will di cu the literature search strategies utili zed to select the sixteen studies, three clinical practice guideline and upplem entary articles used w ithin thi project. Inclusion and Exclusion Criteria The inclusion criteria for this proj ect comprised research data regard ing fo ll ow-up care for adult women of childbearing age who have experi enced exual a ault. Exclu ion criteria included any data relating to patient le th an 18 years of age or m en who have e perienced sexual a ault. In addition, arti cles publi h d before 2004 were exc lud ed. Tab le 1: In clusion/Exclusion riteria Inclusion Criteria Arti cles published 2004 or later fEnglish language Exclusion Criteria Arti c les published earlier than 2004 Languages other than English 23 or R earch arti Literature earch One n initial literature earch w a c ndu cted u ing th e ni ver ity f N rth m Briti h utilizing ea rch term and keyw rd a id ntifi ed in ppendi B . M aj r ncept in lud ed s xual assa ult, ~·amin a l ion, fo llow-up are, p rimary are and . que/ae. T he e c ncept and imil ar ea rch term were ch en a they repre ent the variou term appli ca bl t th qu e ti on being re earched . Th e Boo l an phra e ''o r" w a utili zed wh en ea r hin g with lik term a ll w ing fo r grea ter re ult w ith le overlap . The Boolean phra e "and " wa u d when ea rchin g ubj ect heading and enabl ed results which yielded applica bl e informati on on ex ual a ault and fo ll ow-up care. A earch f the IN AHL databa e yielded 6,134 articl e for review and 1, 164 arti cle after the applicati on of the inclusion criteria. A ea rch of th e M DLINE databa e yield ed 17,709 arti cle fo r revi w and 459 1 ati icles after the applica ti on of inc lusion criteri a. R eview of th fi r t 450 artic le of the CINAHL databa e yield ed even miicles fo r u e w ithin thi proj ect. T h review of thi earch wa di co ntinued a these earche re ulted in too m any article fo r a thoro ugh review . The seven a11icles selected were kept and add ed to elections made fro m litera ture earch two . Literature Search Two T he second ary sea rch was rev ised t incl ud e onl y the emotio nal and menta l health [! llow- up care need of wo men o f childbearing age after , ual a sau lt. The search tcm1 \\ere revised t re Oect thi focu change and to help narrow th e . earch r r app licable articles . 'e 24 n ept and imilar t rm . he B ol an phra e" r" wa uti I iz d wh n Table 2 [! r Maj r earching with like tenn all wing D r greater re u 1t with 1 ft r ca re • • • e ual abu e e ual violenc Rape v ictim • • • • • • • • p t-e p ure D 11 w-up F 11 w-up M edi ca l [! 11 w-up t t [! 11 w-up P y h l gi al [! ll w- up Health care n eed Trea tment eekin g behav i r H elp- eeking beha i r • • • • • • • • • • • • erlap . Rape- trauma yndrome r atm nt c mpli ca ti n c mpli ca ti n cute tre di rd er rd er, p t-traumati c mpli ca tion Treatment utc m e cia! pr bl cm lf-m edi ati n ti gma H ea lth Impac t A Victim Similar to literature earch ne, the Bo lean phra e "a nd " wa u ed w hen arching subject heading and imilar tenn and enabled re ult which yield d applicable infonnation on the exual as ault and follow-up care pecific to mental health equ elae. A earch f the IN AHL database yield d 342 article for review and 18 article after the applica ti on of th e inclu ion and exclusion criteria. A earch of th e M DLINE databa e yielded 68 arti cle for review and 21 articles after the application of inclu ion and exclu ion cri teria. Tlu·ee arti cle were duplicates from the INAHL search and were thu eliminated 1 avi ng a total of 1 artic le A combined total of 36 article from INAHL and M DLIN were reviewed. lo cr in pection of the articles re ulted in elimination of 2 article as so m e focu ed n acute care management following ex ual a au it rather than th e [! llow-up ca re need of women within a primm· care cttin g. ther were eliminated a they either did not prov ide a ny guid ance or rcc mmcndation for[! ll w-up ca re n d of w me n or th ey pro id cd recomm end ation , pecific to other ·arc eli c ipline n t app li able to th e primary ca re rol e . h ·c exc lu sion · yi ' ld cd a total or nine 25 article for inclu ion. The ixteen article for u mbinati n f literature arch ne and earch two yielded a total of within the literature r view. The literature earch al o yi ld ed a t tal f three guidelin care of women after exual a ault. The pr i u ly de cri bed applicable to the follow-up IN HL databa e earch yielded one document for use and a hand earch f the article reference li ts u ed within this proj ect identified a econd document for inclu i n. A earch of the World Wide Web u ing the tenn exual a aultfollow-up care guideline and primary care yie ld ed two document for use and a imilar earch u ing the tenns trauma iJ?formed care guidelin es yielded one document for inclusion. As few relevant guidelines for the follow-up care of women after sexual assault exist, documents developed ea rlier than 2004 were included for review . ne of the five documents was eliminated as it wa a duplicate and another document was eliminated as it contained no recommendations for follow-up care within a prim ary care etting. Therefore a total of three guidelines were collected for use within this literature review. Grey literature and supportive articles were searched using the UNBC databa es, Google Scholar and the World Wide W eb. In addition, a hand search of supportive literature was further conducted by reviewing available article from previous assignments and resources utilized during my studies within the Fmnily Nurse Practitioner Program at UNBC as well as a hand search of the references used within this project. 26 HAPT R THRE Findin gs The earch m thodol gy d crib d in hapter Two re ult d in a total of ixteen tudi and tlu·ee guideline for u e within thi literature review t an wer the re earch que ti n. Thi hapter will analyze the clinical practi c gu id line with pecifi c recommendations for po tsexual as ault m ental health follow-up care. It will al gathered from the lected tudi e u ing individual, per onal r lati n hip , community and ocietallevel per pective a Furthermore, this ynthe ize and analyze information et :fl rth in the eco logical framework discu ed in hapter ne. hapter will al o highlight recommendation mad e within these tudies specific to the emotional and p ychological follow-up care need for women after exual as ault. Clinical Practice G uid elin es Clinical practice guidelines are ystematically developed reco1m11endations that guide health care providers' decision-making about appropriate care, screening and management for specific health challenge or circun1stances (AGREE Next Steps Consortium, 2009). There are few practice guideline available that address the follow-up care need of women after exual assault with fewer addressing the emotional and psychological needs of women. This section will review three documents offering recommendations for follow-up care after exual a sault. The World Health Organi zation [WHO] (2003) created a document called the Guideline for Medico-legal Care for Victims of Sexual Violence. The main purpose of thi document is to gui de the immediate forensic and medical health care of persons after sexual as ault. Little guidance is offered for follow-up care within the primary care tting. Thi document was developed in collaboration with multiple intemational partner from variou countri . It was also peer reviewed by an xten ive li t of intemational expert in the field of se ual violence and 27 the need of p r on after e ual a ault. Thi guideline i pe1i-based with upp 1iive lit rature citation throughout the document. A are ult no cientific proc wa identified or grading y tern for the trength and quality of the rec01nmendation provided within thi document. The WH (2003) document i 154 pag in length with only thr page devoted to the di cus ion of the medical and mental health£ llow-up care for persons po t-as ault. f these pages, ju t over one page i devoted to th mental health needs of per ons after sexual assault. The author recommend follow -up care interval at two week , three months and six month to address the medical and emotional tatu of patient , with recommendations to refer as necessary (WHO, 2003). These interval appear to be based on the m edical care needs more than the mental health care needs of patients a each visit interval represents a time period for particular medical testing or investigation. o guidance is provided about specific m ental hea lth assessments. Instead , empha is is placed on refenal to supp01i organizations and counseling as necessary. The authors provide suggestions that help providers relay to pati ents the benefits of counseling and offer a list of suggested supp01i services for practitioner to con id er. A limitation of the WHO (2003) do cument is its reliance on expert opinion, however, the extensive list of international contributors and peer-reviewer certainly add s strength to its recormnendations . This document offers guidance for care providers in the imn1ediate medicolegal care after sexual assault which can be beneficial for those working within rural and remote communiti es without access to specialized services to provid e such care. However, for the purpose of this project, this document provides limited insight into the emotional and psychological care required after sexual as ault. This guideline pmiially an wered my re arch question as it provides recommendations for follow-up care timing intervals and provide sugge tions for support services referral considerations. 28 Ray and Me neaney (20 14) d v loped a more r c nt d cument call d Survivor of Sexual Violenc :A Guide fo r Prima ry aring fo r are NP . Th author clearly state th purpo e f thi document i to provid r conunendation that improve the care w men rece ive after exual a ault within the p1imary care etting. Whil thi document i gear d to th care provided by NP it i applicable to all primary health car pr vid rs . hi guide i ba ed on the expert opinion of the author with upp rtive literature d cum entation. A uch, there is no identified cientific proce , and no trength or qu ality grading of the literature u ed to upport the expert opinion provided within thi document. Ray and McEneaney (2 0 14) provided an overview of exual as ault and its conunon phy ical and psychological con equ ences with reconunend ation for the inunediate care required post-assault. As many wom en do not eek health ca re service after sexual assa ult or are Jost to follow -up care after the initial care management, the author emphasized the importance of implementing screening practices within primary care offices. Whil e screening is not pertinent to answering my current research question, it mention within this section draws attention to an area for possible future explorati on of the value and imp act screening has within the primary care setting. Ray and McEneaney recommended NPs provide individualized, patient-centered care in a supportive and non-jud gemental mmmer that offers a safe environment for wo men. The majority of follow-up care recommendations provid ed within thi s document pertain to the way in whi ch NPs can decrease the anxiety and emotional distress associated with pelvic examinations thus preventing further re-traumatiza tion. As the Ray and Me neaney (201 4) guide is ba ed on expe1i opinion, the trength of it recommendati ons is limited. While upportive literatu re wa used throu ghout the document, no literature selection process or evidence grading was provid ed, nor wa there any indi ca ti on a 29 peer-rev1ew proce occmTed . De pite th e limitation , Ray and Me neaney provid d an ea y to read guide for the care of women after exual a ault. They ofD r helpful recommendation for pelvic examination which can be one of the more em ti nally di tre ing a pect of follow -up care for women after exual a ault. The author r commend follow -up care interval within one to two week of the a ault, two to four we k , i w ek , and three and six month a indicated by medical need with each vi it repre enting an pportunity to a e m ental health status . Thi s document helped to partially an w r my re earch qu e tion by offering rec mmendation for follow-up care provided by P within the primary care setting that aim to decrea se the emotional distres experienced by women po t-as ault. The Briti sh olumbia Center for xc II nee for Women's Hea lth [BCCEWH] (2 0 13) published a document called the Trauma-Informed Practice uide. he purpose of this guide is to support the transfonnation of trauma-informed principles into practice with the overall goal of bettering the care provided to those with histories of violence and trauma . The implementation recormnendations within this document are expert-based with the addition of suppOiiive literature. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess the strength and quality of this practice guide with scores provid ed over six domain . Domain one examined scope and purpose achieving an overall score of 90% whil e domain two scored 76% for its description of stakeholder involvement. Domain three scored 52% in te1ms of its developmental rigour while domain four examined clarity of pre entation with an overall score of 86%. Seventy-one percent was attributed to domain five for applicability of the recommendations while domain six received a score of 57% for its editorial indep nden Despite the low er score for rigour and editorial independence, the overall quality of this document wa rated as 7 1% . See Appendix for the complete A RE II a essment of thi 30 document. Thi guide offer reconun ndati n for impl mentation of trauma-informed care at the organizational and provider level with the cav at that provider approach ne d to be tailored to m et th ne d of pecific trauma exp ri need and the individual n ed f each patient. The B CEWH (2013) provided rec mmendation for trauma -infonn d care that embodie the principle of trauma awar n and connection a well a , afety and tru tworthine , ch ice, collaboration trength promoti nand kill building. Whi le this document is not pecific to only exual a ault, the underl ying premi e of care and hann -reduction is empha ized with the overall goal of e tabli hing a po itive and supp rtive relationship with patient that minimizes emotional and psychological distre andre-traumatization. This document offer recommendation for providers that can be tailored for the care of women after sexual a aul t and as uch, serve to partially an wer my re earch question. AGREE II . The AGREE II tool for appraising guideline was used to eva luate th e BCCEWH (2013) guidelines as the entire document has implications for use within primary care. The guidelines for WHO (2003) were not evaluated using this tool as the reconunendations for practice related to the mental health follow-up care of women after sexual assault consisted of just over a page of counselling and referral options for patients. Concrete recmmnendations were not made with regard to mental health follow -up care, but instead expe1i opinion of what resources may be helpful for women. The Ray and McEneaney (20 14) document wa not assessed using the AGREE II tool as this document was presented in a1iicle fonnat repre enting an informal guide for the care of women who have experienced sexual violence. In summary, this section examined three documents which have been dev loped to guide hea lth care profes ionals providing care to women after exual assault. Each of the e document offered recormnendations that partiall y upport my research qu tion tiu·ough in ight into the 31 m ental health need f women po t-a ault. Two of the document provid e recomm ndati n on how to approach and implement thi car at either apr vider or organizational ! vel that minimize the motional di tr exp ri need by the e w m en . Individual L evel of Influ ence Information examined at the individu al! vel includ the per onal hi tories, biological fa ctor and a ault characteri sti c th at influenc a w man' emoti nal and p yc ho logical re pon e after ex ual a ault ( ampb 11 et al. , 2009). Factors w ithin thi level can h ave a profound effect on a wo man' abi I ity to co pe w ith th e emotional trauma as ociated w ith sexual assault. Thi section examine even tudi e pr viding in ight into the individu al fac tors related to fo llow-up care prevalence rate , ri k fac tor fo r sexual a ault, exual assault characteri ti c , a well as the impact of past exual a ault experience and m ental health historie of wo men who experienced a recent sexual assault. The first study examined within this section is a retrosp ective cohort an alys is compl eted by Ackerman, Sugar, Fine and Ecke11 (2006). The authors examined what demographic and sexual assault characteri tics influenced access to fo llow-up care after sexual assaul t. A ca ereview of 812 cha11s of women 15 years of age and older who presented to an urban hospital with the repm1 of sexual assault was conducted. Analysis revealed only 35.5% of women received some type of fo llow-up care with 18.5% receiving both m edical fo ll ow-up care and counseling, 14.5% having medical follow-up care onl y and 2.5% receiving counseling only. Demographic information revealed follow-up rates declined as age increased. A lso, lower rates of foll ow-up care were associated with homelessness, underl yi ng p ychiatric disorders, incarcerati on and poli ce custody. xaminatio n of assa ult characteri tics by Ack nnan et al. revealed factors more ugges tive of a perceived threat of harm were a ociated with greater rate 32 of follo w-up care. These fa ctor includ d genital trauma, a ault occurring within thei_r own hom e , memory imp ainnent