Literature Review Matrix
· Tutorial on how to find peer-reviewed articles
· Individually, you will find 3 GOOD articles specific to the requirements for each “Article Set”.
· My advice is you work on this with your group so that you make sure the articles you all read HELP with part 2 of your paper and the articles everyone reads can be used.
· Article 1: Find one article that discuss your selected health topic – define the topic, provide risk factors, justify why it is an important public health issue, research etc
· Article 2: Find one article that discuss evidence based prevention/management strategies tackling your health issue using
· Health education/Health policy/environmental change/communication
· At least two should be policy focused
· Article 3: Find one article that discuss specific interventions that have been implemented to tackle your health issue (and population of interest)
· Local/ state/national level — include a mix of these levels
· After reading each one write your annotated bibliography and then fill out the matrix table for each
· Notice that each “article set” matrix asks for different information
· This aligns with Part 2 section headings
· Article 1 – XX as a Public Health Issue
· Article 2 – Prevention and Management of XX
· Article 3 – Targeted Intervention Strategies
Part A: Annotated Bibliography
Article 1
Article 2
Article 3
Part B: Literature Review Methodology & Matrix
Write a paragraph providing information about how you conducted your article search. What databases you used; key words; Studies found; how were articles selected for inclusion into LR? (see my example on D2L)
Articles Matrix

Article 1

Year, Title of Journal Article, Journal Name, Vol #, Page Numbers
(APA 7th)
(In text citation)

How is the health issue defined?
What are the major risk factors discussed?

A few key points (or findings) from
the article
How do they justify why this issue is important to public health?

Why are these points/findings important to epidemiology and public health? (What is the “real-world” application?)

Article 2

Year, Title of Journal Article, Journal Name, Vol #, Page Numbers
(APA 7th)
(In text citation)

How is the health issue defined?
What factors does the intervention tackle?

A few key points (or findings) from the article
Summarize the evidence-based prevention/management strategy
· What strategy was used? (education, policy, etc)

How have these been effective in tackling your health issue?
(this helps with the “real-world” application?)

Article 3

Year, Title of Journal Article, Journal Name, Vol #, Page Numbers
(APA 7th)
(In text citation)

What level was the intervention? Local/state/community?
Who did they target?

A few key points (or findings) from the article
Summarize these specific interventions implemented
· what was done?

How have these been effective in tackling your health issue?
(this helps with the “real-world” application?)


Literature Review Assignment


Part A: Annotated Bibliography
Article 1: Immigration as a Social Determinant of Health
Castañeda, H., Holmes, S. M., Madrigal, D. S., Young, M.-E. D., Beyeler, N., & Quesada, J.
(2015). Immigration as a Social Determinant of Health. Annual Review of Public
Health, 36(1), 375–392. doi: 10.1146/annurev-publhealth-032013-182419
Although immigration and immigrant populations have become increasingly important foci in
public health research and practice, a social determinants of health approach has seldom been
applied in this area. Global patterns of morbidity and mortality follow inequities rooted in
societal, political, and economic conditions produced and reproduced by social structures,
policies, and institutions. The lack of dialogue between these two profoundly related
phenomena—social determinants of health and immigration—has resulted in missed
opportunities for public health research, practice, and policy work. In this article, we discuss
primary frameworks used in recent public health literature on the health of immigrant
populations, note gaps in this literature, and argue for a broader examination of immigration as
both socially determined and a social determinant of health. We discuss priorities for future
research and policy to understand more fully and respond appropriately to the health of the
populations affected by this global phenomenon.
Annotated Bibliography
The article reports on the importance of identifying social determinants and the effects of
socially determined structures among immigrant populations in the United States. The study
identifies ways in which immigrants health outcomes are based on biases due to using

