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Abstract
Objectives Most people who have experienced sexual violence (SV) will disclose the event(s) to someone. Key recipients of disclosure are those working in healthcare, and using sexual and reproductive health services can be an important step in accessing necessary medical care and being signposted to other services. Accessing this care and disclosing SV can be challenging. Evidence is lacking about how best to create a safe environment for disclosure to take place, how services can make changes to better facilitate this experience and what changes matter most.
Design Realist evaluation.
Setting Sexual and reproductive health settings.
Participants 1-1 interviews with service users who have disclosed SV (n=18), three focus groups with healthcare professionals and survey respondents (n=2007).
Outcome measures Initial programme theories of what works, for whom and in what context were tested and refined with empirical data from a national survey, 1-1 interviews and focus groups. The final steps are presented here, bringing strands of the study together and informed using substantive theory.
Results The key steps in using healthcare on disclosure of SV relate to self-identification as a worthy candidate irrespective of background or presentation, ensuring empowerment during navigation of services, initial access to sexual healthcare made straightforward, validation by healthcare professionals when receiving disclosures, choice and control for service users during a collaborative interaction with healthcare professionals and aftercare that reflects needs particularly of minoritised groups.
Conclusions We propose a novel way of considering Dixon-Woods’ candidacy theory seen through a trauma-informed lens for healthcare following SV, and how, by holding a trauma-informed lens to candidacy, steps of healthcare access and utilisation can be framed to ensure a safer environment for disclosure. This modified substantive theory marks the chosen endpoint of the realist evaluation and provides a transferable programme theory that can be considered in other settings.
- Gender-Based Violence
- Genitourinary medicine
- SEXUAL MEDICINE
- Health Services Accessibility
Data availability statement
Data are available upon reasonable request. Previous data included published studies referenced in the article.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
By following published realist reporting standards, this realist study provides an in-depth evaluation of a complex healthcare intervention to create safe places to disclose sexual violence.
The use of mixed methods data strengthens the study findings.
By using a modified candidacy theory, a step-by-step look at how to create a safe and supportive environment for disclosure is presented.
This study is primarily based within sexual and reproductive health services, and the findings are not generalisable to other settings; however, using substantive theories supports transferability.
Introduction
Pawson and Tilley described a theory-driven evaluation approach for complex interventions, to address the question ‘what works for whom in what circumstances and how?’1 2 Their seminal work on scientific realism encourages us to be cognisant that outcomes are not driven by interventions per se but by mechanisms that may be hidden and only triggered in specific contexts.3 This realist evaluation works to explain how, for whom and in what context, sexual and reproductive health services (SRHS) can best create a safe and supportive environment to facilitate disclosure of sexual violence (SV). In this paper, the final step of this theory-driven realist evaluation, findings are produced at a level of abstraction that allows transferability across settings.4 5
Healthcare provision in the aftermath of SV gives an opportunity to alleviate some of the potential harms, including addressing pregnancy risk; sexually transmitted infections (STIs) such as Chlamydia trachomatis, hepatitis B and HIV; genital and other physical injury; acute and chronic pelvic pain; and psychological ill health. There is also the opportunity to provide links to further care such as counselling, safeguarding, social and legal support, collection of forensic evidence and police reporting.6 In addition to physical injury, SV may have significant and often long-term, negative psychological impacts contributing to it being described as a major public health issue.7 Persistent negative effects arising after experiencing violence can result in difficulties forming or maintaining relationships, poor regulation of emotions and low self-worth with feelings of guilt and shame. Psychological trauma can also be associated with flashbacks or vivid memories of the distressing event, sometimes triggered by ‘routine’ medical situations or procedures, and it is therefore unsurprising that the effects of trauma can hamper a person’s ability to access and engage safely with health services.8 Avoiding attendance at services and avoiding healthcare procedures might be related to fear of retraumatisation, a perceived loss of control, concerns over the power disparity of the consultation, of not being believed and being blamed when participating in healthcare encounters.9 10 Disclosing SV to a healthcare professional and subsequently feeling safe and supported during the consultation is not guaranteed. Earlier studies describe how poor responses to SV disclosure can result in harmful outcomes.11 This study focuses on services that offer sexual and reproductive healthcare. These are settings where those with a history of SV and other forms of abuse may choose to attend.12 13