voluntary alcohol u e, and tran mi sion of infection ( TI ). xually tran mitted onver ely, decrea ed fo llow-up rates were noted w ith charact ri tic indica ting exu al a ault by a partner, a ault within a publi c plac , and ill egal sub tance u e. Limitation of the Ackerm an et al. (2006) tud y includ e th retro pective na ture of the tud y itself. In addition, no documentati on about pa t history f victimization nor whether any fo ll w-up wa condu cted with another organi zati n wa provi ded. D e pite the limitations, thi study highlighted dem graphic and ex ual a ault characteri tic that may make women more or less likely to seek fo llow-up care. Ackennan et al. reported that optimal timing for specifi c care intervention remain unclear, however recommendations fo r fo ll ow -up care that i within close proximity of the a ault itself may be key in identifying and treating those patients at risk for depression, PTSD and substance abuse. Recommendations al o included fo llow-up care that includes both medical care and counselling as few retu1n fo r counseling services alone. Thi s study partially answers my research qu estion providing some recommendation for fo llow-up care that includes both medical and mental health care within close proximity of the sexual assault. The second article relevant to the individual level of influence is a retrospective study by Boykin and M ynatt (2007) which examined the i1npact sexual a aul t characteristics have on fo llow-up care. This study conducted a computerized chart review of 78 adult women who presented to a sexual assault nurse examine ( AN ) program in a large urban center for examination where a sexual assault repmi was made to police. Assault characte1istics revealed 83% of assaults were completed by a single offender, of which 49% were strangers. W eapon were used in 54% of a ault with firearms being the most common at 22% . Phy ica l fo rce wa used in 71 % of cases and 86% involved penile penetration. Boykin and Mynatt fo und 33 a ociati n by B ck r tal. (19 4) and B wn et al. (19 1) indicating exual a ault with the of a weapon wa a ociat d with gr at r le fPT Danddepre i n(a citedbyB ykin u & Mynatt 2007). With r gard t £1 llow-up c ntact, nly 2 % f patient were able t be reached by tel phon fl r a thr e month fl llow-up all de pite c n nt btain d for futur £1 llow-up given by 99% of participant during the initial e aminati n. Th exual a ault characte1i tic within the B ykin and Mynatt (2 007) tud y were not examined with r gard to their impact n attendanc f £1 llow-up care app intm nt a s en in the tudy by A ckennan et al. (2006) but in tead w re included a they can have negative emotional and p ychological con equ ence for w m n . Boykin and M ynatt highli ght a ociation between the u e of coercive D rce and weapon during exual assault with increa ed level ofPT D and depre ive symptom . are ult, Bo ykin and Mynatt tre ed the importance of follow-up care that include not only meetin g the ph ys ical and mental health needs of women, but also care that includes recovery, health maintenance and future prevention. Limitations of Boykin and Mynatt' (2 007 ) re earch include it retrospective nature and its reliance on available documentation. There was no documentation abou t fo llow-up care provided at different sites, nor wa there any data coll ected on the sexual as ault characteristics of tho e who pre en ted for examination without a rep011 to poli ce. In addition, the mall ample size impacts the generali za bility of the e findings to larger populations. Despite these limitation , Boykin and M ynatt served to hi ghlight the difficulty in contacting women for follow-up care and the need for improved, individualized follow-up care to m et the medical and psychologi al need of these patient . The authors recommend ed follow-up care to addre th p ychological need of pati ents starting a earl y a 24 to 48 hour after the initial e amination, with medical foll w- up appointment within one to tw o w ek f th a ault and laboratory tc ting at i , 34 tw lve and twenty-D ur w k inter al . he data and rec mmendati n pr vided by B ykin and Mynatt ffered rele ant evid nee that partially an w r my re earch qu e ti n . Th third tudy e amined i a r Rauchfu (200 ) which - cti nal tudy by M ark, Bitzker, Klapp and pl r d wh ther the pre ence f ual vi 1 nee xp ri nee incr a d urv y the prevalence of chr ni gynec 1 gi al ympt m in adult w m en aged 18 t 65 year . examining the phy ical and e ual abu e ex peri nee of 7 0 w m n at different time peri d in their li e wa c nduct d . R e ult re al d that 4 7 .5% f w men ex peri enced ph y ica l attack 52 .5% experienced e ual a ault with 1 .5% r porting ex ual vi lence with co mpl et d rap e. ignificant a ociation b tween exual vi lence and chr ni c pelv ic pain , vaginal infccti n and dy menorrhea wa found . are ult, th e e wom n often al rate , which as Market al. ugg have higher hea lth care utili zation ted, may ace unt D r why increa ed rate of exual vio lence were noted within the medical etting examined in thi tud y. Mark et al. (2008) noted that 1941 women were eli gibl e for parti cipation in thi only 730 completed the survey. This may be con idered a weakne tud y but of the tudy a lower re pon e rate are often a ociated with hi gher prevalence rate a women with no hi t ry of violence may be le inclined tore pond . A een in other tudi e , a limitation of the Market al. tudy is its cross-secti nal design a it re ult rely on reca ll bia which may lead to over or underestimation of it findings . Regardl e of the limitation , Market al. believe thi tudy supports the theory that experience of vio lence can have a profound impact on women, e pecially in the area of reproductive heal th . Health care provider mu t u e caution in th tr examinations of these w men t prevent p ible re-traumati za tion . Mark et al. al o trc ed the imp Iiance of expl ring the need for aD ty planning and r ~ rral to m ntal health profe .. ionaL t treat re ulting em ti nal and p ych 1 gical mani fe tati n . hi tud o(Tcr pmiial support in 35 an wering my re earch que tion by ffering recommendation for care that may decrea e the prevalence and everity of the emotional di tre A pro pective longitudinal tudy by experienced by worn n after exual a ault. lir ch et al. (2014) examined whether women 18 year of age and old r who reported acute sexual a ault e perienced a clinical wor ening of pain and omatic ymptom at ix week and three m nth indep nd ent f the area of trauma u tained as a result of th exual as ault. Women who pre en ted for car to a AN Program within 48 hour of the e ual a ault were recruited yielding a final ample of 84 women. Financial incentive wa offered re ulting in a follow-up co mpletion rate of 89% at ix weeks and 82% at three months . Ulir ch et al. examined as ault characteristic noting 71% were a saulted by a non-stranger, 8% of women were as aulted by multipl e per ons and 88% repOiied penilevaginal penetration. Fifty-five percent of examinations yielded no identifiable physical finding . Despite this finding, 58% of women repOiied clinically significant new or worsening pain (CSNWP) in at least one body region at the six week follow -up and 60 % at the three month follow-up appointment. Thi1iy-two percent of women reported CSNWP in three or more body regions at the six week follow-up and 28% at the three month follow-up appointment. Slightly greater than 10% of women reported CSNWP in five or more body region at each time point. Areas of CSNWP were widely distributed with the four most cotmnon areas being the head, neck, back and abdomen. Only 23% of CSNWP were in regions where the sexual assault exam noted physical injuries at the six week follow -up with 14% of tho e being present at the three month follow-up appointment. Ulirsch et al. (20 14) also examined somatic symptoms using a Liketi Scale from 0 to 10 to measure symptom everity and noted all women experienced an increase in number of omatic ymptom with an av ra ge increase of 4 .3 at ix week and 4.8 at th three month r vi w. The 36 mo t co1runon mani:D tation at ix week includ d nau ea, difficulty concentrating, taking longer to think, r tle ne , per i tent fatigue racing heati, in omnia and leep difficultie . At the three month appointment, imilar ymptomologi were een with the addition [worsening noi e ensitivity, more severe itching eye and skin and mor ever trembling or shaking. Ulir ch et al. reported 93% met criteria for PT D at the ix week appointment and 78% at the three month vi it. PT D everity in thi tud y wa hown to have a low to moderate correlation with number of body region with C NWP and a moderate co rrelation with the number of omatic ymptom at the ix week and three month vi it . A strength of the Ulir ch et al. (2014) study was its pro pective longitudinal design , however its reliance on retro pective report of exual a sault exposures and symptom prevalence and severity may be seen a a limitation. In addition, its m all sample ize limit the generalizability of the findings to the general population. De pite these limitation , Ulirsch et al. provide evidence that CSNWP and somatic symptoms can be persistent consequence of sexual assault lasting a minimum of three months . These findings have impotiant implications and as such partially answer my research question as they suggest that follow-up care shortl y after the assault may decrease the prevalence and severity of PTSD and depressive symptoms experienced by women after sexual assault. Brown, DuMont, Macdonald and Bainbridge (20 13) examined whether the presence of a pre-existing mental health condition increases a woman's ri sk of experiencing a se ual as ault, and if assaulted, the prevalence of specific sexual assault characteristics. The authors reviewed the database of a hospital-based SAN program and identifi ed 467 per on who had experienced a recent exual assault with 92% of tho e person being female. Roughly 34% of the sample repmied the presence of at lea tone mental health condition with the largest categorie b ing 37 anxiety and depre ion followed by bipolar p ctrum disord r, and sub tance addiction. Compari on made betw en tho e with pre-exi ting m ntal h alth condition and tho e without mental health hi torie demon trated that tho e per on with underlying mental health condition were mor likely to be vaginally (62.4% ver u 55.7%), orally (26.4% ver us 15 .6%) or anally (20.3% ver u 14%) penetrated. Brown et al. make the a health hi tories appear to be a ciation that pre-exi ting mental ciated with more evere fmm of exual a ault. No mention is made within the tudy about the emotional or p ychological impact the e findings have on those with pre-existing mental health historie . However, Brown el al. highlight the difficulties in contacting patient for follow-up as 89% provided a number for follow-up contact and only 64% were able to be reached with 49.9% attending one follow-up visit. Despite pre-exi ting mental health conditions, no differences exi ted for coun eling referral and it i unknown whether tho e with pre-existing mental health conditions sought follow-up care from previously accessed mental health servi ces. Limitations of the Brown et al. (20 13) study are its retrospective nature and its reliance on predetermined information and self-repmis contained within the cha1is reviewed . A weakness of this study may be the lack of sociodemographic data which may have added a better understanding of the fmdings, such as age and previous victimization histmy which have also been associated with increased rates of sexual assault (Brown et al. , 20 13). Despite its limitations, Brown et al. recommend follow-up care that includes screening for co1nn1on mental health issues such as depression, suicide, bipolar disorder, anxiety and sub stance use. Additionally, the authors recommend the provi ion of individualized care and treatment planning to meet the emotional and psychological needs of patients such as pecialized coun eling referra l and multidisciplinary response . The findin gs within thi study partially an wer my 38 re earch qu tion by highli ghting rec mm nd d appr ache £ r follow -up care that may decrease the development and everity f the m ental hea lth con equ enc as ociated with sexual a ault. A retro pecti ve, cro - ectional tud y by Dubo c et al. (2012) examined th m diating role of PT D and d pre sive ymptom in the relati n hip betw en early adult ex ual a sault and di order d eating in female tudent ag d 13 to 30 year of age. A qu e tiom1aire xamining the e factor wa compl ted by 296 female tud ent . f the e women, 3 7% reported one or more incidents of exual a ault w ith 41% seeking om e type of pr fe ional a si tance. Twenty-one percent met criteri a for di turbed eating behavior and 22% cored high enough to warrant clinical evaluation for PT D . Results also demonstrated a con elation between PTSD and depressive symptoms, as well a di ordered eating with a hi tory of early adult ex ual as ault. When examined to gether, PTSD and depressive yn1ptoms were responsible for fully m ediating the relationship between sexual a sault and di sordered eating. Dubose et al. postulated the development of disord ered eating after sexual assault ma y occur fro m avoidance of negative cognitions and emotions or fro m feeling sexuall y objectified . The Dubose et al. (20 12) stud y is limited by its cross-sectional design and its incorporation of a convenience sample that m ay not be representative of the general female student population. In addition, the length of time since the sexual assault was varied making it difficult to understand the acute versus chronic emotional consequences of the assault itself. In addition, limited data was coll ected about assault characteristics experienced and their impact on the development of PTSD, depression and disordered eating. Dubose et al. makes reference to recommendations made by Holzer et al. (2008) which proposes a pos ible need for emotional regulation as a means for coping with depression, PT D and the prevention of eating disorder development, however, no further information is provided as to what that emotional regulation 39 entail . De pit the e limitati n d pre i nand di Dub rd red eating p verity f PT D , d pr t- , et al. ugg t d impl ementing cr ual a aul t a thi may limit the devel pm nt and i nand eating di rd er in w m en after e ua l a ault. Thi provided ome in ight int the m ental h alth :G 11 w-up care n ed a u ch ha mad partial c ntributi n t an wering m y r Th la t tudy within thi ning £1 r ecti n i retr tudy ha f w m en after exual a ault ear h que ti n. pec ti ve in nature with pr p cti v comp nent conducted by Wil n, W aldr n and ca rp a (2 0 14 ). They e amm d wheth r a hi t ry of ex ual victimizati n wa a cia ted with an increa ed level of di inhibiti n thu incr a ing a woman ' ri sk for exual re-vi ctimi zati on . Di inhibiti n in thi tudy referred to alcohol abu e, ex ual promi cuity and gambling. The ampl e c n i ted f 2 11 yo ung adult fe m ale college tud ent from a large publi c univer ity. Forty- three percent were initi all y identifi ed as hav ing experi enced exual victimization and 32.2% identifi ed a exual victimi za ti on having occ utTed during th e IX month pro pective period . Finding revealed prior exual v ictimiza ti on wa a ociated w ith hi gher rate of di inhibition whi ch i peculated by Wilson et al. to be a coping m ech ani m fo r the p ychological di stress stetruning from the a ault. R es ult al o dem on trate di sinhibiti on i con id ered a parti al m edi ator between a hi tory of exual victimizati on and re-victi miza tion identify ing di inhibition as a likely ca usa l m echani m . Wil on et al. highli ght th e impo rtance of these findings citing literature by Gidycz, MeN am ara and dwards (2006) and Patriqu in, Wil Kell eher and Scarpa (201 2) suggesting that di inhibition i a ociated wi th phy iological blunting ca u ing decreased phy iological arou al to exuall y ri ky itu ati n and redu ced threat detecti n pl acing it victim at fut1her ri k for re-v ictimizati on. A limitati n fth e Wil n et al. (201 4) tud y i it retro pecti e de ign, alth ugh th add iti on o f the pro p ctive co mponent pr v ide mor trcngth to it findin g,. How ,, . ' r, thi s n, 40 tudy continue to remain reliant on th recall of it participant lending it to po ible recall bias. De pite it limitation , Wil on et al. r ommend that health care profe ionals a e s women for phy iological blunting po t- ual a ault with care planning that includ educati nab ut ri k threat detection for re-victimiza tion and trategie to deer a e 1i ky behavior . As a factor result f the evidence provided within thi tudy rec nunendations w re ugge ted that erved to partially an wer my re earch que tion . In mmnary the individual level of influence analyz d within this ection, such as age , pre-exi ting mental h alth condition previou exual as ault hi tory and sexual a ault characteristics erved to demon trate the negative influential impact these factors have in the development of PT D and de pre sion in women after sexual a ault. The evidence demon trates they also play a role in placing women at higher Iisk for re-victimization , furth er adding to the psychopathology that can ari e as are ult of sexual as ault. These studies provided valuabl e evidence supporting the need for comprehensive mental health creening and care within close proximity of the a sault, with recommendations as earl y as 24 to 48 hour after the assault (Boykin & Mynatt, 2007). Personal Relation ship Level of Influ ence Examination of personal relationships such as family, friends, intimate pminer and peers are important as these relationships