information based on group behaviors instead of on an induvial case. The impact of migrant and
immigrant individuals, physical and mental health in these communities’ changes as social,
economic, and political policies take place. This article is helpful in that broadens the
immigration experience including more central factors than just language, income, or education
as the cause of all health related problems in this community. But to show factors of power
structures and the ability to put in place effective health interventions that respond to direct
causes of poor or declining health in these populations.
Article 2: Fear by Association: Perceptions of Anti-Immigrant Policy and Health Outcomes
Vargas, Edward & Sanchez, Gabriel & Juárez, Melina. (2017). Fear by Association: Perceptions
of Anti-Immigrant Policy and Health Outcomes. Journal of Health Politics, Policy and
Law. 42. 3802940. 10.1215/03616878-3802940.
The United States is experiencing a renewed period of immigration and immigrant policy
activity as well as heightened enforcement of such policies. This intensified activity can affect
various aspects of immigrant health, including mental health. We use the Robert Wood Johnson
Foundation 2015 Latino National Health and Immigration Survey (n = 1,493) to examine the
relationship between immigration and immigrant policy and Latino health and well-being. We
estimate a series of categorical regression models and find that there are negative health
consequences associated with Latinos’ perceptions of living in states with unfavorable anti-
immigration laws, including reporting poor health and problems with mental health. This article
builds on the work of public health scholars who have found a link between this heightened

policy environment and the mental health of immigrants, yet expands on this research by finding
that the health consequences associated with immigration policy extend to Latinos broadly, not
just immigrants. These findings are relevant to scholars of immigration and health policy as well
as policy makers who should consider these negative effects on the immigrant community during
their decision-making process.
Annotated Bibliography
The article explores the relationship between anti-immigrant and anti-Hispanic policies
and the effects on health outcomes between both communities. The study shows the health
consequences associated with national and state laws and services that spread beyond the
undocumented community. Hostile environments created by these immigrant laws have led to
increases in fear anxiety, depression, blood pressure, heart disease and other health related
stressors. This article is useful as it identifies the connection between immigrants and Latino
Americans and the fear amongst either communities when accessing or the denial of healthcare.
These findings are relevant to health policy and policy makers, who should contemplate the
disparaging health consequences of legislation being passed. The research finds it convincing
that amongst Latino’s regardless of their personal immigration status, they could be impacted by
retaliatory laws if they happen to look like an immigrant.
Article 3: Policies of Exclusion: Implications for the Health of Immigrants and Their
Perreira, K. M., & Pedroza, J. M. (2019). Policies of Exclusion: Implications for the Health of
Immigrants and Their Children. Annual Review of Public Health, 40(1), 147–166. doi:

Public policies play a crucial role in shaping how immigrants adapt to life in the United States.
Federal, state, and local laws and administrative practices impact immigrants’ access to
education, health insurance and medical care, cash assistance, food assistance, and other vital
services. Additionally, immigration enforcement activities have substantial effects on
immigrants’ health and participation in public programs, as well as effects on immigrants’
families. This review summarizes the growing literature on the consequences of public policies
for immigrants’ health. Some policies are inclusive and promote immigrants’ adaptation to the
United States, whereas other policies are exclusionary and restrict immigrants’ access to public
programs as well as educational and economic opportunities. We explore the strategies that
researchers have employed to tease out these effects, the methodological challenges of
undertaking such studies, their varying impacts on immigrant health, and steps that can be
undertaken to improve the health of immigrants and their families.
Annotated Bibliography
The article examines the struggles immigrants face obtaining healthcare access and
services for themselves as well as their children. The article uncovers current healthcare policies
and denial of service, and how the United States should provide more inclusion healthcare
policies. Current policies in place don’t provide defined status of care for “immigrants in
transition”, those who are in the process to become legal citizens. With such gaps, levels of care
are not accessible to pregnant woman and children. This article points out the accessibility to
services, when healthcare policies and programs are put into place without properly defining
each population and their right to service. This is relevant because immigration is a transition,
therefore federal, state, and local policies should cater to this shift.