Two substantive theoretical concepts are brought to the final stages of this study. The first theory is the contemporary theory of trauma that informs a trauma-informed approach to care.14 The contemporary theory of trauma shifts focus from what is wrong with a person to what has happened to a person and informs a different approach to service provision.14 The contemporary theory of trauma acknowledges that trauma is influenced by factors beyond the traumatic event(s), like structural and cultural contexts (eg, racism, poverty), inter-relational contexts (eg, family support) and individual context (eg, temperament, previous abuse). The associated trauma-informed approach addresses the prevalence of trauma, its impact and the needs of those experiencing trauma, and was initially deployed within substance misuse services15 and more recently in healthcare settings.16 The five principles of a trauma-informed approach are safety, trustworthiness, collaboration, empowerment and choice.16 These have increasingly been incorporated into best practice by those supporting abuse survivors.17 The approach is implemented not only where people have already disclosed distressing events but, because of the ubiquitous nature of traumatic events, is employed routinely. The trauma-informed approach aims to make healthcare settings more accessible and the healthcare interaction a safe one.18
Candidacy theory, the second theoretical concept applied during the synthesis of our realist evaluation, focuses on access and utilisation of healthcare.19 Dixon-Woods considers candidacy as a social construct influenced and altered by sociocultural, as well as by health service and individual factors.19 The candidacy theory is described in seven steps, accounting for patient and healthcare professional factors and beliefs when determining eligibility for services and was initially applied to vulnerable groups in the UK.19 In our synthesis, we focused on elements of candidacy theory that outlined issues particularly relevant for the healthcare journey after SV: identification of candidacy, navigating services, service permeability, appearing and asserting candidacy, healthcare professional adjudication, offers of/resistance to services and operating conditions. The theory assists in understanding undeclared, and at times unseen, factors that contribute to service engagement. Published examples where the candidacy theory has been used to further understand healthcare access and utilisation include aspects of women’s health,20–23 substance misuse and addiction services,24 barriers created by the use of digital technologies25 and in the complex care needs of minority ethnic groups.26 27 To our knowledge, its use has not previously been applied to access health services after SV.
In this article, we propose an approach designed to improve healthcare service provision after SV by incorporating candidacy theory19 through a trauma-informed lens. This modified substantive theory is the conclusion of our realist evaluation. Using a realist evaluation allowed us to consider obstacles existing at the level of the user and provider within a wider sociocultural context and to examine what is needed to take place in order to overcome these barriers. We provide a fresh perspective on how best to address such barriers and to support the provision of a safe healthcare environment.
Methods
Theoretical framework
The stratified view of reality held by the realist acknowledges the real but often hidden forces that are instrumental in affecting outcomes and are recognised as key in realist theory development.28 29 Our epistemological approach identified causal mechanisms (eg, empowerment) critical in driving the outcome of creating a safe and supportive environment. Realist terminology is presented in table 1.
Realist terminology
Project overview
The steps of this realist evaluation are outlined in figure 1. We initially developed explanatory theories on how to create a safe environment for disclosure.30 These theories were then tested and refined using mixed methods data in the form of interviews based in two National Health Service (NHS) centres and a national survey.30–32
Project overview.
This paper reports on the synthesis stage of the realist evaluation. This step allowed for ‘a “to and fro” between the refined programme theories and a more substantive (or formal) theory, that is, existing theories within particular disciplines’.33 34 Identifying and applying substantive theory to our work provided an opportunity to better understand our findings and to allow for transferability between settings.
This paper focuses on the synthesis of context, mechanisms and outcomes previously identified within the data and used to refine programme theories. In the final step, the emergent substantive theories contributed to the synthesis of findings to improve safe and supported disclosure of SV, where novel and creative ideas were considered and the refinement of theories ‘went beyond reportage and summary of an existing state of affairs’.35
Patient and public involvement
An advisory group was established at the beginning of the study and included patient advocates, researchers and other stakeholders with a range of experience and expertise in the care of people after disclosure of SV and in the use of different research methods. The group met at four time points to discuss the direction of the study. Patients taking part in the interviews were offered summaries of the study.
Results
Step 1—realist review
The findings of the review, using contexts, interventions, mechanisms and outcomes (CIMOs) as building blocks in theory development, resulted in realist terms, four ‘initial programme theories’. The theories addressed first, health promotion and activism to tackle rape myths, stereotypes and gender inequalities; second, the need for improved information about services; third, trauma-informed practice and finally, joined up care (online supplemental appendix 1). The paper reporting the development of these theories is published in full and describes the importance of expert opinions of service users, advocates and researchers from the advisory group combined with key informant interviews (n=4), in steering theory development, particularly in light of the paucity of diversity in the literature.30 36
Supplemental material
Step 2—empirical data collection and analysis
Findings from the review were used to inform a mixed methods data collection step using a mixed method exploratory sequential design. Initial programme theories were tested and refined during this step. The interview and survey findings are published in full31 32 and summarised below.