can profoundly impact women ' respo nse and ability to cope with the emotional and psychological trauma as ociated with sexual assault as well as her willingness to access treatment and follow-up care. This section will examine three studies providing insight into the per onal relationship factor that can impact women after assault. ual 41 The flr t tudy within thi ection i a retro pective tudy by Vidal and P trak (2007) that examined wheth r feeling of hame contribute t incr a d level of traumatic stre s in women aged 16 year of ag and older who have perienced sexual victimization. Participant wer recruit d from both clinical and non-clinica l etting re ulting in a final ample of 25 women, 20 of which were recruited from a clinical etting. Re ult indicate 44% of women experienced sexual a sault within 12 m nth of completing the que ti onnaire with 80% of women indi cating they were a aulted by omeone they knew. ixty-eight percent reported experi encing phy ical consequence as ociated with the exual a ault uch as pelvic pain, pregnancy or Tis. Fifty-six percent reported consuming alcohol voluntarily prior to th e as ault and 17% of women tated they were given alcohol or drugs against their will. Forty percent of women completed a medical/forensic examination after the sexual a sault. Eighty percent of women con idered not telling others about their sexual assault experience, however 28% of those women at orne point later chose to disclose with 52% choosing not to disclo eat all. Sixty-four percent of women reported they felt they were to blame for being sexually as aulted. Vidal and Petrak (2007) used a revised Impact Evers Scale based on which 88% of participants indicated the presence of traumatic stress. The Experience of Shame Scale was administered demonstrating high levels of shame amongst participants. Women who felt they were to blame for the assault scored significantly higher levels of shame than tho e who did not blame themselves. Those who reported physical consequ ences related to the sexual a ault and those who completed a medical/forensic examination scored significantly higher on levels of bodily shame than those without con equence or examination completion. No further information i provided explaining the fact r as ociated with higher level of hame after a completed medical/foren ic examination. ln addition, keeping the a ault a ecret was a sociated 42 with in rea ed 1 el f ham , a wa ha ing be n a aulted by w m n with hi tori f pr a 1 timiza tion hi 1 u m e n th y kn w. ln additi n , ic timiza ti n c r d high r le el f hame than th e with ut t ry. Limitation f th idal and P trak (2007) tud y in lud it r tro 1 ectiv d e ign and mall er ample ize. In additi n m t p a11 i ipant were recruited fr m a clinical etting wher Vidal and P trak p culat d w m n ma y b m r w illing t di cu perc pti n than tho w h ch n t t p arti ipate. e pite it limitati n demon trated re ult co n i t nt wi th th lit rature tha t i exacerbating di tre and traumatic tre p th eir ex peri e n e and Vidal and Petrak ugge tive f ham e playing a role in t- ex ual a ault. Th rap euti c interventi n and emp werment w re reco mm end ed for wo m en with hi gh 1 v l f ham e and e lf-bl ame t decrea e nega tive elf-percepti on and pr mo te re iliency and rec very. T he finding wi thin thi stud y erved to partiall y an wer m y re earch qu e tion by prov iding in ight into th e appr ach to follow-up care needed to decrea e the nega tive emoti onal di tre ex peri enced b y wom en after sexual a ault. Littleton (20 10) co nducted a retro pective, cross- ecti nal tudy with pro pective components, w hich examined how the role of perceived ocial upp rt and negative di clo ure reactions impacted the development of PT D , depre sive ymptoms, and adaptive and maladaptive coping in wom en who have been raped. An initial urvey xamining n gative exual experiences, coping and p ycholo gical hea lth wa condu cted with a follow-up urvey at i m nth with imilar questi n . Women al o comp leted everal ca l Dr P and invcntori to a c 0, depression, negativ cognition , c ping trategies and per eiv d ocial uppoti . Initially 1744 women were li gib le to participat in thi report d being raped and were tudy. r th initial 1744, 340 women lected t parti ipate, howe er only 262 \ m n ·ompri ed the 43 final ample a the e worn n c mpl ted b th the initial and ix m nth follow -up urvey. Women who completed the ix month follow -up urvey recei ed a $2 0 gift certifi cate. Re ult within the Littl eton (2010) tud y found 33% of exual a ault occuned within one year, 49 % within the past two year and 1% of women were a aulted by meone they knew. Women were more likely to di clo e the a ault to omeone they knew with 83.3% di clo ing to a fri end. Formal di clo ure to hea lth care provid er avera ge, women reported di tr ccurred le often (ll %). On level ju t below th cut-off: for PT D and depression diagnose at both the initial and ix-month fo llow-up urvey. Women r ported high er levels of satisfa ction with their ocial support sy tern , however, it wa noted that negative di sclo ure reactions by their ocial supports, while di tre ing, were often unintentional. Littl eton speculated that thi occur as a result of the oc ia l support per on's di ffi cul ty in manag in g th eir own comfort level with the disclosures. Di traction and egocentric responses were the mo t cotnmon reactions expressed whereas stigmatization and contro lling responses were the least common. Littleton noted perceived positive social support wa as ociated with greater positive self-cognitions and use of adaptive coping. Conversely, negative disclosure re ponse were associated with increased negative self-cognitions and maladapti ve coping. Littleton al o noted both social support and negative disclosure responses, whil e thought to be distinct constructs, appear to moderate associations with the development of PTSD and depression during crosssectional analysis. However, in longitudinal analysis, a moderate associa tion was onl y noted between negative discl osures and PTSD . The limitations of the Littl eton 's (20 10) stud y include its retro pective design, however the use of prospective longitudinal data serve to strengthen the e fi ndings . AI o, the low parti cipati on rate of the wo men and the tudy' reli ance on elf- report limits the generaliL.ability 44 and trength of the tudy finding . De pite the e limitation , Litt leton hi ghlight d the pot ntial impact ocial upp01i and negative di cl ure can have n w m n ' emotiona l and p ychological re pon after exual a ault. a r ult, Littl ton rec 1nm nd ed caution b exercised when encouraging women to di clo e their a sault experi ence a this study h a hown that negative di clo ure can negatively impact th emoti nal health of wo men . Littl eton al o rec01nmended that prov id r a s th tr ngth f w men ' cial support networks and any disclo ure experiences they have had a the e can affect recovery. These rec01nmend ation made by Littleton parti all y up port my re earch question by gu iding the provi ion of foll ow-up care that decreases th e emoti onal suffering experienced by ome wo men. Hellman (2 014) conducted a literature review that examined common sexual a sault survivors' respon es to, and long- term effects of, sexual assault, the m ediating fac tors fo r recovery and the prevalence of any reli gious or spi1i tual reco1nmendati ons the authors m ade that promote recovery. Hellman clearly id entified her search m ethodology resulting in twenty- three peer-reviewed a11icles fo r review and analysis . Negative health consequ ences of sexual a aul t within these articles included anxiety, depression, PTSD, avo idance coping, decreased selfesteem, substance use, suicidal ideation/attempts. These responses were infl uenced by social support, the perceptions of others and the presence of additional traumas or substance use. The greater the negative social reactions experienced from others, and the greater avoidance coping utilized by women, the higher the levels of distress and PTSD experienced . Mediating factors for recovery identified included positive support, belief in a just world, perceived control and the number of coping strategies utilized. The literature demonstrat d that the greater the positive support experienced, the grea ter the psychological well-being re ulting in decreased level of di tress and PTSD. Belief in a just world a a mediator view the occunence of e ual assault a 45 a ituational o UIT n e a opp w r t blam . In r a d level ed t th e beli f that chara t r r beh avi ural circum tance f p erceived c ntr 1 wer in trumental in p itive p a ault adju tm ent . La tl y, a grea te r numb r f c pmg m e h ani m and trat g i w m en after e ual a a ult w r a ciat d w ith 1 wer 1 f di tr t- exu al utiliz d by exp en cnc d . P itive piritual c pmg m ch ani m incl ud d th c m.G rt and trength garn er d by the belief in a hi gh er power, th upp rt and acceptance recei ed fr m th e religi u c mmunity, and th e u e of prayer a an outl t for m ti n al relea e (Pargam ent, euill e & Burdzy, 20 l J a cited in H ellm an, 2014). H ellman (2014) identifi d gap within the literature uch a uburban and rural popul ati on , change in th e beli ef pattem xu al a ault within f th er , and re li gio u up port. T he mall numb er of arti cle that m et inclu i n criteri a upport thi a e11 i n, but i al o een a a weakne a it limit the am ount of infonnati on ava il abl e .G r review. F urth ermore, th e tud y findings are completely reliant o n previou ly publi hed research w ith va ryi ng sa m ple ize , participant selectio n proce se and tud y m ethods. D espi te the e limitati on , Hell ma n identified the long- term effects su ffered b y orne wo men after ex ual a (\Ult, a well a the mediating fac tors a ociated w ith positive recovery journey . This study highl ights the imp rtance of P P offerin g po itive, upp rtive care to wo men w hil e aiding them to regain con trol of their bodi lives and environment. T his stud y p artially an wer m y re ea rch q ue tion as the recommended approach to care may help decrease wo men' perceived powerl es ness and as u h the prevalence and everity f P D and depre sion , thu pro mo ting recovery. he tudi e rev iewed w ithin thi ecti o n provid ed trong evidence demon trating the impact both p siti ve and nega tive per nal upport netwo rk can ha eon women' emotional re p n e to ex ual a ault. No n-di clo ure a nd nega ti ve d isc lo urc response , were as. o iated , 46 with higher 1 vel s of n gative If-cognitions, maladaptive c pmg trat g1e and high lev 1 of hame thu increa ing the ri k for the development of PT D and depr reconunendation n ted within thi ion. The ecti n provide guidance for po itive and upportive follow - up care that empower and meet the m ental h alth needs of women aft r exual assault with further recommendation for a se ing pa t di clo ure exp eri ences and the limitation and strength of ocial upport n twork . Communi ty Level of Influ ence Analysi of co nun unity level fac tor includ e examinati on of the community ettings in which women who have been exually assaulted li ve and the interaction between these w omen and the fom1al sy tern in place to support them uch a the health care system. It also includ e examining effi cacy of protocol and practice of provid ers w ithin the hea lth care centers them selves. Thi section will examine four studie highli ghting the community fac tors that m ay impact the emotional and psychological well-being of wo men aft er sexual assa ult. The first study in this section is a retrospective study by Thurston, Patten and Lagendyk (2006) which examined the preval ence of physical assault in wom en 16 years of age and older and sexual assault in women 18 years and older within a rural conu11unity. Thurston et al. also examined the relationship between the report of assault and self-reported health behav iours and health services use. As the ages examined for physical assault and sexual assault differed slightly, both groups were an alyzed ind ependent of the other. Of a sampl e of 526 women, 5% reported physical assault within the last 12 month , w ith 66 .7% of the as ai lants b ing known to the wom en. Of a sample of 5 15 wom en , 24% repotied experiencing exual as ault in their lifetime. While 30% of wo men rep01ied using illicit drugs on at lea tone occa ion, women who reported sexual as ault were found to be more like ly to report havin g u ed illi it drug in their 47 lifetime than women who did not report exual a au lt. With rega rd to health erv1ce u e, women who reported phy ical a sault were igruficantly more likely to acce s em ergency and mental health ervices within the past 12 month however no ignificant differenc w ere noted in the use of primary care, emergency care and mental health erv·ice for women who rep01ied experiencing exual a ault (Thur ton et al. , 2006). Limitation of the Thur ton et al. (2006) stud y include the lack of consistency in comparing phy ical a sault ver u exual assault outcome . nly tati sti cally relevant data was provided within thi study making data compari on di fficult to c ntrast. Another limitation is the original data used within thi s tudy wa co ll ected a p art of a general health survey providing Canadian rural population data rather than data specific to physica l or sexual a sault. Given th e nature of the questions posed within the original survey, it is also difficult to asce1iain whether there was an increase or decrease in risky beha viours and/or health services usage post physical or sexual assault. Despite these limitations, Thurston et al. id entified hea lth risk , such as alcohol consumption and illicit drug use that may be associated with physical or sexual assault within rural communities. Thurston et al. noted that practitioners within the health sector are well positioned to work with others such as educational and legal sectors to develop co llaborative service-based models to meet the health needs of women who have experienced sexual violence. Thurston et al. suggested that examination of gender and the social determinant of health within the context of the rural setting need to be considered as these factors can prevent or exacerbate the ilnpact exual vio lence ha on women. This tudy partially an wered my research question a it yielded finding that identified mental health and risk as essments for women after se ual a sault with recommendation for community level collaboration to improve the ac es ibility of po t-sexual assault services. 48 utherland, Font n t and Fanta ia (2014) conducted a qualitativ , retro p ective analy i which examined the documented provid r re pon e to di clo ur (IPV) or exual a ault ( of interpersonal violence ) within£ ur urb an famil y pl anning clinics in Northea tern U . The tudy u ed informati n collected a part of a larg r retro pective review involving 2000 m edi cal charts. A po itive re pon e to tandard health hi tory que ti n about vi lence wa found in 570 charts hi ghlighting an overall rate fo r lifetime violence of 28 .5% . a result, the e chaJi were the sampl e u sed for analy i and yield d thre main provid er re pon es: no documentation, de ctiptive respon e and action-ori ent d re pon e to violence. Sutherland et al. found 13% of charts with a po itive creen fo r violence contained no documented provider re ponse, 8 1.5% of provider do cumented descriptive re ponse with ubcategori es to further describe the type of violence experi enced: pa t IPY (40.8%)· cunent IPV (5 .9%); and A (24% ). Slightl y over 4% of providers addressed social factors of substance abu e w ith ome notation about contextu al factors associated with the violence. Nine percent of charts noted a childhood hi story of SA w ith no insight into outcome or legal involvement and no association to cunent episodes of violence. Sutherl and et al. noted action-miented documentation of v iolence in less th an 6% of charts w ith provider responses including refen als, safety planning, lethality assessm ents, and recommendations for counselling and/or edu cation . The m ajmity of documentation di scu s ed cuiTent episodes of violence with little to no discu ssion of pa t experiences of violence. Sutherl and et al. contend s that poor documentati on may resul t in increa ed disclo ure experi ences, which in turn, may further increase the emotional distres experi enced by women . A few limitations were noted in the study by utherland tal. (20 14) . The retro pecti ve chart review and the fac t that data was gathered fro m one geograp hi cal location limit th tr ngth and transferability of these findings. Despite these limita tions, Sutherland et al. highlighted th 49 importance of a thor ugh a m ent f th a ciated ri k and a£ ty concern with c mplete action-ori nted do cum ntati n in luding r ferral to needed ervic . uth rl and et al. adv cated for the u addre of organiza ti onal practice t ol and electr mc m dical rec rd ( MR ) to help documentati n banier xp rienced by many pr v id er , uch a time c n traint . Rec01nmend ati n fo r individual practice etting to d velop tand ardized procedure , algorithm or documentation t may pro e benefi cial in en uring th rough a e ment and care planning. In additi on, utherl and et al. rec mmend ed each prim ary care offi ce h ave a compl ete list of available re ource £ r w m n that includ e upport group , shelters mental health service and legal upport. The e re ult provid e parti al upp ort for my re earch qu e ti on a sugge ted practi ce level reco mmend ati on fo r improving ex ual a sault fo llow- up care may serve to decrea e the emotional di tre s ex perienced with di orga ni zed or time-constrained