Part B: Literature Review Methodology and Matrix
Literature Review Methodology
To conduct this literature review, an exploration of literature inclusive of credible
organizations and publications was undertaken by two student researchers. The first researcher
perused publications using the search terms “oral health AND low income” as well as the US
Census Bureau, 2020 and the U.S. Department of Agriculture’s (USDA) Special Supplemental
Nutrition Program for Women, Infants, and Children (WIC). The second researcher conducted
two separate searches using CINHAL and Academic Search Complete databases. The first
search terms used were “oral health AND prenatal care AND health promotion AND African
American women AND prevention”. The second search terms used were “oral health AND
pregnancy AND health promotion AND interprofessional collaboration. To further limit these
results, findings were restricted to peer-reviewed publications between 2015 – 2020 in the United
States resulting in 41 and 8 articles in the first and second search, respectively. An abstract
review then determined inclusion of the article into the literature review report. A total of 19
journal articles and three websites were included in this literature review.


Literature Review Matrix: Focus on Oral Health among Pregnant Women
Year, Title of
Journal Article,
Journal Name,
Vol #, Page
(APA 7th)
(In text citation)
A few key points (or
findings) from the
Determinants of oral
Strategies to improve
oral health
Why are these
important to health
(What is the “real-
world” application?)
Azofeifa, A.,
Yeung, L. F.,
Alverson, C. J., &
Beltrán‐Aguilar, E.
(2016). Dental
caries and
periodontal disease
among US
pregnant women
and nonpregnant
women of
reproductive age,
National Health
and Nutrition
Survey, 1999–
2004. Journal of
public health
dentistry, 76(4),
(Azofeifa et al.,
• Pregnant women
susceptible to dental
carries, gingivitis &
periodontal disease
• LIPW have higher
prevalence of
untreated dental
• Targeted oral health
education during
prenatal visits
 Hormonal changes
during pregnancy a
contributing factor
to oral health
among LIPW
 Oral health literacy
& provider
knowledge on oral
health an
influencing factor
for oral health
 Integration of oral
healthcare into
primary prenatal
care settings
 Supports systems
theory to integrate
oral and prenatal
 Justifies need for
intervention among
 Oral health
education effective
in increasing
knowledge about
good oral health and
safety of dental care
during pregnancy
 Increasing coverage
for at risk population
improves access to
preventive and
curative oral care
among vulnerable
Byrd, M. G.,
Quinonez, R. B.,
Lipp, K., Chuang,
A., Phillips, C., &
Weintraub, J. A.
(2019). Translating
prenatal oral health
clinical standards
into dental
education: results
and policy
 Pregnant women
do not receive
pregnant care
during pregnancy
 Provider oral health
knowledge a
contributing factor for
oral health among PW
 Integrating IPE and
PCP into this program
will improve access to
oral health by taking
into consideration
limitations of dental
 Care integration
provides a “one
stop” shop that
tackles logistic and
economic barriers
LIPW face
 Intervention idea to
also train providers
on how to conduct
oral health histories

Journal of public
health dentistry,
79(1), 25-33.
(Byrd et al., 2019)
care providers and
Henderson, E.,
Dalawari, P.,
Fitzgerald, J., &
Hinyard, L. (2018).
Association of oral
health literacy and
dental visitation in
an inner-city
Journal of
Research and
Public Health,
15(8), 1748.
(Henderson et al.,
• Health literacy =
“cognitive and
social skills which
determine the
motivation and
ability of
individuals to gain
access to,
understand , and use
the information in
ways which
promote and
maintain good
• Oral health literacy
linked to higher
odds of dental visits
• Low OHL among
racial ethnic
• Example
incentives: oral
health toolkits
 Oral health literacy
an influencing
factor for oral
health and care
 Access to care a
contributing factor
of oral health and
integrating oral
health education in
primary settings
tackles this barrier
 Justifies need for
intervention among
o Culturally adapted
oral health education
effective in
improving health
while addressing
needs of vulnerable
o Needs of participants
informed education
o Program needs: oral
health kits
(toothbrush, fluoride
toothpaste, floss &
recommendations for
proper OHC)
Naseem, M.,
Khurshid, Z.,
Khan, H. A., Niazi,
F., Zohaib, S., &
Zafar, M. S.
(2016). Oral health
challenges in
pregnant women:
for dental care
professionals. The
Saudi Journal for
 Pregnancy and oral
health are related:
preterm delivery,
LBW, higher risk
of early caries
among infants
 Dental procedures
can be safely
 Contributing factors
for oral health is lack
of knowledge &
value, negative OH
experiences, negative
attitudes towards OH
professionals &
dental staff
 Recommendation for
primary providers to
assess patients
current dental health
status and then
educate on expected
changes during
pregnancy and
measures to avoid
pain and distress