Qualitative phase
Using 1-1 interviews, initial programme theories were brought to 18 service users who had previously experienced SV and disclosed this at a healthcare setting.32 They were aged 19–54 years and included 15 women, two men and one transwoman. In addition, three focus groups (made up of six, four and five people) incorporating a range of healthcare professionals, including two doctors, five nurses, seven health advisors and a counsellor, were used to generate ideas and further develop theory using discussion between group members. An interview was carried out with a representative from a third sector organisation specialising in advocacy after SV (representatives from a third sector organisation specialising in advocacy after SV were four in total in the study; one key informant interviewed during the review, two in the advisory group (one LGBTIQ independent sexual violence advocate (ISVA) and one general ISVA) and an ISVA manager interviewed in the qualitative phase). CIMO configurations were identified through the coding of contexts, interventions, mechanisms and outcomes in the focus group and 1-1 interview transcripts. The CIMO configurations at this stage developed, refined and refuted the review’s initial programme theories. For transparency, this process was recorded on NVivo using the ‘Memo’ tab, with additional memos added when substantial refinement took place. There was an iterative approach to the refinement of theories using interview data. Mechanisms identified included service users feeling empowered, having choice and control, feeling listened to, and feeling they would be viewed as worthy candidates for care on disclosure. Mechanisms involving healthcare professionals included being confident and competent in their role, for example, through appropriate flexing of professional guidelines and being able to support a healing relationship with service users.
Service users, especially those from minoritised groups, identified a need to feel empowered to access care. To help validate, their disclosure material was needed to address rape myths, stereotypes and the silence surrounding SV. During the healthcare visit, a whole service approach was required to create a safe environment for disclosure of SV. This included appropriate booking facilities for the appointment, supportive attitudes and behaviour of reception staff, consideration of the types of posters used to promote the service, the waiting area layout and integrated referral to other support services. Perhaps the most critical element of the healthcare visit was the interaction between the service user and the healthcare professional. This relationship was highlighted multiple times in the interviews and supported fundamental mechanisms for safe and supported disclosure—being listened to, validated and having choice and control in the consultation.
Quantitative phase
An online population-based survey was used to test key variables identified in the realist review and further interpret the qualitative findings. It was based in England, UK, with 2007 respondents. A full description of the survey and analysis is available.31 The majority of respondents were of white ethnicity (85.5%), female (62.3%) and heterosexual (87.0%); 14.2% reported being disabled, and 72.4% stated that they were currently in an intimate relationship.31 Findings also reported previous experience of SV as 27.1% (n=532), 2.3% (47/2007) opted to not give a response to this question, and a proportion answered ‘not sure’ if they had experienced SV. Respondents (n=89, 4.5%) who were ‘not sure’ if they had experienced SV provided reasons for their response; they had been under the influence of alcohol or drugs (n=37, 41.6%), they used words other than ‘SV’ to describe what had happened (n=27, 30.3%), they had initially agreed to sexual activity but then changed their mind (n=21, 23.6%) or another reason given (n=4, 4.4%).31
Just over half, 51.3% (n=1030) of respondents were aware that SRHS offered support after SV. Those who had experienced SV and had attended SRHS (n=183) were asked to rate their experience when disclosing SV in this setting. 142 (77.6%) of those who had disclosed SV at this setting agreed or strongly agreed that they felt believed. The survey helped to assess how acceptable the service intervention of routine enquiry (asking all service users about SV when safe to do so) might be. Most respondents supported routine enquiry during the sexual and reproductive health consultations (84.4%), although acceptability was significantly lower in older age groups.
Step 3—synthesis
Evidence from the review, 1-1 and focus group interviews and survey were synthesised during step 3. The national survey findings were used to validate the emerging programme theories from the review and interviews. For example, where the interviews highlighted the importance of the relationship between healthcare professional and service user (describing it as having the potential to be ‘healing’ and ‘therapeutic’, feeling valued as an individual, developing ‘rapport’ and being shown ‘humanity’), the survey reported the majority of survey respondents felt believed and safe during the healthcare interaction in a sexual and reproductive health setting. False beliefs about rape and a lack of understanding of consent were identified during the review and interviews as creating a barrier to safe disclosure. This was further evaluated in the survey. The survey confirmed issues around an understanding of consent, with 4.5% (n=89) being unsure if they had experienced SV, as for example, they had been under the influence of alcohol or drugs at the time. During interviews, routine enquiry about SV was theorised to remove stereotypes and myths surrounding SV, as all would be asked about SV irrespective of background or clinical presentation. The survey reported support for this intervention, although notably some groups, for example, older age, were less in favour. Repeated CIMOs identified in the qualitative data and supported by the quantitative data were synthesised back into the initial programme theories. This step involved ‘using patterns of generative causation to support and justify theory refinement’.5 This refinement was iterative as evidence from different study strands was synthesised. Refined programme theories are presented as ‘if…then’ statements (table 2).