encounters. Amstadter, McCaul ey, Ru ggiero, Re nick and Kilp atrick (2008) condu cted a cro sectional analysis which examined whether hi tories of more than one sexual as aul t, the presence of mental health conditions or substance u e are as ociated w ith any help-seeking behaviour among women after sexual assault. An initi al group of 3000 women were recrui ted fro m two national population samples, of which 556 women reported a history of rape . The e women comprised the fmal sample used within thi stud y. A telephone interview wa conducted with participants selected w ith a random-di git-di al methodology. Amstadter et al. (2008) found 60% of women reported eeking help with 38% eeking help from a medi cal prac titioner and 54% fro m a mental hea lth profe ional. Relatively high levels of PT D, maj r depression and substance u e were noted within thi tudy. PT D was assoc iated with increa ed help- eeking behav iour while ubstanc u e wa moderately a ociated so with h lp- ekin g. Am tadter et al. not d a hi t ry f fl rcibl e rape and major d pr epi od among w m en were a 1ve ciated with in rea ed help - eeking from m edical pr fe ional , wher a PT D wa a ociat d with increa d h lp- king fr m mental health pro[! ional . Linear regre i n anal y i revealed that p ri-traumatic fear, PT D and maj r d pre 1 n were ignifi cantl y a ociated with greater numb r f ace women with depre ion eek care mor ed ervic . Am tadter et al. p tulated that ft n fr m medica l pr fe i nal a they oft n pre ent with num rou unexpl ained phy ical manifl tati n requiring inve ti gati n . While findin g may sugge t a greater affinit y for help- eeking fr m medi cal pr fe i nal for depre ion and mental health profe ional for PT D , Am tadter et al. hi ghlighted findings ugges ting either profe ional may be acce ed with either condition. A limitation of the Am tadter et al. (2 008) tud y includ e it reli ance on self- reported data which increase the ri k for recall bia leading to pos ibl e over- or und errepre entati on of the study findings . Furthermore, the b1ief nature of the interview could also be con idered a limitation as it restricted the comprehensiveness of information coll ected. Despi te the e limitation , Am tadter et al. made important recomm endations for health care profe sionals caring fo r women after sexual as ault. Firstly, the author recommend ed that provider a e women after sexual assault for substance u e di ord ers as preva lence rates were high within thi tud y. In addition, findings highlighted the need fo r mental health education for medical health practitioners as they will likely care for the emotional and p ychological need of women after sexual as ault. This continuing edu cation should include information about exual a ault and common reaction experienced by women. Practitioners hould includ the u e of PT D and depre ion creening tool and al o n ure th yare infonned abo ut the non -phan11a ological and 51 pharmac 1 gi al th rap1 e a ailabl t tr at th e nditi n . The r evid nc that erv d to partially an w r m y re earch qu Padd n (200 ) conduct d are iew f th r t prom te awaren and pr mental h alth need f w m en aft r e ual a ault. ult f thi tudy yi ld ed ti n. arch r gardin g e ual a ault and it effect ide r c mm nd ati n D r hea lth are pr ider in caring [i r the lit rature r view m thod arch r e clu i n crit ri a r numb er f article u ed w re provid ed D r thi review . In t ad th auth r pr ide e p rt pini n w ith re earch upp rt r garding the con equ nee of e ual a ault bani r t rep rting and implica ti n [i r th e D 11 w- up care f wom en who have expe1ienced exual as ault. Padd en n ted multipl e ph y iologica l and p ychologica l co n qu nee a ciat d with xual a ault and th e developm ent f PT D . he al o m ake reference to re earch by Frayne et al. ( 1999) that n ted a ciati on between hi gher rate of health care utilizati on and wom en with exual a ault hi torie . Furthermo re, Padd en noted barri ers to di clo ure of exual a ault experi ences inc lud ham e, elf- bl am e, guilt and embarrassment, fea r of not being believed or upp orted by in fo m1al and forma l y tern a w 11 as fea rs a sociated w ith breeches in confiden tiality. Both hi gher rate of hea lth care util iza tion and th e multipl e barri ers th at impac t wo rn n' di sc lo ure of th e ir e peri ence pro mpt Padd n to recommend general screenin g fo r sexual assa ult in primary ca re p ractices . Whi le screening do not address the research qu estion for this project, it does draw att n ti on to the need for further re earch on the impact of screenin g fo r sex ual assault wi thin primary care etting . A the Padd en (2 00 8) a1iicle provide infom1ati on derived from expert opini n and re earch findin g with no id ntifi ed earch m ethod r tr ngth fit outcom e . lecti on tra tegy for its u age, it limit the pite the e limitati n , Padd en provid recommendation simil ar to oth er tudi e w ithin thi revi w that upport a upportive, non-j udgemental and empathetic 52 re pon e from health care provider wh n caring for women after e ual a ault. Rec01mnendation that guide health care provider in e tabli hing tru ting rapp01is with women to et th foundation for upportive care are pr vid d. Further rec ffiln endation includ practitioner develop a comprehen ive li t f available referral ervi e for provider u e and re ource available for u e by women ace ing care. This article provide partial uppoti in an wering my research question by providing guidance for P P , uch a NPs, in the provision of afe and therapeutic follow-up care after exual a ault. In ummary, revi w of community fac tor of influence revealed that geographical isolation, provider time constraint and lack of provider know ledge about sexual assault and its management act as barrier to the provision of follow-up care that meets the emotional and psychological needs of women after exual a ault. The author within thi s ection partiall y answered my research que tion offering recommendation for care aimed at improving the services provided within rural and remote areas, the development of organizational tools to improve practitioner efficiency and care provision, as well as increasing access to edu cation that enhances provider know ledge and comf01i in caring for women after exual assault. Societal Level of Influ ence This section will examine two studie highlighting the societal factors that may impact the emotional and psychological well-being of women after exual assault. Examination of studies at the societal level allow for insight into the mental health impact societal belief , norms and the acceptance of rape-myths have on women who have experienced sexual assault. The first study within this section is a qualitative, comparative descriptive tudy conducted by Kelleher and McGilloway (2009) examining the key i sues and challenge reported by service workers employed in exual violence upport organization . Th ampl e con i ted of 53 1 £mal rvice work r r admini t red in per ruit d fr m anou rganizati n . mi- tructured intervi w wa n, rec rded and tran cribed ~ r thematic analy i . Key th m tudy includ d e aminati n f barri r and urr nt gap in rv1ce pr within thi i i n . K lleher and Me ill way identified hame and guilt, naming r ackn wledgement f th e a ault and ocietal myth ar und rap e a ignificant bani er t ace ing car aft r exual a ault. hame and guilt were th ught t r ult fr m w m en' perc e i ed re pon ibility ~ r the exual a ault, th am unt th ey re i ted and th c ncem over th ere p n e and r acti ns by th eir informal upport y tern . K ell h rand Me ill way (2009) n ted that reluctance in naming r acknowledging their exual a ault ex p ri nee ft n pre ented women fr m di cl ing th eir experience re ulting in w m n trying to co pe with nega tive emotion without upport from ervice provider or informal upport . Furthermor , K ell eher and M e illoway not d th e prevalence and acceptance of rap e- myth ften perp etu ate negati ve elf-cogni ti on If-bl am e and shame in women after exual a ault a their ex peri ence of exual a ault do e not match the stereotypical belief of who a victim or offender i or the circum tance unounding th e sexual assault it elf. The concern that women will not be beli eved or upported wa a ignificant batTier for access to initial and follow-up care. K elleher and M e illo way identified the large t gap in ervice provi ion to be the limited edu ca tion and awarene women have about available services, and for communiti e and ociety, about ex ual as au lt itself. imitations of the Kelleher and Me illowa y (2009) tud y include it and th e qualitative nature o f th e tud y exa minin g th e erv ice providers' b li ef mall ample ize f what impact the care f women. The e both limit th e tran ferability of finding t the general population . Whil e thi s tudy fi cu ed on erv ic provider in cri i center , finding can infonn ' trategi ~ targeting ocietal belief: and view employed by h alth care pro id r ,. Kelleher and 54 McGillow ay ugge ted u ing appropri ate language wh n communicating t the public to nsure all women can id entify their experience a varying ocietal level about acce xua l a ault. ""' du cation and awarene targeting the xual a ault, it varying pre entations, it impact and how to health erv ice can help decrea e tereotypical belief , thus limiting the negative emotional consequ ence experi enced by wom en. Thi tudy pr vide vid ence that partially support my re earch que tion with recommend ation geared at ocietallevel y tem change Adding to the di cus ion of ocietal influ nee, Munro (2 0 14) condu cted a literature earch which examined the barri er that decrea e acce to c mprehensive care for women of child beating age after sexu al a ault. Munro utilized Whittemore and Kn afl 's (200 5) integrati ve review method for this stud y which yielded twelve tudie and four nati onal surveys:[! r review . Munro themed her finding according to personal and env ironmental factors that act as barriers to accessing care. Personal fa ctor identifi ed within the literature includ ed em oti onal states such as sham e, embarrassm ent, humiliation, guilt and self-blame. Fear of unh elpful interactions with formal system s such as not b eing believed, negative reaction s, and lack of confidentiality were also p ersonal factors identified that ma y deter women fro m accessing care. Also, fea r of reprisal from the offender or the public as well as a lack of knowledge of available services to care for wom en after assault further impacted accessibility. Munro also identified environmental factors within the literature in the fo rm of structural or organizational barriers such as limited ervice or access to services as well as care by health care professionals who are inexperienced in providing care to women after sexu al assault. Furthermore, Mum·o noted that societa l myths are a significant enviromnental barrier to care as they affect both informal and fo1111 al sy terns. The e myths can m ake it difficult for wom en to nam e or acknowledge their ex peri ence a e ual as ault causing them to feel their ex perience wa not seri ou enough to warrant care. In addition, many 55 ervice provider including health car pro£ ional may re pond inappropriately when caring for women as are ult of rap -myth acceptance. Limitation of the Muru·o (2014) review include it complete reliance on previou ly publi hed re earch, many of which wer retro pective with a cro - ecti nal design r liant on elf-reported data or condary data urce . trength ofMunro ' tudy i its u e ofthe Whittemore and Knafl (2005) integrative review m th d and it clearly demonstrated literature earch re ults and ample election criteria. ln addition, Munro made many recommendations for NP practice to better care for women of childb earing age after sex ual assault. Recommendations specific to emotional and p ychological well-being included provid er awareness of the po sibl e mental health and somatic symptom that may manife t as a result of emotional distres uffered after sexual a sault. Munro also stated that NPs have a responsibility to conduct thorough health histories and assessment of cunent health care needs. NPs were encouraged to become familiar with the structural and organizational barriers pecific to their practice environments and problem-solve methods to decrease these baniers. Fmihe1more, Munro advocated that NPs provide education and raise awareness about sexual assault to women, conununities and society as a whole. In addition, compilation of a resource list for fonnal supports available wa provided that may be helpful for providers in aiding women's access to other services. To summarize, societal influences perp etuating feelings of hame, self-blame and guilt among women after sexual assault may result in feelings of fear and concern that infon11al, formal and publi c systems may not believe or may attribute further blame on the e women for the occunence of the assault it elf. Furthermore, women often have difficulty locati ng or accessing available health and social ervices to help cope with the trauma they have experienced. The e two tudi e en oUI·age providers to ngage in societal level trategie aimed 56 a ing educati nand awarene to help w m n after exual a ault. for my re earch qu f ual a ault, it a re ult th e e r n qu nc ea r h ar1icl and 1 tce availabl pr vided partial upp rt ti n . ummary of Findin g In urnmary review f e i ting guid eline th at in.G rm th care needed .G r w m n po texual a ault wa limited . he applicati n fa traum a- in.G nn ed appr ach to care, while n t p cific to e ual a ault, repr ent a n appr ach t car th at aim t minimize th em tiona! exp rienced by women . An ec l gica l framework wa utilized t di stre remainin g literatur all wing for multi -level analy i and p ychological re pon e t as ault characteri tic ynth e ize th e f fa t r that impac t women ' emotional xual a ault. Indi iduall evel finding reveal that demographi c, pre-ex i tin g mental hea lth co ndition , and p r onal c ping re p n e ca n negativel y impact women' emotional re pon e after ex ual a ault. xaminati o n of per onal relationship were pivotal in identifying the role ocial uppor1 ca n have in promoting recovery or conver ely, increasing the nega tive elf-cogniti on and em ti nal di tre s ex perienced by women. ommunity and ocietallevel intera ction were closely related in that negati ve re ponses by fonnal ystem and ociety it elf can further p erp etu a te the hame, embarra ment and the negative emotional re pon e xhibited by m e wo men. Furthermore, lack of educati on and awarene s of sexual a ault, it impact, the care needed and there o urce a ai lable further negati vely impedes women' acce sibility to avai labl e ca re and ervicc . A ignificant gap ex ists within the literature rega rding follow -up care that m ct the em ti nal and p ychologica l ca re of wom n after cx ual a ault. ew article mad r c mmcnd ations .G r optim a l timin g fo r G llow-up care wi thin primary ca re etting after ' e. ual a ault. pite identifi ed ga p , th e va ri u auth r, pro id "'d rcc mmcndation. and strategic 57 ba ed on their tudy finding that ither 1 ecifi cally related t provid ed by primary care practiti ner including re earch findin g and furth r e pl r the trat gie rare tran ferabl t the care P . The [! 