Dental Research,
7(2), 138-146.
pregnancy with
certain precautions
Rocha, J. S.,
Arima, L. Y.,
Werneck, R. I.,
Moyses, S. J., &
Baldani, M. H.
Determinants of
dental care
attendance during
pregnancy: a
systematic review.
Caries research,
52(1-2), 139-152.
(Rocha et al.,
 Periodontal
disease during
pregnancy a risk
for preterm birth
and LBW
 Dental care
utilization during
pregnancy is low
 LIPW less likely
to have routine
dental care
 Pregnancy a
contributing factor for
oral health
 Other contributing
factors for oral health
are: cost, lack of
insurance, dental
anxiety, low literacy
and health beliefs
about safety of dental
care during pregnancy
 Socioeconomic
status a major
determinant for
access to oral
 Justifies intervention
focus on LIPW

Facial emotion identification and sexual assault risk detection among college
student sexual assault victims and nonvictims
Alexander J. Melkonian, MAa, Lindsay S. Ham, PhDa, Ana J. Bridges, PhDa, and Jessica L. Fugitt, PhDb
aDepartment of Psychological Science, University of Arkansas, Fayetteville, Arkansas, USA; bG.V. (Sonny) Montgomery VA Medical Center,
Jackson, Mississippi, USA
Received 10 June 2016
Revised 7 March 2017
Accepted 19 April 2017
Objective: High rates of sexual victimization among college students necessitate further study of
factors associated with sexual assault risk detection. The present study examined how social
information processing relates to sexual assault risk detection as a function of sexual assault
victimization history. Participants: 225 undergraduates (Mage D 19.12, SD D 1.44; 66% women).
Methods: Participants completed an online questionnaire assessing victimization history, an
emotion identification task, and a sexual assault risk detection task between June 2013 and May
2014. Results: Emotion identification moderated the association between victimization history and
risk detection such that sexual assault survivors with lower emotion identification accuracy also
reported the least risk in a sexual assault vignette. Conclusions: Findings suggest that differences in
social information processing, specifically recognition of others’ emotions, are associated with
sexual assault risk detection. College prevention programs could incorporate emotional awareness
strategies, particularly for men and women who are sexual assault survivors.
Emotion recognition; risk
detection; sexual assault
prevention; social
information processing
Sexual assault in college presents a major public health
concern. Although many college sexual assault prevention
programs have been developed and implemented, college
sexual assault rates have remained consistently high.1
Sexual assault is defined as unwanted sexual contact
including but not limited to attempted and completed
rape, incapacitated sexual contact obtained through
alcohol or drugs, and sexual contact obtained through
physical force or coercion. Studies suggest rates of sexual
assault for undergraduates while enrolled in college range
between 19% and 35% for women (as many as 43% may
experience sexual victimization in their lifetime), and 5%
and 15% (23% lifetime rates) for men.2–5 Sexual victimiza-
tion is associated with many negative outcomes, including
elevated rates of depression, anxiety, alcohol use disorders,
post-traumatic stress disorder, and revictimization com-
pared to nonvictims.6–8 Among college student survivors
of sexual assault, 11% changed their residence, 8%
dropped classes, and 3% changed universities following
the assault.9 Although the blame for sexual assault lies
solely on the perpetrator and therefore prevention efforts
should target perpetrators’ behaviors, targeting bystanders
and potential victims could also help reduce incidence
rates of sexual assault. Research to identify relevant factors
that contribute to risk for sexual assault can be used to
empirically inform prevention efforts for potential victims
or bystanders who may have the opportunity to intervene
in a sexual assault.
Studies that empirically examine individual factors
relating to risk for sexual assault frequently use vignette
methodology, in which participants read or listen to a
scenario describing a social interaction and then respond
to questions assessing the identification and interpreta-
tion of risk in potentially hazardous social scenarios.10–12
Such methodology is based on the premise that reduced
identification of risk in a hypothetical scenario is associ-