Study synthesis using a trauma-informed candidacy theory
During the final stages, ‘a refined middle-range theory of how a programme works by identifying common patterns within reality’ was produced.5 Existing sociological models which offer a substantive theory with explanatory power were considered, like Anderson’s model of health service utilisation and Levesque’s model of access to healthcare.37 38 From these, a best fit theory—Dixon-Woods’ theory of candidacy of healthcare utilisation—was identified and used to inform the study’s findings.19 Synthesis involved exploring patterns within the refined CIMO configurations and considering theoretical frameworks to inform our data interpretation.39 This process is illustrated with the use of building blocks from different CIMOs that supported the need for a ‘porous’ healthcare service after SV (online supplemental appendix 2). By identifying patterns key to creating a safe and supportive environment for disclosure of SV across the different datasets, the substantive theory of candidacy was found to provide a useful theoretical framework when seen through a trauma-informed lens. It expanded our understanding of the mechanisms and supported the transferability of findings, allowing application more broadly.40 It also provided a ‘plausibility check’ of the findings, helping us to situate the refined programme theories in existing formal theory.41 Candidacy is a socially constructed theory giving us a framework to consider how service users who have experienced SV assess their eligibility for accessing healthcare and, conversely, how healthcare professionals and services respond to this. Elements of the candidacy theory, as applied to safe and supportive disclosure of SV at healthcare settings, are described in table 2, with supplementary evidence provided in online supplemental appendix 3.
Supplemental material
Supplemental material
Discussion
The majority of those experiencing SV eventually disclose to someone what happened.42 Although for most, this disclosure is to a close contact rather than a formal support, studies have shown that accessing healthcare matters to individuals after SV.43 44 Benefits of disclosure are not restricted to medical treatments and appropriate onward referral pathways, and it is recognised that acknowledging trauma can in itself be a step in recovery.45 However, engaging safely with healthcare after SV is complex.42 46 Barriers exist at personal, interpersonal, organisational and societal levels47–49 that need addressing.46 50 51 Since disclosure of SV is of potential benefit both for direct healthcare and for psychological unburdening following a traumatic event, we wanted to understand in what ways healthcare settings could support safe disclosure of SV and what potential service users needed to facilitate this process. We refined four initial programme theories (online supplemental appendix 1) during the evaluation of how to create an appropriate, safe and supportive healthcare environment. In this final stage, a modified substantive theory, candidacy theory through a trauma-informed lens, was used to explore how the relationship between the potential service user and the offer and delivery of healthcare services could be optimised.
The identification of candidacy, the initial step in Dixon-Woods’ theory, was analysed in detail in the context of SV.19 Successfully identifying as a candidate for care can be challenging because of the stigma associated with SV, including feelings of shame and blame, and a lack of understanding about consent. Rape myths and stereotypic views of SV compound these barriers. The diversity of people affected by SV calls for services to reflect this in their service promotion, so people will see themselves as potential service users, feel able to seek help, knowing their disclosure will be listened to and be validated irrespective of clinical presentation or background.52 This initial step in candidacy is also achieved through the training of healthcare professionals to recognise the importance of validating disclosure, irrespective of the background or presentation of the service user.
The response to a disclosure by a healthcare professional is key in determining whether it is beneficial and safe. A review by Lanthier summarised helpful responses as ‘validating the disclosure and providing emotional support, and providing tangible aid’.46 While recognising that a healthcare response is important after SV, we also acknowledge that the timing of disclosure of SV should be under the control of the service user. By creating an optimal healthcare environment, ultimately, the decision to disclose SV should lie with the survivor. Where the service has created a universally safe and supportive environment for the provision of care, those attending, irrespective of a previous experience of SV, will feel safe and be able to develop trusting relationships with the healthcare service and staff.
Using a trauma-informed lens provides focus and complements much of Dixon-Woods’ original intention in explaining the steps of candidacy. For example, in Dixon-Woods’ original work, more permeable services were the ones ‘most comfortable for people to use, with the fewest qualifications for candidacy and that required less work’ to gain entry.19 When considering the ‘permeability’ of healthcare after SV, it is useful to identify factors that facilitate or detract from a porous service because of the effects of trauma. For example, explaining the limits of confidentiality prior to engagement or prior to possible disclosure allows for a more ‘porous’ and safer service with clear boundaries on information sharing. This transparency between service users and healthcare professionals ensures the service user feels in control during the interaction. Having a porous service that is trauma-informed also means offering choice with booking processes and appointment types. Having fewer requirements for candidacy, for example, avoiding having to recount the reason for booking an appointment, or the option of booking appointments online, or by speaking to reception staff trained in a trauma-informed response reduces the risk of retraumatisation. Through each step, we recognise the importance of the candidacy construct but highlight the need for safety through a trauma-informed lens in achieving this.