11 wing chapt r will di cu the e ugge ted t de rca e the preval n e and verity f PT D and depre i n in adult w men of hildbearing age aft er ual a ault. 58 HAPT RF R Discu ion Much of the lit rature availabl di cu the importance of follow -up car in deer a mg the negative effect as ociated with a particular medi cal or p ychological health con quence related to exual a ault but there are fe w document that provide any pecific rec mmendations for care that meet the mental health need f w m n. In peakin g with care provid er involved in the follow -up car £ r wo men after exual a sault, their focu of care ha been to a e general mental health tatu , any inj urie u tained at the time f the a ault, review and reord er neces ary diagno tic te ts, provide treatment pecific to client concern and initi ate referrals as needed. There i little time and little guidance on the nece ary element needed to addre s the emotional impact exual as ault has on women. Review of the research described in Chapter Three ha yielded ome important contributions to und erstanding the mental health foll ow-up care needs of women after sexual assault. This Chapter will discuss these findings within an ecological framework to hi ghlight existing gaps in the mental health follow -up care of women aft er sexual assault. Specific areas examined within this section will include optimal timing intervals fo r fo llow-up care, and the role individual level characteristics, personal relationships, community and societal fac tor have in influencing the emotional and psychological well-being of women after sexual as ault. Discussion of the impact these ecological level of influence have on women will erve to infonn strategies that improve the care provid ed after sexual assaul t. Specific recom1nendations for fo ll ow-up care will be discus ed in more detail in Optimal Intervals for Follow-up Ca re hapter Five. 59 There are no standard r conunendation indicating ptima l int rval for fo llow-up care that target the p ychological trauma that re ult after xual a ault. Th WH (2003) recomn1end two week, tlu·ee and ix month£ llow-up vi it aft r a exual a ault. Ray and McEneaney (2014) ugge t foll w-up care interval betw none and four week , ix we ks and at ix month . However mo t of the e r comm ndation are related to the m dical care need of women after exual a ault u h a further TI and pregnancy te ting. R earch ha documented the consequenc of PT D d pre i n and £ r ome women, drug and alcohol u e a a coping mechani m for intru ive thought a ociated with sexual a ault, yet follow-up recomm endations or interval for care do not adequately refl ect the e care needs. Thi represents a significant gap in the emotional and p ychological care of women who have be n exuall y as aulted . Ackerman et al. (2006) noted that care should take place within clo e proximity of the a ault itself and should include care that address both the medical and mental health needs of women. Interestingly Boykin and Mynatt (2007) felt that m ental health follow-up care shou ld begin much sooner starting within 24-48 hour of the sexual assault with following appointments provided at two week and three month intervals or as needed based on individual need . These studies have shown women are easily lost to follow-up, therefore stmiing follow-up care that addresses the emotional and psychological well-being of women within one to two weeks of the assault may represent an acceptable approach to improving mental health care after sexual assault. Individu al Levels of Influence Factors imp actin g follo w- up care. Individual level examination of factor that can impact follow-up care andre-victimization are important in not only under tanding th baniers in accessing care for women who have experienced exual as ault, but also serve to hi ghlight 60 important variabl practiti h uld con ider when caring for the e women in the aft rmath of a ault. Factor that can impact follow-up care in lud demographic such a age and level of education, previ u hi tory of exual a ault and pa t mental h alth hi t rie . Demographic characteri tics. Th finding impact women' acce ibi lity and rec ptiv ne older women, homele women and th ugge t that demographic characteri tic t foll w-up car . Ack nnan et al. (2006) found e incarcerated were a ciated with decreased rates for follow-up care. In compari on to lder women, younger age at the time of exual a ault showed greater a ociation with the development of hi gh risk sex ual behaviour ( amp bell , Sefl, & Alu·ens 2004). It i theorized that thi may be r lated to the difference in nonnative developmental proce e and health eeking behaviour a ociated with each age category (Ackennan et al., 2006; Campbell et al., 2004). It wa al o suggested that women who ab tain from sexual encounters after sexual a ault di play low-ri k sexual behaviours, yet one mu t speculate that perhaps these women abstained from sexual relations du e to traumatization (Campbell et al., 2004). This raises the question whether low-risk sexual behavior exhibited by these women represent a positive health outcome, or conver ely, a negative response to a traumatic event. These findings highlighted the complexities that mu t be considered when examining demographic characteristics and health outcomes after sexual assault. This project provided a small glimpse into the research available discussing the impa ct demographic characteristic have on women's mental hea lth and acces ibility of servi ces. A a result, its clinical relevanc i not entirely clear. What is clear from the e findings i the emotional and psychological follow-up care after sexual assault shou ld target all women with individualiz d care planning tailored to the pecific demographic, developmental and educational stages of each woman. 61 Past hi tory of sexual as ault. Th d vel pment of h alth ri k behaviour (Wil on et al. , 20 14), PT D depre ion di ordered eating (Dub (Market al. , 2008; c et al. 20 12) and chronic pain dis rder lir ch et al. 20 14) ha e b en a There i no conte ting the impa t xual a ault hi tori cia ted with pa t hi torie f exual a ault. can have on the development of negative mental and phy ical health. How e er, caution mu t be exerci d when a king about pa t sexual as ault hi torie a thi can have a negativ impact on the mental h alth of women. While knowledge ofpa t hi torie f exual a ault can aid provider in better under tanding the impact the e trauma have on the em tiona! health of women, non-disclosure hould not change the care that providers offer women. The premi e of trauma-informed care is that di closure of past or pre ent exual as ault is not nece sary for its provision (B EWH, 20 13). Individual consideration and ongoing as e sment i needed to d cide whether disclosure of past histories will improve the care we provide to women and if o, when in the continuum of care is that disclosure appropriate. Strategies that infonn conversations about past trauma histories may be crucial in decreasing the emotional distres experienced by women, but a provider 'a bility to assess a woman's readiness to di sc lose and di screti on around when to ask about trauma may also be of paramount importance. Pre-existing m ental health disorders. Review of the literature ugge ts that pre-exi ting mental health issues may be a predisposing risk factor for more serious forms of sexual assault involving oral, vaginal and anal penetration (Brown et al., 20 13). One could speculate that preexisting mental health conditions and higher rates of penetration may have implication for higher rates of emergency and follow-up care services (Mark et al. , 2013 ). However, unrelated to the direct ffect of sexual a sault, higher utilization pattern w re in tead associated with exacerbations of chronic illnesses (Market al. , 20 1 ). The e finding demon trate the dynami 62 interplay f variable that impact exual a ault charact ristic as w 11 a the a ociat d phy iological complexitie that m ay occur in the aftennath. What the e studies do not discu s is the mental health linpact exual a ault ma y ha e on women with pre-exi ting m ental health condition . In normal daily life mo d and em ti n naturally flu ctuate in resp nse to daily phy iological and p ychol gical tr ors. v n in the mo t tabl mental health condition , periods of mood fluctuation and in tability m ay occur (Patel et al. , 20 15) . ne can onl y ima gine the linpact exual a ault might have on a woman with a stabl e pre-existing m ental health condition, let alone a conditi on that i poorly m anaged. Awarene s that pre-exi ting mental health condition can in crea e wo men' s ri sk of experiencing more severe form of exu al a ault is integral to understanding the indirect impact mental health di orders have on the health and wellne of women. Furthermore, the importance of managing pre-existing mental health probl ems is key to decreasing the prevalence and severity of negative emotional and p ychological consequences associated w ith sexual assaul t. Assault characteristi cs . Sexual assault characteristics serve to describe the nature and severity of an assault. These characteristics, in orne cases, have been shown to have a profound effect on wo men' s emotional health (Ackerman et al. , 2006; Campbell et al. , 2009) . The development ofPT SD often results from negative based emotional response related to pecific sexual assault characteristics, such as assaults by known or multiple offenders, use of a weapon, the presence of genital trauma and alcohol usage (Ackerman et al. , 2006; Boykin & Mynatt, 2007; Jozkowski & Saunder , 201 2). Therefore, assessment of sexual assault characteri stics and the emotional impact they can have on women is impera tive to individualizing care that meet the psychological needs of wo men after sexual assa ult. However, similar to disclo ures of pa t sexual assault hi tori e , a trauma-inform ed approach to care where provid er as e a woman's 63 readine to di cu the characteri tic urrounding th a ault i fundam ntal to providing afe and upportive care. Indi iduallevel analy i of th fa ctor that af:D ct D 11 w-up care and the impact of exua l a ault characteri tic ha highlight d the influ nee the e fa tor ha ve n dev loping or exacerbating th negative m ti nal re pon experi nc d by orne women . However, caution mu t be exerci ed when a e ing worn n wh have been as aulted as each experience can impact women differently. Thu an individualized appr ach to as e sment and care with attention to factor that ma y further impact the health and wellnes f th e e women is paramount. Personal Relation ship s Level of Influ ence Social relation can be a positive mediating factor in the recovery of wom en who have been sexually as aulted (Hellman 2014), how ever it mu tal o tand to rea on that negative social relationships or responses can have the oppo ite effect. W omen assa ulted by non- trangers and those who kept the assault a secret were noted to have higher levels of shame (Vidal & Petrak, 2007). Previous sexual assault histori es have been associated with increased characterological and body shame and higher level of concern about how they are perceived by their peers and close relations. Research has demonstrated strong cotTelations between lack of social support and negative disclosure responses with the development of PTSD and depression (Littleton, 201 0) . The severity of these long-term psychological health effects are dependent on the level of social support available and other's perceptions (Hellman, 2014 ). Re earch reviewed suggested a need to examine the role of shame in exacerbating stress level post-sexual a sault (Vidal & Petrak, 2007) and as such represents important points to discuss when caring for women after sexual assault. ommunity and Soci etal Levels of Influ ence 64 01rununity and ocietal influ ence can have a hu g impact n the m ental health and well-being ofwom n. Thi c01nmunity ection will di cu s th imp act community level influ ence tting, provider comfo11 l el, and pr vid er d cumentati n practice can hav the care provided to wom en aft r exual a ault. It will al influence uch a cultural and uch a n examm the impac t oc1 tal level i tal n01m and the u e of language can have n the development of nega tive m tional con equ ences xperi enced by women. Communi ty setting. Much of the literature reviewed wa wri tten with reference to large urban centers with easy acce to multidi ciplinary care and refen al s rvices . However, there are many women who live in remote area that do not have access to such pecialized ervices . Often PCPs in the e area deliver most, if not all of the fo llow-up care provided to these women. Furthe1more, although preva lence rates of sexual assault were similar between urban and rural settings (Thurston et al. , 2006), high er health care utilization patterns were noted among sexuall y assaulted wom en in the urbanized areas (Levine et al. , 2008 ; Mark et al. , 2008). This prompt the question as to whether women may be less inclined to seek health care within smaller communities. Within rural settings, the fear of jud gment and breach of confi dentia lity are co1nmon barriers that acco unt fo r wo men' s relucta nce to disclose the ir sexual assau lt ex peri nee or access health care ervices . Other identified barriers to care for women living in rural setting include geographical isolation, lack of servi ces and social sy tem complications relating to a small town, which are oft en fm1her complicated when the offender is known and living within the same co1nmunity (Thurston et al. , 2006). The impact of exual a sault in rural conlll1uniti e and its associated ban·iers to care require fm1her study to determine how b t to care for thi population. 65 Provi der comfort level. Many health care profe i nal don t routin ly pr vide follow up care to women after exual a ault. A a r ult, care pr vid r are often uncomfOiiable di cu ing the event of a xual a ault or the emotional di tre it ha cau ed for the wom n who experience it (Am tadter et al., 200 ). This ma y be perceived a a econdary victi1nization fmiher exacerbating hame-ba ed beli ef , thu p ibly c ntributing to the development of PT D and depres ive ymptom (Vidal & Petrak, 2007) . Jn rea ing a provid r' comfort in havin g these en itive conver ation with women and increa ing their knowledge of the m ental health follow-up care needed after exual a ault i vital t promoting recovery (Am stadter et al., 2008) . Provider docum entati on practi ces. There are few tudies available specifi cally analyzing documentation practice found within formal sy tems related to exual a sault disclosures or follow-up care provision. Incompl ete charting can negatively impact providers ' abilities to provide comprehen ive care for women post-assault as littl e information may be available about care planning to guide longitudinal care (S utherland et al. , 2014). Furthermore, follow-up care can be complex requiring multiple care visits and often a multidisciplinary response to help facilitate recovery and prevention of further re-victimization. With access to incomplete documentation, repeated assault di sclosures to new provider or multidi ciplinary team members may occur which may futiher exacerbate the negative emotional reactions experienced by women (Littleton, 201 0). Moreover, there is no statute of limitation on the reporting of sexual assault (Limitation Act, 1996), thu the importance of thorough documentation practices cannot be overstated. Medical record provide legal do umentation of disclosure and the health impacts as ociated with sexual as ault (Sutherland et al., 20 14). Incomplete or poor documentation can cause women further emotional di tre s while compromi ing their legal pur uit . 66 Two of the mo t cotrun n bani r t thor ugh d cum ntati n include multipl e comp ting demand on P P and lack f documentati n tim e ( uth rl and et al. , 20 14). ]though not m entioned within the literatur , lack f kill in m edi co! gal documentati n could al o be een a another common d cumentati on bani r. practice tool and c mputerized utherl and et al. ugge ted the u e of organizational MR to help addre are valid option , it only p a1i ially addr th e e batTier . While the the i ue of d u ggestion umentati on . D ocumentation inad equa cies m ay al o tem from lack of awarenes or training of what con titute important information to includ e when docum entin g care enc unters w ith wom en after sex ual assault. Infonnal education ession highlightin g important detail s to be inc lud ed during documentation and utilization of the SOAP fo rmat for charting that includes ubj ective, objective, a essm ent and planning information should al o be consid ered . Social and cultural norms. An increase in negati ve ham e- based beliefs and selfcognitions experi enced b y women m ay result when characteristics of a sexual assault do not m atch the constru cts of prevalent rape-m yths (Munro, 20 14; Vidal & Petrak, 2007; Weiss, 2010). These negative em otions and cognitions can have strong implicati ons fo r the developm ent of PTSD and depression . H owever, community and societal level strategies to chan ge the acceptance of rape-m yths are challenging a effmis are required th at involve all ecological level of influence. Education and awareness of sexual assault, its consequences and the re ource ava ilabl e to help women are needed that target individuals, their personal relationship , community organiza tions and providers as well as ociety as a whole. This is not an undetiaking of one person, but instead of m any. The identifica ti on of stakeholder and collaborative partn er hip are key in pro motin g changes to soc ie ty's res ponse to sexua l as ault disclosure and ava ilability of ocial suppmi . 67 Language. ocietal influence can b en in th t n11inology that we u to de cribe exual a ault and the worn n who experience it. There ar variou tenn u ed to discu s exual as ault within the literatur , often u ed interchang ably, however th ir und erlying meaning can be interpreted quite differently. ee App ndix D fo r Definiti n of Term . Tenninology i important a how one define what they ex perienced can certainly impac t their willingn e di close and acce health care to rvice (Thur ton et al. 2006) . Furthermore, how a wom an i id entified after a exual a ault can al o have negative emotional ramifications. W om en have been commonl y referred to as victim , and more recentl y, urvivors (H ellm an , 20 14). orne wo men have diffi culty identifying w hat happened to them a rape and may also have diffi cultie accepting the label of victim or urvivor. These tem1 can increase fee lings of shame, guilt and other negative cognitions thus increa ing the ri k fo r the development of PT D and depression. The u e of neutral tenninology and/o r having discussions with women about the term that they find empowering may help them in their recovery process (Kelleher & McGilloway, 2009) . The Role of Nurse Practitioners in Follow-up Ca1·e Nurse practitioners care for a num ber of vulnerable pati ent popu lations and often provid e routine care to both women and children (Dahrou ge et al. , 2014) . Often, NPs have sli ghtly longer appointment times allowing them to spend a greater amount of time providing education, support and counseling (Dahrouge et al. , 2014) . As there is a great deal of psychosocial trauma and support needed for women who have experienced exual assault, the NP model of care provide the necessary time needed for longitudinal care of these women. Women who have been exuall y assaulted often have poorer health status than women with no hi tory of assault and greater health care uti lization patten1 (Levine et al. , 2008; Pikarinen, Sai to, Schei, wahnberg, & Halmesmaki, 2007). It can then be inferred that with poorer health statu s and increa ed 68 encounter with the health care y tem the e wom en will fac increa d medical co t and mi ed time from work. " are provid d by NPs ha been a ociated with les time los t from work, low r overall dru g co t .. . and fewer ho pitali za ti ns" (N ur e Practiti oner of Ontari o, 2011 , p . 3) . rtainly the hea lthcare m del fr m which an attracti ve option for the provi ion f po t-a ault negati ve ly impact a wo man h alth wellne Association P provide care makes them xual a ault care. exual a ault can and qu ality f liD . A a re ul t, a comprehen ive approach to fo llow-up care that i not ru hed i imperative to the mental health care of women after sexual a sault (Lind en, 20 11). 69 HAPT R FIVE Recommendation s for Nur e Practitioner Practice The purpo e f thi proj ect i to xamine the re earch to d ten11ine whether follow-up care within two week of a exual a ault w uld decrea e the preval nee and ev rity of PT D and depre ion in wom en of childbearing age. Whil e no re earch tudie were found that examine the impact of fo llow-up car on health utcomes the re earch analyzed w ithin thi proj ect offers insight into th mental h alth trategie that could be incorporated into follow-up care to decrea e the negati ve emotional re pon e and cogniti n of women after sex ual a ault and thus the incidence and potential everity of PTSD and depre sion . These recommend ations will be organized using an ecological per pective examining trategie fo r follow-up care targeting the prov id ers' re pon e to indi vidu a l, perso nal relati on hips, community and oc ieta l levels of influence. Furthermore, while recommendations in this Chapter discuss using strategie targeting specific levels, recommendations are dynami c with the overall outcome aimed at decreasing the negative mental health consequences experienced by women after sexual as ault. See Appendix E fo r a qui ck reference of recommendati ons m ade within this project. Recommendations for Optimal Follow-u p Care The authors report that optimal timing fo r specific care interventions remain unc lear, however, recomm endations for fo llow-up care within close proximity of the as ault it elf may be key in identifying and treating those patients at risk for depress ion, PT D and ubstance abu e (Ackerman et al., 2006; Ulirsch et al. , 201 4). FoJJ ow-up care specifically addres ing the psychological needs of women may need to tart as early as 24 to 48 hours after sexual a ault or the initia l foren ic examination (Boykin & Mynatt, 2007). arly follow-up care otTer. an ppOliunity to pr vide supp rt, education, anticipatory guidance, and initiate r D rral need d to 70 facilitate recov ry (B ykin & Mynatt, 2007). There£ r , initiating D llow-up car within a maximum of two w k f th e ual a ault r pr nt a r a facilitate the initiati n f appr priat int rv nti n and acce nab l tim e frame that may t care ne ded t Interval for future appointm nt will d pend on the le f em ti nal di tre women. How ever g n ral D ll ow-up care app intm ent h uld al upp rt rec very. exp ri enc d by be c n idered at two and 1x week a w 11 a D ur and i m nth . Th e interval repre ent pportuniti e for m edi cal the m ental h alth and erve a a tim wh re provid er can a wellne s of w m n who have not been id entified a needin g cl er fo llow- up . Recommendation Targetin g Indi vidual Level of Influ ence Thi ection w ill di cu recommendation fo r provid er w ith pecific trategie aimed at the provi ion f care to women at an individu al level. The e includ e approaches to care, m ental health follow-up care component and ongoing care pl annin g. Approach to care. A trauma- info nned approach to care offers a so lid fo und ation from which to base the mental health follow-up care for women after sexual a ault. This approach i well supported within the literature (Jina & Thomas, 20 13; W adsworth & Van Order, 2012) and embodies the use of non-judgm ental, empathetic and upportive approaches to care that create safe, trustworthy and confidential environn1ents fo r wom en to share their experience (B WH, 201 3). Provid ers are encouraged to u e neutral, non-verbal communication as se n with open po ture, culturally appropriate eye contact with positioning at eye level while al o remaining attun d to the non-verb al behaviour exhibited by women during ar (Padden, 200 ). tablishing rapport w ith women, ackn w ledging their fee li ngs and con t li sten to their stori can help d cr a e their nega ti ve If-b lie£ (Ray uppot1ive comments u h a 'T m orry thi hap pened to you. 1t tak ms and taking the time Me neancy, 20 14 ). a lot of c ura ge to talk 71 about omething like thi ' (Padden, 2008, p. 112) convey empathy but al o emp wer worn n by acknowledging the trength of character needed to di clo and eek care after s xual as ault. An approach to upportive and non-intru ive care al o require that w m en be involved in the care deci i n-making pr c llowing worn n to hare their :D llow-up care need and providing women with infonnation about variou care option empow er women, allowing them to regain orne of the control ver their bodi e th ir h alth their lives and their envirorunent (B CEWH, 2013 ; Hellman, 20 14· Vidal & Petrak 2007). Thi co llaborative approach to care may help decrea e th ir perceived powerl e n and negative elf-perceptions while promoting resiliency and recovery (B CEWH 20 13 ; Hellman 20 14). Primary care provid ers mu t al o exerci e caution in their examination approach to prevent re-traumatization (Mark et al. , 2008). How providers approach the medical care, such as gynecological examinations, can impact the emotional health and well-being of women. Ray and McEneaney (2014) recommend that NPs ''take the time and effort needed to perfonn gynecological exams in ways that decrease anxiety on the part of the patient and promotes future engagement with health care practitioners" (p. 48). Explaining examination component and reiterating to women that they control the aspects involved in the care provided is imperative. Options for gynecological examinations can include providing women with a minor so they can inspect their genitalia while providers de cribe normal, healthy anatomy offering reassurance of health (Ray & McEneaney, 2014). Allowing women to insert the speculums them elves or avoiding the use of foot rests and instead using a modified lithotomy po ition are alternative options that have been shown to dec rea e women 's emotional di tress (Ray & McEn aney, 2014 ). There are varying approaches to care that can be employed, however, all of th m require open, non-judgemental , and supportive appr aches that incorporate patient choice. 72 Mental health follow-up care components. Mental health [! llow-up care involv a e ing women ' pa t m ntal health and xual a au lt hi torie a w II a the characteri tic of their mo t recent a ault. Th x ual a ault e c mpon nt can impact the emotional and mental h alth of women after exual a ault ( ckerman et al. , 2006; Brown et al., 20 13). Furthermore, explorati n of cunent m edical and mental health conce1n hea lth care need are m et whil al o increa ing their willingne erv e to en ure women· s to acces care in th e future. However, caution mu t be exerci ed by prov id er w hen a e ing for pa t exual a ault hi torie and a ault characteri ti c a the e di clo ure can increa e th e emotional distre s experienced by women. As essment of women readines to di clo e bee mes imperative to not onl y developing a tru ting and therap eutic rapport, but al o in minimi zing further nega tive m ental health consequence . Further recommendations for mental health follow-care includ e screening for co1nrnon mental health issues that often present after sexual assault such as PTSD , depression, anxiety, substance abuse and disord ered eating (Amstadter et al., 2008 ; Brown et. al., 2013; Dubo c et al. , 20 12; Jina & Thomas, 20 13) . Various tools are available to assist providers in asse sing for these conditions such as the Primary Care - Post-traumatic Stress Disord er (PC-PTSD ) screen, the Patient Health Questionnaire (PHQ- 9) for depression, the Generalized Anxiety Disorder (GAD7) questionnaire, the CAGE-AID qu estionnaire for ubstance use and the COFF questionnaire for disordered eating. See Appendix F for more information on the e mental health creening tools. Assessment of physiological blunting hould also be encouraged as tllis may predispose women to engage in health risk behavior thus increasing their risk for re-victimization (Wil son et al. , 2014). 73 qually imp rtant within th realm f fi 11 w -up care i th pr vi i n of ed uca ti n women b tt r under tand what exual a ault i and the varying effect it can have n their h alth . Furthen11 r , it i imp rtant that w m n are made aware they ar n t t blame for the xual a ault. Thi educati n can h lp w m en b tter id ntify and ackn wledge their xpenence and may a! o to erve t d crea e th guilt and ham a ociated with ex ual a ault. Much of the literature fo cu e a n id entifi cation f nega tive health con equence ciated with exual a ault, and whil e trem ely imp rtant, nl y ne re ource di c u ed identifying indi idual tren gth of women and h w t further de e l p a w man' capacity for c ping and resiliency (B WH, 2013 ). uc h trategies inc lud e tri gger recognition , relaxation and grounding technique and po iti ve elf-talk (B WH , 20 13 ). After all, it i through improved coping trategie and trength building that women are better able to mana ge th e various ecological levels of influence that nega ti vely impact the ir emotional wellne s. Thi strategy, while di cu ed at the individual level, is applicable to all levels of influence . A an example, po itive elf-talk canal o be u ed when confronted with negative disclo ure re ponse from friend and family, the health care and legal sys tem and the general public a a w h !e. Ongoing care planning. The prov ision of individualized care and treatment planning i a key component in th e longitudinal care of women after sexual a ault. ngoing care planning components uch as indi v idual coping and safety planning vary over the care continuum, thu ongoing assessment, reinforcement and modifications to care plan are important in meeting th l ngitudinal mental health needs of women after exual as ault. Thi car planning hould include ongoing edu cation about risk factor , threat detection for re- ictimi zation and strat g ie to decrea e hea lth risk behaviour (Wil on et a!., 2014 ). 74 Multidi ciplinary and peciali t referral c un ling and p cialized behavi ural th rapi proce uch a m ntal h alth team , upp rt erv1ce , , h uld al be includ d in th care planning to help with th managem nt f em ti nal and p y h I gi a! maniD tati n (Br wn et al. 20 1 · Mark et al. 200 · Dub c t al. 200 ). ympt m m nitoring i r c mmended t ng ing mental hea lth D 11 w-up care and n ure that mental health c ndition d pre ion can be id entifi ed arly and managed approp1iately (Jina uch a PT D and Thoma , 20 1 ). While not di cu ed within the literatur , ne might con id r the u e of at evaluat the impact f m ntal health ymp t m adv cate for the u e of the World H alth (WH DA ) a a to 1 t a e ability to get around and participation with 1 that n daily functi ning. The APA (20 J ) rganizati n Di ability A e sment chedul e di ability aero ix domain : und er tanding and commu ni cation, elf-care, interacti n with ther , activi ti e f daily living, and interaction ciety. imple cori ng method ofu e wi th thi t 1 represents an ea y and practical approach for bu y clinicians ( P A, 20 13). While no studies have mea ured the efficacy of such a tool in caring for worn n after exual a au lt, it ce11ainly would provide a generalized overview of the mental health impact f exual a ault on women and p rhap offer insight into areas of daily functioning requiring closer as es ment. Recommendations Targeting Personal Relationships Level of Influence There earch strongly a ociate negative di clo ure experience with the de elopment of emotional distress and negati ve elf-cognition , the development f PT D, and depre sion (Kelleher & Me ill oway, 2009; Littleton, 20 10) . trategies targeting th in flu nee per onal relationship have on women after e ual a au lt begin with a c in g \\ omen' di clo urc e perienc . Rec mmendati n for pr vider include a e in g the trcn gth of\\ men' , 1 ·ial upp rt network and any di clo ure e peri n c th y have had ( ittlcton, 20 l 0) . Padden (_()() ) 75 rec01runend u ing open-ended que tion uch as " who el e have you har d thi information with'' (p. 112). ocial upport and po itiv di c1 ure experience can be a po itive mediator for recovery, however negative di clo ure experi ence or a lack of social upp li can have the oppo ite effect fulih er cau ing emotional harm (Hellman, 20 14). Following a e m nt of ocial upp rt and di clo sure ex periences, recommendation are made for providing women with variou re urce to help uppoli th eir recovery proce . Thi is beneficial for all worn n, but e peciall y fo rth e with limited or negative ocial support system It i also recommend ed that informal upport y t m , uch a per onal relation hip and infonnal support provid er , are provided w ith edu cation andre urces to help them better support women after sexual assault. Campbell et al. (2009) advocate for referrals to or implementation of sexual assault awarenes program s to edu cate informal support providers about sexual assault and the varied effect it ha on wome n. "These program s should al o emphasize ... that pos itive reacti ons such as emotional support and tangible aid are helpful for recovery, and negative reactions , such as egocentricism and bl ame, may overshadow any positive efforts'' (Campbe ll et al. , 2009, p . 239). While these reconunendations are discussed within a personal relationship level, change at this level does not occur with these suggestions in isolation. Strategies developed and implemented at the societal level of influence will also help improve the responses and suppOii offered by personal suppoti networks. Recommendation s Targeting Communi ty Levels of Influ ence Recommendations for providers targeting c01rununity level of influence are impOiiant in decreasing the negative emotional responses a sociated with lack of provider knowledge and comfoli in the discu sion and provi ion of sexual a ault care. trategi will be reviewed that 76 addr th rgani zati nal batTi r that impact pr id r' abiliti t d li v r c mprehen 1ve mental h alth ii llow-up car to w m n after e ual a ault. trategie for provider . 11 health car pr fe i nal h uld en ure they are comfortable rec gnizing and managing vari u m ntal h alth di a ault u h a PT D and depre i n (Ray & M e n aney, 20 14 ). rd r a ciat d with ex ual ntinuing education should includ the u e of mental h alth cr enin g t ol and the variou strategie u ed t manage the condition (Am tadter tal. , 200 ). Provider h uld be edu cat d and en itized about ex ual a ault and it ef£ ct with additi nal training on how to r p nd t di c1 ure and guide di cussion with women ab ut ex ual a ault and th eir experi enc e (Jina & Thoma , 20 13). In addition to education, every primary care provid er invo lved in the care of women after exual a ault should have a complete li t of online and local re ource :D r w m en uch as support group , mental health service and legal upport (Ray & M e neaney, 20 14; uth erland et al., 2014). When providing written re ource , it i important to ensure they are culturall y appropriate with attention to the langua ge and literacy level of the women receiving the e resource (Jakubec et al., 2013 ). A list of local specialist and resource to up port providers should also be compiled for quick reference (Munro, 20 14; Padden, 200 ). ee Appendix G for nline Resource for Patients and Appendix H for R esources for Care Provider . The B CEWH (20 13) i the only docum ent that al o advocates for the education and awareness of care providers about vicariou trauma. Vicariou trauma i the emotional impact or indirect emotional trauma providers can experience when caring fl r women who di clo e th experience of trauma they have ndured ( merican ounselling A ociation, 2011 ). It i imp rtant for pr viders t be aware of vicari u trauma and to implement afeguard to protect th ir own cmoti nal health. hi conditi n can not only impact provider on a per nal lev 1, but 77 thi di tr canal hav an gative impact on the care th y pr id t w m en after xua l a ault. trategie for organi zation tructural and rganizati nal bani r probl m - olve w ay t ur e pra titi n r need t becom fami liar with th p ific t their cun nt practi ce ettin g and ac tive ly verc m the e bani r (Munr , 20 14 ). he m o t c n1111 n barri er include multi p i co mpetin g d mand D r pr docum ntati on. trat gi id r ' tim a nd Ia k of tim e fo rth ro ug h ugge ted incl ud e the devel pment f tand ardized pr cedure and the u e of MRs with ea il y acce ibl practice to a essm ent m ental h al th creenin g t 20 14). Tool and templ at u h a algoritl1111 , afety and lethality 1 and docum entati on templ a te ( uth erl and et al. , 1 cti on or developm nt require an as es m ent o f the MR capaci ty fo r typ e of templ ates and the ea e of their accessibility and u e w ithin such a ystem . It al o require an a e m ent of the u er w ithin th e prac tice to a e s :D r c mputer literacy and willingnes to utili ze these tools. Therefore, a collaborative approach to developm ent wo uld be best to ensure tools developed are ucce fully integrated into practi ce. T he tool may help increase provider efficien cy and care provi ion , de pite the multiple competing demand for prov ider · time. Fu rthermore, organi za tion are encouraged to implement rou tine integrated processes for updating educa tion al, referral resources and algorithm utilized to ensure up-todate care is provided to wom en after sexu al assault (J aku bec et al. , 20 13 ). Recommendation s Targeting Societal Levels of Influ ence Intervenin g at a ocietal level i often con id ered the mo t diffi cult a comprehen ivc interv enti n model are requir d that target multi- y tern levels whic h ho uld include "a \ id e va riety f trategies, uch a p licy change, organi zationa l c han ge, ys tc m advocacy, m ' di a camp aign , and rape awa rene /prev enti on edu cation to c real a broad-ba cd s ~ t mi c change" 78 ( ampbell et al. 2009, p . 