With other candidacy steps, the integration of a trauma-informed lens changes the emphasis of Dixon-Woods’ original framework more significantly.19 For example, the ‘offers of and resistance to’ services take on new meaning when viewed through a trauma-informed lens. The offer becomes one of a collaborative approach to care between user and professional, maintaining choice and control by an informed service user. Training of healthcare professionals that goes beyond the medical management of SV and ensures they are able to address this step of candidacy in a trauma-informed manner is vital. Being able to recognise the importance of supporting a service user in their decisions on medical care, even when they decline care or their choice does not conform with professional guidelines, should be incorporated into training.
Although Dixon-Woods defines candidacy as: “…the ways in which people’s eligibility for medical attention and intervention is jointly negotiated between individuals and health services”19 we agree with authors van der Boor and White that the power imbalance is weighted towards services and systems and therefore the onus and responsibility in ensuring candidacy should also sit here.53 Furthermore, we recognise the social and cultural conditions that contribute to the local production of candidacy. The weight of rape myths, stereotyping of SV and the silence surrounding the topic can create barriers to the construct of candidacy set out by Dixon-Woods. The integration of a trauma-informed lens highlights the importance of addressing social and cultural factors, as well as service factors and personal factors when working towards candidacy. Acknowledging these factors in the response to service users, in the training of healthcare staff and how the overall service is configured is required to create a supportive healthcare environment.
Limitations of a realist evaluation include a lack of generalisability of findings to other healthcare settings. This study is based primarily in SRHS. We acknowledge this is a setting where healthcare professionals often have more experience and training in responding to disclosure of SV. Furthermore, SRHS are more likely to have established links with other services, like psychological services, to facilitate onward referral for those who disclose. The use of substantive theory does support transferability of our findings, although the specific context of other settings needs to be considered. Although, the studies used in the realist review predominantly focused on women and often did not record sexual orientation or race, we ensured we captured a more diverse population in the survey and during the interviews. However, despite our efforts, there remain groups whose candidacy is not fully addressed, for example, non-English speakers and refugees, who will likely have unique barriers to care. These populations require additional research to establish what they need to create a safe healthcare environment for disclosure of SV. Finally, although we discuss ways in which candidacy through a trauma-informed lens can be implemented in a healthcare setting, these practices need further evaluation both in terms of outcomes for service users and success of implementation in the healthcare setting.
The findings of this synthesis use underlying theory to provide practical guidance on how to develop safe, trauma-informed healthcare that supports access and meaningful engagement for those who have experienced SV and reduces blame, silence and perceived judgement. We emphasise that healthcare delivery changes are needed during the entirety of the interaction with the service user to achieve a safe outcome rather than discrete changes to practice. We propose a novel way of considering the provision of safe and supportive healthcare and how, by using a trauma-informed lens to candidacy, each step of access and utilisation can be framed.
Data availability statement
Data are available upon reasonable request. Previous data included published studies referenced in the article.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and Ethical approval was obtained through the Health Research Authority (HRA approval granted 27 July 2021, substantial amendment no. RG_19-102 SA01). Informed consent was obtained prior to interviews and from respondents online prior to accessing the survey. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
James Hodson provided statistical analysis for the survey data.
References
Footnotes
Contributors RJC applied for funding and ethics, carried out earlier data collection and analysis of interview and survey data. RJC synthesised the findings and wrote the initial draft of this manuscript. JR, CB-J: supervised the project, advised on survey design and interview analysis and supported subsequent drafting of this manuscript. RJC is responsible for the overall content as guarantor.
Funding This work was supported by University Hospitals Birmingham NHS Foundation Trust, United Kingdom, as part of PhD funding (grant number N/A).
Competing interests JR reports personal fees and financial support to attend conferences from GSK Pharma; ownership of shares in GSK Pharma and AstraZeneca Pharma; lead author of the UK and European Guidelines on Pelvic Inflammatory Disease; Member of the European Sexually Transmitted Infections Guidelines Editorial Board. He is an NIHR Journals Editor. He is treasurer for the International Union against Sexually Transmitted Infections and chair of charity trustees for the Sexually Transmitted Infections Research Foundation. RJC is a trustee and treasurer of charity for the Sexually Transmitted Infections Research Foundation.
Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.