240). While thi pr ject will n t d 1 p m del for the imp 11:ance f appr priate languag u age educati nal trat gie int rventi n it will di cu to increa e awarene rib h w to d P rol a an adv ca t fl r change targ ting and the cietall vel of influence. Langua ge. Language i di cu individual and pr vider thinking but al d at th ci tal lev 1 a it require a hift in not only a hift in th thinkin g and beli ef Educational effort and interaction with w m en familie and c mmuniti e that i neutral in nature. u ed uch a f ociety it elf. h uld u e language ot all women ma y id entify their ex peri ence with th e varyin g tenn exual a ault or rap e a it do e not me t the tereotyp d myth widely prevalent within ociety. Perc ption oftenninology d finition can impact wo men's w illin gne follow-up care andre ourc (Jozkow ski & aund er 20 12) . to acce s ing appropriate language uch a forced or coerced exual experiences when co mmunicating with women and the public may help women better identify their experience as sex ual assault and increase their acces to fonnal follow-up care services (Jozkowski & aunder , 2012; Kell eh r & Me illoway, 2009). Education and Awareness. Education and awarene presentations and how to acce about exual a ault, its varying ervice aimed at a societa l level wi ll help facilitate change on a greater sca le than targeting only tho eat the individual level (Kelleher & McGilJoway, 2009; Munro, 2014 ). Dissemination of informati on to the public require long-term tenn trategic planning as it may take many year before there i any evid ence of change. Developin g Partner hip s fot· hange. Nurse practitioner and other car provider are well-positioned within the hea lth care y tern tow rk with variou public ector to develop collaborative ervice-ba ed model that meet the health need of women alter sexual a. ault (Thur ton et al., 2006) . xaminati n f gender and the ocial d tcrminant or health \Vi thin the 79 cont xt of each individual community etting ne d t b c n id red a the e factor can prevent r exacerbate the impact xual vi lence ha on w m n (Thur t n et al. , 2009) . Th overall goal of uch int rventi n i to in rea publi c kn wledg f e ual a ault and it nega tiv emoti nal con equence experienced by w m en in an effort t change the exi ting ter improvin g the c mmunity ' re p n t type thu x ual a ault ( ampb 11 et al. , 2009) . Th action of P ar not confined to the clinic etting and in tead they can act a advocate for chang within the community and ci ty it elf. ur e practitioners can have a huge impact on corru11unity development f ervice andre ource that better the care D r women after exual a ault. Thi can be achieved by becoming involved on the boards of rape cri center , exual a sault coun eling en rtce and oth er specialized support erv tces. ur e practitioner can impact hea lth care legi lati n by lobbyin g for changes and funding that improves the health care response to exual as ault. Furthermore, lobbying to improve accessibility and availability of supportive services for wo men is key to ensuring women receive needed support . Rai ing ocietal awarenes also include m as m edia me ages about sexual assault and its effects, but can al o be accomplished in the fonn of charitable events, that both raise awareness and money to support the improvem ent of ervice and care for these women. Furthermore, NPs can continue to improve the care of women after sexual assault by furthering the research available to guide practice. 80 onclu ion R nur ional e p nence a a regi tered iew of the lit ratur in c njuncti n with my pr caring£ r women in th aftermath f exual a ault pr mpt d a n d to addre a re ul t, the purp h alth follow-up care ervice pr vid d after exual a ault. the mental e f thi project wa to an wer th que ti n : In adult w m en f childbearing age who have experienced a recent xual a ault can ace decrea e the preval nee and e top t-a ault :D 11 w-up car within two week of the a sa ult rity of p t-traumati c tr di rd r (PT D) and d pre sion? Thi paper conducted a comprehen ive literatur r view which re ulted in th u e of three guideline and ixte n re arch article for review. The r view proce id entified significant gaps in the literature around mental health :D llow-up care and th e elem ent nee ary to better meet the p ychological and emotional need of women after exual as ault. An ecological framework was utilized within thi proj ect to synthe ize and analyze th e re earch articles collected. Thi framewo rk allowed for greater ex plorati on of th e ecologica l factors that contribute to the complexity of mental health and the emoti onal responses ex hibited by women after sexual assault. It al o served to help organize strategic and reconunendation for change that target specific levels of influence, all the while und erstanding that the e ame strategic are dynamic and can be effective throu ghout the level . The research examined in thi paper ha posited a ociations for follow-up care interventions and approaches that have potential po itive outcome on the mental health of women, but the e findings are not proofs. uggested recommendation include the u e of a trauma-inform ed approach to care th at mpha ize uppo11ive and non-judg mental care in a , afe and tru tw rthy env ironment may be key to d vel ping rapport with women whil engaging th em to acce future health care ervices . Th rough a smcnt and individualized acti n- 81 oriented care planning within clo proximity of the a ault, preferably within a maximmn of two week after the exual a ault, may be important in h !ping women c pe with the physical, emotional and p ychological trauma a ociated with exual as ault. Recomm ndations aimed at individual, per onal relation hip c01rununity and ocietallevel of influ ence are provid ed that ma y a i tin improving the em tiona! and p ychological asp cts of follow -up care. Nurse practitioner are well-po itioned within primary care etting to care for women after exual a ault. The P model of ca re allow for the time needed to better meet the m ental health needs of the e women. trategies mpl oyed by NPs are required on all levels of influ ence including those eff01i that go beyond work within the clinic setting. Further research is needed in the f01m of randomized control tri al to better understand the health impact current follow-up care strategies have on improving the p ychological wellness of wo men after exual assa ult. 82 References A ckerman, D ., ugar, N ., in ., & ck rt L. (2006) . a iated with foll w-up care. A meri an Journal of b t tries Retri v d from http ://www .aj g. rg/article/ 0002-937 (06)00 ARE ' 194(6) . ext t p on rtium. (2 009) .Th A REE II In trum nt. Retri eved fr m www.agr etru t. rg Alberta Ju tic and licitor eneral lb rta rown Pro cuti n ervice . (2 0 14 ). A D om tic Vio l nc H andbook for Po li rvic an d rown 1 rose utors in A lb ria. R tri v d from http ://j u ti ce.alb Iia.calpr gram _ erv1 e /fa milie /d cument /dome tic viol ncehandbo k.pdf Ameri can oun elling ciation. (20 11 ). Vi ariou Trau ma . R tri eved from http ://www.coun ling. rg/doc /traum a- di a ter/fac t- heet-9- --vicari ustrauma. pdf? fvr n=2 Ame1ican P ychiatric A ociation [APA]. (20 13) . Diagnostic and Statistical Man ual o.f M ental D isorder (5th ed .). Arlington VA : American P ychiatri c Publi hing. American P ychological A ciati n. (2 0 15). exual A bu e. Am ri an Psycholog ical A ociation. Retrieved from http ://apa.org/topic I exual-abu e/ind ex .aspx Am tadter, A . B., McCauley, J. L. , Ruggiero, K . 1. , Resnick, H . ., & Kilpatrick, D . . (2008). Service utilization and help seeking in a national sampl of fem ale rap e victim s. P y chiatric Service , 59(1 2) . doi : 10.11 76/appi.p .59 .12.1450 As-Sanie, S., levenger, L.A., Gei er, M . E ., Willi am s, D . A ., & Roth, R . . (20 14). Hi tory of abu se and its relationship to pain experience or depres ion in wo men wi th chronic pelvi c pain . A merican Journa l of Obstetrics & Gy necology, 21 0( 4 ). doi: 10.10 16/j .aj og.20 13. 12.04 8 Averill, J. B., Padilla, A . 0 ., & Clements, P. T. (2007) . Frightened in isolation : Uniqu e considerations fo r re earch of exual as ault and interp ersonal violence in rural area . Journal of Forensic Nur ing, 3(1 ). doi: 10.lll llj . l 939-3938 .2007. tb0009l. x B ykin, A. & Mynatt, . (2007). A ault hi story and fo ll ow -up contact of women urv1vo r of recent sexual assault. Issues in M ental I-lealth Nursing , 28(8) . doi : 10. 1080/0 16 1284070 1493394 Brennan, . & Taylor-Butt , . (2008) . xua l as au lt in anada. an adian Ccntrejhr Justice Statistic Profile cries. ( 19) . Retrieved fr m http://www . tatcan.gc.ca/ pub/85fDO m/ 85 m200 80 19-cng. htm mo Bri ti h olu mbi a enter of x li enee ~ r W men ' ll ealth [8 WH ]. (~0 I ). T'rauma - 83 Inform d Pra ti uid . R trie ed fr m http ://bc ewh.bc .c wpc nten up] ad /2012/05/201 _ TIP- uid .pdf Briti h lumbia In titute f T chn 1 gy [B IT]. (20 15). For n, i F or n ic H alth 'Pti n our .. R etri ed fr m http ://www .bcit. c tud /pr gram /525 ha rt#c ur e c1 n Te hn olo Br wn R ., DuMont J. M a d nald , ., ainbridge, . (20 13 ). mp arati ve an aly i f v ictim f ual a ault w ith and with ut m ental h alth hi t n c : cute and [! llow -up care characteri ti c . Journ al of For ns i urs ll1 9(2). d i: 10.1097/J F .Ob01 3e3 1 2 106df Buneviciu , A . Le em1 an, J., & irdl r, . . (20 12) . H yp th alamic-Pituitary-Thyr id axi functi n in w m en w ith a m en tru all y relat d m od di rd r: ciati n w ith hi t ri c of exual abu e. P. ycho. om ati M di ·ine, 74( ). d i: 10.10 7/P Y .Ob01 3e 1 26c33 97 . . (2004). T he impa t f rap e on wo men' ex ual health ampbell , R ., efl T. , Ahr n ri k behavior . H alth Psychology, 23 (1 ). d i: 10.103 7/0278-6 133 .23 .1.67 ampbell, R ., Dworkin , ., & abral, . (2 00 ). An cologica l m del f th e impact o f a ault on w men' mental health . Trauma, Vio lence & Abuse, 10(3). d i: 10.117711 524 3 00933 4456 xual anadi an Nur e A ociation . (20 10). anadi an ur e Practiti o ner: ore competency framework . anadian N urses A sociation. Retri eved fro m http ://www .cn .org/GlobaVfor/m ec/pd fl ompetency ram ework _ en.pdf handl er, H . K ., Ciccone, D . ., & Raphae l, K . . (2 006). Loca li za ti on of pain and elfreported rape in female community ample. P ain M edicine, 7( 4 ). doi : I 0.111 1/j .15264637.2006 .00 185.x. hiver -Wilson, K . A. (2006) . Sex ual as ault and po ttraumati c tres di ord er: review of the bi ological, p ych logical and ociological fact r and trea tm nt . M cGill Journal of Medicin e, 9(20). http ://www. ncbi .nlm.nih.gov/pmc/arti cles/PM 2323517/ ollege ofRegi tered N ur e of British olumbia [ RNB ]. (20 15). pp lying the omp etencie Required for Nur e Practiti oner in Briti h olumbia . College of Registered N urses of British olum hia. Retri eved fro m https: //www.cmbc.ca/R egistration/ i t /Regi trati nRc ource /440PL R.pdf Dahro uge, S., Muld n, ., W ard , N ., Hogg, W ., Ru el, ., & Ta lor- u ex, R . (2014) . Role of nur e practiti oner and fa mil y phys ic ian in commu nity hea lth centre . Canadian Family Physicia n, 60. Retri eved fro m http://www .cfp .ca/ on ten 60111 I O~O . full.pdf ub c, A ., apitain , M ., rank, . ., Bui , ., Brun et, A ., habrol, H., ' Rod gers, R. . 84 20 12). arly adult e ual a ault and di rd r d ea ting: he m diating r p ttraumatic tre ympt m . Journal o.f Trauma ti tr s, 25( 1). d i: 10.1002/jt .2 1664 Famil y Practi c http ://www .fpn t b f a/ . R etri ev d fr m l.htm amil y Practi c teb k. (20 15b ). FF u . tionnair . Retri c ed fr m http ://www .fpn teb k.com/p ych/e at cfl tnr .htm ergu on, . & p ck, P. (20 10) . T he ~ r n ic nur e and vi 1 nc p reventi n and re p n e m public health . Journal of F or n i ur. in , 6(3). d i: 10. 1111 /j .1939-39 .20 I 0.0 1080 .x Fra er H alth Auth ri ty. (20 15). mm uni ty cl inic upp rt th e w h have experienced dom e tic vi lenc and xu al a ault. Fra r 1-fea/th ewsroom . R etri ved fro m http ://new .fra erh alth.c w I pril-20 15/ mm unity-clin ic- upp rt -th e-w hohave-experienc.a px H llman, A. (2014). xa mining ex ual a ault urv iva l of adult wom en : R pon e , m edi at r and current theorie . Journal o.f Foren ic urs in , 10(3) . do i: 10.10 16/j .aj g.2006 .0 .0 14 Henry, N . & Powell , A . (20 14) . Preventing sexua l vio lence: 1nterdisciplinwy approaches to overcoming rape cultu re. ew York, Y : Palgrave M acmill an Jakubec, ., Catier- nell, ., frim , J. , & kand erup, 1. (20 13) . Identifying rural exual a sault ervice tren gths, co ncerns and education al need in rura l and Abori gin al communi tie in lbetia , Canada. E1~{erm eria , 12(3 1). Retrieved from http ://revi ta .um .e /eglobaVarticle/viewFil e/ 174751/ 1505 11 Jina, R . & Thom a , L. . (20 13) . Health con equ ence of e ual vio lence again t wom en. Best Practice & R e earch Clinical Obst /ric & Gy naecology, 2 7( 1). doi : 10.10 16/j .bpobgyn.20 12 .08 .01 2 J hn Hopkins M edi ci ne. (n .d.) CA GE Subs tan ce Abuse S creening Too l. R etri e http ://www .hopkin medi cine.org/john _ hopkin _ healthcare/dow nload ance%20 creening% 20Tool. pdf ub t Jozk w ki, K . N . & aunder , . A . (20 12). Health and s ual out om e ofwomen who have ex peri enced fo rced r coercive ex . Women & 1-fea/th . 5~ ( 2 ) . do i: 10.1080103630242.2011.64939 7 Kell eher, . & Me ill way, . (2009) . ' No b dy ever choo thi s ... ' : qua litati\ e stud of ervice pr vid er w rkin g in th e e ua1 v i lcncc c tor - Key issues and challenges. 11 alth and ocial are in th e Co mmunit_v. 17( ). d i: 10. 111 Lj . l365 -2 5_4 ._ ()() .00 34 85 f Intimate Partn r i 1 nee: i 11 L 1 r m lamin g th e Victim t 34( ). d i: cting ine, J. M ., Br wn K . . h awar ki M ., i llin . White, W . . & ledg , W . H . (2 00 ). M aj r d pr ion and r cent phy ica l r e ual abu e increa e readmi i n am ng hi gh-util izing primary car pati nt . M ntal H alth in Fam ily M edi in 5( 1). Retri e ed fr m IN HL 1 Limitati n ct, R "i d fat ui o.f British lumbi a (1 6, c. 2 6 ). Retri ved fr m http ://www .bclaw .c c i i /d cum n id/ mpl et I tatreg/ 1201 3_ 01 Linden, J. A . (20 11 ). ar M dicin , 3 65(9) f th adult pati ent aft r e ual a ault. ew 4- 41. d i: 10.1056 JMcp11 02 69 ngland J ournal o.f L ittl eton, H . L. (2 0 10) . The impact of c ia1 upp Ii and nega ti ve di c1 ur reacti on on exual a ault v ictim : cro - cti nal and longitudina l invc ti gati on . Journal o.f Trau ma D i ociation , 11 (2) . doi: 10.10 0/ 15299730903502946 M ark, H . Bitzker K ., Kl app , B . F . & Rau hfu , M . (200 ). yna c 1 gical symptom a sociated w ith phy ical and exual v iolence. Journa l of P.sycho omatic Obstetrics Gy necology, 29(3 ). doi: 10.1080/01674 207 01 32770 M cinturff, K . (2 01 3) . The ga p in the gend er gap : Violence again t wo m en in anada. Canadian entre fo r Policy A ltern ative . R etri eved from http ://w ww .policya ltern ati ve .ca/ ite /default/fil es/upl oad /publicati on ati onal%2 0 ffi ce/201 3/07/Gap_ in_ Gend er_ Gap_ VA W .pdf M ental H ealth Commi ion of anada. (20 12). Making the cu e for inPe ling in mental health in Canada . Retri eved fro m http ://www. m entalhealthcommi ion.ca/Engli hi y tern/fil e I private/docum ent/Investin g_ in_ M ental_ H ealth_ F INA L_ V er ion_ G .pdf Munro, M . L. (20 14 ). Barriers to care for exual assault urvivo r of childbearing age: n integra tive review . Wo men 's Healthcare: A Clinical Jo urnal fo r Ps. 2(4). Retri eved from INAHL Na ti onal enter fo r Injury Preventi on and ontr 1 & enter [! r Di ea e ontrol and Pr v nti n. (20 11 ). The Na tional Intim ate Partn er and exual Violence Surn'y: 2010 ummary R 'POri. Retrieved fr m http ://www .cdc.gov/violenceprevcntion/pd f/ni v r pOii20 10a.pdf N ur Practiti on r ' A Clatl on r ntari . (20 I I ). Fa ct heel 0 17 th e \'alue o(nurse pra ctitioners. Retri eved from http ://www .bcnpa . rg/ tin mcc/plugin fil cmanag ~r fi l ~ . Va lu e of N P a t heet ovem b r 7 20 ll .pdf Padd en, M . . (200 ). c ual vi len c and th il nt reaction to rap ·: lmpli ati on. for nurses . 86 ur 111 for Wom n' I-I alth, 12(2). Retri ed fr m IN H Patel , R . Ll yd, T . Ja k n R . Ball, M ., h tty, H ., Br adb nt M ., ... Tay l r, M . (20 I 5). M d in tability i a c mm n featur f mental h alth di rd r and i a cia ted with p r lini al utc m . B riti h M di a! Journal, 5(5). d i: 10. 11 6 mj pen-20 14007504 Perreault, . & Brennan . (20 10) . riminal R tri v d fr m http ://ww . tatca n.gc . t1m1 zati n in anada , 2009 . Juris /at , ( 0) . pub/ 5 -002-x/20 10002/articl Ill 40- ng. htm P rnn B . (20 10) . lm i. ihle 'hain : 'anada 's underground world of human trc~ffickin . T r nt : P enguin r up . Pikarinen , ch i, B . wa hnb rg, K ., & Halme m aki , . (2007) . xperi ence phy ical and ual abu and th ir impli ca ti on [! r current hea lth . Ob tetrics y necology, 109(5). d i: 10.1097/01. .0000259 0 . 1 4 74. 6 . f Quadara, A . & Wall , L. (20 12). What i ffecti e primary preventi n in exual a ault? Tran lating th e evid nc for acti n. A u Ira/ian nt rfor th e Study of exual Assault. R trieved fr m http ://www3 .aif: .gov.au/ ac a/pub /wrap/wrap 11 /w ll.pdf Ray, L. & M e n aney, M . (20 14 ). aring ~ r urviv r f ex ual vi Ience: gu id e .G r primary care P . Women ' Health 'are. Retri eved from http ://npw m n healthcare.com/wp-content/upload /20 14/04/Violence_ Ml4 .pdf ex Information and du cation Council of anada [ IE A ]. (20 11 ). ex ua l A ault in anada : What d we know? SexualityandU. Retrieved fr m http ://sexualityandu .ca/uploads/fil e I exual ssaultT20 11 -E .pdf tati tic anada . (20 10) . end er difference in poli ce-reported vio lent crime in anada, 2008 . Governm ent of anada. R etrieved from http ://www . tatcan .gc. ca/pu b/8 5 fD03 3 m/2 0 10024/part -parti c 1-en g. htm# h2 _ 9 tati tics anada . (20 11 ). Population, urban and rural, by province and t rritory ( anada) . Governm ent of anada. Retri eved from http ://www . tatcan.gc.ca/tabl e -tabl ea u I um m/10 1/c t01 /demo62a-eng.htm anada. (20 1 ). Police-reported crim e tat! tics in anada , 20 12. m·ennnent of an ada. Retri eved from http ://www . tatcan .gc.ca/pub/ 5-002- /20 1 00 llm1i I 111 54eng .htm?fpv=269303 uthcrland , M . ., Fontenot, H . B ., & anta . ia, H. . (20 14 ). Beyond a. c sment: . ammmg provider ' re pon t di c1o ur of violen e. Journal oft lie American Assocwtwn of Nurse Pra ·tition ers, 26(1 0) . doi : 10. 1002/2 27-6924. 12 10 1 alb t, K. K., N ill , K . ., Rankin, . . (20 I 0) . Rape-acceptin g attitude of univ 'rsit 87 und rgraduat tudent . Journal of Forni 93 .2 010 .010 5. ur 111 , 6(4) . d i: 10.111 1/j.1 Ta ara L. (2006). e ual i 1 nc . B t Pra ti R ar h. lini a/ y na olo , 20( ). d i: 10.101 /j.bp bg n .2006 . 1.011 b t tri Thur t n W ., Patten ., ag nd yk, L. (2 ). Pre al n e f i 1 nc again t w m en rep rt din a rural hea lth regi n . anadian Journal of Rural U >di ·in , 11(4). Retri eved fr m IN HL ., Ballina, . ., ward, ., R . Haud a W ., H lbr k, ., ... M Lean, . (20 14 . Pain and m ati c ympt m are quelae f c ual a ault: R e ult fa pr p cti 1 ngi tudin al tud y. Europ an Journal o.f Pain , 1 (4). d i: 10. 1002/j . l5 22 149.20 1 .00 95 . niver ity ofBriti h lumbi a. (n.d .. Pati nt H >a/th Questionnaire (PHQ-9). Retri eved from http ://www.ubcm d.ca/ ad/PH -9 .pdf . D epartment of Vet ran Affair . (20 15 ). PT. D : a tiona/ enter for PTSD, Primwy PTSD Scr en (P -PTSD). Retri ved fr m http ://www .pt d.va.gov/profe i nal/a e ment/ creen /pc-pt d.asp are Vaillancourt, R . (20 10) . end r di ffere nc in police-rep rt d violen t cri m e in anada, 2008 . Canadian entre for Ju lice Stati tics Profile Series, (24) . R etrieved from http ://www .statcan .gc .ca/pub/85fD033m/ 5fD033m20 10024-eng. pdf Vidal, M . E. & Petrak, J. (2007). hame and adult exual as ault : tudy with a g r up of female urvi vor recruited from an a t London popul ati n. Sexual and Relationship Th erapy, 22(2). doi : 10.1080/ 14681990600784 143 Violence Prevention Alliance. (20 15). The ecological framework. World H ealth Organi::ation . R etri eved fr m http ://www .who.int/v i lencepreventi on/approach/ ecolo gy/en/ Wad worth, P . & Van rd er, P . (20 12) . are of the sexually a aulted woman . Journal For Nurse Practitioners, 8(6) . doi: 10.10 16/j .nurpra.20 11 .10.007 W eis , K. . (20 10) . oo a harned to report: D econstru cting the hame of e ual victimization . Femin ist riminologv, 5( ). doi : 10. 11 77 I 15 70851 10 76343 Whittemore, R . & Knafl, K . (2005) . he integra ti ve revi w: upd at d methodology. Journal o( Advan ·ed Nursing, 52(5) . d i: 10. 1111 /j . l 365-264 .2 005 .0362l.x Wil n, . ., Waldr n, J . . , & carpa, . (2014) . Di inhibition a a mcchani min . c. ual vtctlm1 za ti n: pr p tive tudy. Journal o/Aggrcssion. !lfaltrcatmcnt and Trauma. 23( ). d i: 10. 10 0110926771.20 14.94 10 88 W men gain t Vi 1 nee Again t W m n. 20 14 ). Rap M th . R trieved fr m http: //www . wa aw . mythbu ting/rape-myth I ]. 200 . uid lin forth M di o-1 al car of Vi lim of W rld H alth rganizati n [W d fr m ual Viol n . R tri .pdf?ua= 1 n /2004/ 2415462 http ://whqlibd .wh .in 89 1 p ndi P t- Guidelines Medical Care Follow-up Guidelines for Medicolegal Care for Victims of Sexual Violence ../ Trea tme nt f ph y ical ar R c mm endati n ../ ../ ../ ddr ng m g m edi ca l ../ Tl, Hl pregna n y immuni za ti n ../ are pl a n fo r 2 week , 3 6 m nth ../ ../ ../ ../ ../ ../ TI, HIV, pregnan cy, immuniz ati o n A c knowl ed ge trea tment fo r phy ical/m ental health equelae duca ti on elf-ca re H ealth ri k beh av ior upport Referral to Consider Advocacy Group Follow- InJUn C I1Cel11 Caring for survivors of Sexual Violence: A guide for primary care NPs ault e r rce ../ Legal upp rt ../ R ap e cri i centre ../ helte r ../ HIV/Al c un e llin g ../ L ega l c un el ../ Vi c tim erv rce ../ upp rt g r up ../ Therapi t ../ Finan c ial A i tance ../ c ia ! Follow-up Care Intervals ../ 2 w k ../ m nth ../ 6 m nth ../ ../ HlV p ecia list ../ oun elling ocial w rk ../ lea t 6 m o nth ../ T I te tin g in 1-2 week (no pro ph y lax i ) ../ 2-4 week (if g 1ven prophy laxi ) ../ 6 week fo r yphili and HIV te ting 90 App ndix B it ratur Sexual As ault • Rap • exual abu e • exual violence • Rap e victim arch • • • • • • • • examination ual a ault examinati n Foren ic e aminati n Phy ical e aminati n P ych 1 gica l xamin ation H ealth assessment Pati ent a e sm ent Rik a sessment n Maj r • • nc pt and • • • • • • • t-exp ure flu • • • • imilar Term F 11 w-up M di cal fl u L t t flu p t-exp ure pr phylaxi ynecology P ychol gy Health care need Treatm nt eeking behavior yn eco logical • • • • • • • • flu • • • • • • • c nter Rural health p r liD 1 H pita! rural Rural popul ation Rural health erv1c Rural health nursmg Rural areas Rural health Australian rural nur e and midwives N urse practitioner (Acute are, Ad ult, merg, Obgyn) Primary care providers Health care providers exual assault nur e exammer Primary health are • • • • • • 0 • • • • • • • • • • • • • • • Rape- trauma yndr m e Tr atm nt complication , delayed Treatment compli cation complication exuala ault complications cute tr s di order tre -di ord er, po t-traum atic Ri k [! r injury Acute co mpli catio n hronic compli cations Impact of events scale Pain Pelvic pain Acute pain Chronic pain bdominal pain Treatm nt utcom Rape p ycho ocial ocial probl m elf-m di ation e ually tran mitt d infection tigma Health Impact , e.. m 'nt 91 App ndi II e m nt of linical Pra ti c uid line AGREE II Domain and Overall Assessment of Trauma Informed Practice Guide Score: Likert scale rating 17 with 1 representing strongly disagree and 7 representing strongly agree D upp 11 th tran lati n of traumapra ti c t better th e care .G r th e e and traum a. 2. 7 o p cific qu e ti n p ed, in t ad pr vide recommendati n that trauma-inform ed ca re be provi ded for all intera ction with per n with a hi t ry of vi lence and trauma e peciall y tho e w rkin g within the m ental health and ub tanc abu se area of care. 6 3. Generalized reco mmendati n D r pr id er are applicable to any p r on with a hi tory of trauma or iol ence. 6 verall Dom ain core: 90% Domain 2: Stakeholder Inv lvement 4. The guide deve lopment gr up includ e profe sionals from relevant organization and di cipline . However, exact content experti e and role in guide development pr ce wa not included. 5 5. The benefit and need for the trauma-infonned recommendation wa ba ed on re arch finding presented within the d cum ent. The view of provider caring for the target population were ought, but the view and preference f target population th em elve wa not mentioned . 4 6. The target u er f the guid eline are clearly identified a health ystem planner and health care providers aring for per ns with a hi tory of trauma r vi I nee, pecially tho e wi thin the pra ti eing within the mental health or ub tan e abu e area . 7 verall omam 76°o ' Or' : 92 7. fl r it ofth Th criteri a fl r electing the de crib ed. iden e i n t cl arl y 9. Th guid d crib e limitati n in th a ail able re ear h related t impl m ntati n f tra um a- in~ rm ed prac ti c but refer to multipl e practi c -ba ed re urce that trength en furth er d cripti n the rec 1nm nd ati n provid ed. pr vided. 10. Th m th d for~ rmul ating th e rec mm nd ati n are n t clearl y de 2 rib d. 11 . upportive data i provided that identifi e the m ental health benefit f u ing a traum a- in[! nn ed approach t care and the ri k a ociated w ith n n-u ing thi approach. 12. o explanati n of the proce fl r linking vidence t recommend ati on how ever, recomm nd ati on are ci ted w ith supporti ve literature where practiti oner can further inve ti gate the upp rting literature. 13. The guid eline wa reviewed and pr vid ed w ith fee db ack by exp e11s and leader in the e care area p rior t it publication. 6 5 6 14. No m ention of a procedu re fo r guid e update was no ted. verall Dom ain core : 52% Dom ain 4 : 15. R ecommend ati n are clearl y id entifi d by generalized headings with m re pecific detail provided within eac h section. N indi vidual tatem ent f rec mmend ati on provided. 6 16. he different opti ns for impl ementati n t the popul ati n are c lea rl y pre entcd und er a h g n ralized heading . 6 17. Key guid eline , me age and o erall g al [! r care ar ea ily id cnti fi abl nca r the end of th e d urn nt. 6 vcrall Domain 6°o , rc . 93 Domain 5: Appli abi lity 1 . Th di cu ed pr ider level ban·i r t pr viding trauma inti rm d are u h a vicari u trauma , h w er the guideline d n t cl arl y de ribe fa ilitat r and banier t imp I mentati n f th e pra ti ce . 19. The gu id elin pr id k y pra tice appr ache t impl ementati n a well a an rganizati nal checkli t t upport di cu i n and acti n n imp! mentati n f trauma-inti rm ed practice. 7 20. Th guid e indir ctl y di cu ed the training need t en ure provid r are educat d nth prin ipl and appli ca ti n f trauma-infl rm d practi c a part [the rganizati nal checkli t fi r impl ementati n. 5 2 1. The gu id line indirectl y di cu ed monitoring and 5 eva lu ati n m nit ring and evaluati n crit ri a a pa1i [the organizational ch ckli t ti r impl em ntati n. verall D mam 7 1% Domain 6: Editorial Ind epend ence 22. The view of the fundin g body have not influenced th e content of the guideline a indi cated in the acknowl edgement . 23. re: 7 o mention of competing intere t of gu ide developmen t group member wa noted within the document. Overall domain core: 57% verall Assessment 1. Overall qu ality of the guid eline 2. I wo uld recommend this guid eline a it offers gui dance n approach implementation to trauma- info rmed care wi th the caveat that prov ider approach need to be tailored to the needs of the pecific traum as as ociated with each pa tient popul ati n. 5 94 pp ndi D finiti n f T enn Term lnterp er nal Vi lenc ex Traffi cking " ... an u e f ph ica l r r threa te ned, in a n intimate relati n hip . It m ay in lud a ingle ac t f v i 1 nc , r a numb er f act [! nning a patt rn f abu thr ugh th e u e f a aulti v and c ntr !ling b h av i ur. Th e p attern of abu e m ay includ e: phy i al bu e; emoti nal abu e; p ych 1 gical abu e; e ual abu e· crimin al hara m ent ( talking); thr a t t hatm c hildr n th r fa mil y m mb r , pet and pro pe rty" (A lberta Ju ti c li cit r eneral lb rta r w n Pr cuti on rv ice , 2014, " ... occ ur w hen a n indiv idual recruit , tran p rt , tra n fer , barb ur or receive p e pl e by m ean of decepti n, fraud , coercion, abu e of power, paym ent to th er in c ntr l of the victim, threat f force, u e f fo rce o r abdu cti o n -G r th e purp f ua l xpl o ita ti n'' ( nited ati on , 2000 a cited in Perrin, 20 10). " ... unwant d e ual acti v ity w ith perp etrator u ing force m akin g threat or taking advantage of victim not abl e to give con ent (Am eri can P ychologica l ociati n, 20 15, para 1). ''Fo re d ex ua l ac ti v ity, an atte mpt at ~ rc d x ua l acti v ity, o r unwanted exu al tou ching, grabbing, ki ing, o r ~ ndlin g" (PetTa ult & Brennan, 2010 para 7). The Criminal d f anada (19 5) further ubdivid A into 3 level of ev rity: • Leve l 1:" n a a ult co mmi tted in circum tance of a ex ual nature uch that th e exu al integrity of the victim i vi la ted . .. invo lve min r ph ys ical inj urie or no injuri e to th victim ,. (Brennan & Taylor-Butts, 2008, para 9). • Level 2: A u ing a "weapon, threa t , or ca u ing bodily ham1" (Brennan & Taylor-Butt , 2008, p ara 9). re ultin g in "wo unding, maiming, Level 3 Aggravated A: di fi g urin g o r end ange rin g th e life of th e victi m " (B r nna n • Ta _ lorButts, 2008, p ara 9). Rape 95 p ndix ummary f Re 1ru11 ndati n forM nta l H ea lth 11 w -up are Level ofinfluen ce ptimal Foll w-up ar Interval lndividual Level • • • • • • • r r Per na l Rc lati n hip r r r ti c, upp Jii ve and n n-judg m enta l a ~ , tru tw rthy and c nfid enti al nvtr nm ent f neutral b d y language e f ac ti e li t ning e f upp rti ve and acknowl edg ing tatem nt har d deci i n-m akin g, ch ice and collaborati on Pr vid ex planati on for m edi cal proc dure and th 1r pr ce , uch a gynec logical xamination . • fD r alt rnativ m eth d [! r th p I ic exa m th at decrea e em o tional di tre , uch a w m en in erting peculum th m lv r u ing lith t m y p iti n w itho ut[! t re t M ental health follow- up care co mpo nent • A e wo m en ' pa t m e nta l hea lth hi to ri e , pa t hi tori es of exual as ault and ex ual a ault ch aracteri ti c (a e rea dine to di close) • CuiTent m di cal and m ental health concerns • cr en fo rd pres io n, anx iety, PT D , ub tanc abu e, di rd ered ea ting, phy io logica l bluntin g and health ri k behav iour • Provid e edu ca tion about ex ual a ault and it cffe t • trength identificati on and kill building • ngo ing educa tio n of risk fac tor , threa t-d tectio n for rev ictimiza ti on , and way to decrea e health ri k b ha i ur ngo ing care pl annin g ping trategi and afety pl anning • m nt, r inD rcemcnt and modification to • ng ing a ca re pl ans a determin ed by a wo man· need • Multidi c iplinary and peciali t refena l a needed • ngo ing a e m nt of ymp tom severit , , u ·h a PH -9, -7, a nd W H As ork 96 inD rmal u pp rt n tw rk mmunity L vel ocietal Level ual Y ,. ,. ..._ ,. ,. ,. f e ual a ault and it effec t • du ati n t in rea e pr vid r m.G Ii in rec gni zing and iat d m anaging ar i u m enta l hea lth nditi n a w ith u I a ault • T raining t impr ve pr vid r ability t r ceiv and re p nd t di cl ure f e ual a ault and it c ha ractcri ti c • du ca ti n ab ut vicari u traum a and importanc f elfca re .G r pr v id er • rea t an ea ily acce ibl e li t f online and local re urce :fl r p ati nt • rea te an ea il y acce ibl e li t f re o urce and p ecia li zed refen al fo r pr v id er trat gi .G r rga nizati n • B ee m e famili ar with tru ctural and organi zati na l bani er to care of wo m en after ex ual a ault (multipl e c mp etin g dem and tim e con traint , etc ... ) • on id er c llaborati ve dev I pm ent of tand ardized procedures, asses m ent a nd m an agem ent algo rithm and templ ate D r docum ntati n n id er impl em entin g routin e tra tegie fo r upda ting • edu ca ti o nal m ateri al and racti ce too ls E ducati onal strategies to pro m ote awa rene of exual a au lt that u e neutral language o llabora ti on wi th communi ty partners to develop coll aborativ ervice- based m ode l fo r care B ecom e in vo lved on the board s of upp rt ervice for women after sex ual a ault Lobb y for hea lth ca re reform and legi lative change that refi t th e need of wom en after se u al a aul t ngage in m as m edi a edu ca ti n and awarene , as well a th organiza ti o n of ch ar itable event th at rai e awarene and funding for 97 pp ndix M ntal Health ere ning T Primary ar - P t Traumatic qu ti n u d t ere n fi r PT creen h uld b con id ered po itive if a w man an w r ye to any f the four que ti n . GAD-7 qu tiom1aire (Family Practice otebook, 20 15a, adapted from itzer, 2006) AG -AID qu e tioru1aire (John Hopkins Medicine, n.d., adapted from Ewing, 1984) SCOFF Questioru1aire (Family Practice Notebook, 2015b, adapted from Morgan, 1999) Five que tion tool u ed to creen for di ordered eatin g that i ea y to use within primary care setting . Two or more po itive re ponse is ugge tive of an eating disorder. 98 ppendi nlin R our e .D r Patient '? [[! r ace opportuni ti fi r the publi ab ut e ual i 1 nc , ffer re urce and e-learning prape. rg/ Men ffer re ur e and edu cating targeting yo uth and adult by rai ing awarene i lence and way that male can help mbat vi lenc aga in t w m n f exual Rap )..- Offer re ource edu cati on and upp rt t per on wh have experience exual a ault. enter on Vi ).> Provide re ource , upport, and du cati n to per on wh have experi enced exual f ex ual violence. violence. AI o di cu e intemati nal and global i u 99 pp ndix H R urce fi r are Pr ider ual ault in Po tpub Jial td-mt I ti-it I g ti -ldcit I ecti n-6-6eng. php .r ffer guidance n car and tr atm nt f adol e cent and adult who have experienced exual a aul t. .r ffer guidance on combating for provid er . International xual vi lence, includ e fact heet and link t re ource s ociation ofF ,. ffer contact inft rmation and guidance fi r the foren ic care f per on who have experienced crime, trauma or viol ence. Membership grant acce to variou re ource , webli t and IAF Joumal a11icle . ~ Di cusses edu cation opportunities, upcoming events and re ources for provider . I o ha membership opportunitie for further networking and update on foren ic pra tic . e11ificate. http://www. bcit.ca/stud y/programs/525ha cert ;.... ffers ed ucational opp011unitie in the care of person who hav been a victim f crime, trauma and violence. ervice/embrace-clinic/ ,. NPs providing mobile follow -up care en rrce t per n after intcr-p r onal viol ne e. =-=u:. rr :. . :....:e:...~y--.:.. W:.. . o;:;:.:m :. :. . :. . :;en....: .:. : ' ~....:::..:...:-=.:.-...::::..!...:....!.!....!..!R..:::.T.;::___;T:::....:e:::.!a~m . http :I I u rreyw om n nt re.cal , erv ice /24-h u r- re pon e ,. ffer 24-hour cri i r pon e that provide ervi e in partn rship with UIT , M 'moria! Ho pi tal ver th phon and in-per on , rv1 e for women and girl who have experienced phy ical or s ual vi len .