ated with greater risk for an unwanted sexual experience
based on the lack of recognition of potential harm to
oneself or others. This methodology is supported by pro-
spective studies that have found a relationship between
lower risk detection and future sexual assault experien-
ces: participants who were delayed in their recognition of
sexual assault risk in a vignette were significantly more
likely to experience a new instance of sexual assault at a
follow-up compared to participants who recognized risk
more quickly.13,14 However, social situations are highly
complex and social reactions may not be fully captured
by a written or audio vignette.
According to social information processing theory,15
in order to respond effectively in a situation such as a
potential sexual assault scenario, one must first notice
and accurately interpret relevant social and situational
CONTACT Alexander J. Melkonian, MA [email protected] University of Arkansas, Fayetteville, AR 72701, USA.
© 2017 Taylor & Francis
2017, VOL. 65, NO. 7, 466–473
mailto:[email protected]
cues, which may include direct verbal conversation or
nonverbal communication. Social information process-
ing theory provides a helpful framework for how an indi-
vidual’s or a bystander’s ability to identify relevant social
cues, such as emotional expressions in others, could con-
tribute to recognition of risk in a potential sexual assault
situation. Given the importance of noticing and inter-
preting situational cues as dangerous is an important
step of the bystander intervention process,16 the identifi-
cation of additional factors related to how potential vic-
tims or bystanders interpret social information in risky
scenarios may help to enhance our understanding of risk
for sexual assault.
Emotion identification
Many researchers study perceptions of social scenarios
using written or audio recorded descriptions of situa-
tions; however, these studies may not capture all relevant
components of communication. Human communication
is a complex process with important pieces of informa-
tion conveyed through verbal and nonverbal cues, such
as facial expressions. Nonverbal communication makes
up a critical component of meaning in human interac-
tion.17 Specifically in sexual interactions, important
information related to consent is likely to be communi-
cated nonverbally.18 Thus, studying how individuals
uniquely interpret nonverbal expression and the implica-
tions of misinterpretation of cues in a sexual situation is
a critical component of understanding risk perception,
relevant for potential victims or bystanders.
Not everyone interprets cues in the same way, as vari-
ation in emotion recognition is biologically based and
refined in early childhood.19 Accurate understanding of
visual emotional expression is critical to interpersonal
relationships.20 Indeed, researchers find that difficulties
in facial emotion recognition are related to difficulties
with accurate interpretation of social communication
and increased problems in social relationships.21,22
Though no known published studies have directly
examined the association between nonverbal emotional
cue recognition and sexual assault risk perception,
Walsh, DiLillo, and Messman-Moore23 examined the
role of emotion dysregulation (ie, lack of awareness of
one’s emotions, lack of acceptance of one’s emotions,
and limited emotion regulation strategies) in sexual
assault risk perception among college women. Results
suggest that self-reported difficulties with awareness and
differentiation of one’s own emotions were significantly
related to reduced risk detection in a sexual assault
vignette. Given the observed connection between identi-
fying one’s own emotions and sexual assault risk detec-
tion,23 it is possible that impairment in identifying the
emotions of others may also relate to difficulty detecting
sexual assault risk.
Victimization history
Sexual victimization is associated with subsequent vic-
timization.8 However, results of studies examining the
association between sexual assault victimization history
and sexual assault risk detection have been mixed. Marx
and Soler-Baillo11 and Soler-Baillo et al24 found college
women who had experienced sexual assault displayed
differences in responding to a sexual assault vignette,
taking longer to identify risk compared to nonvictims.
However, other researchers have found no such differen-
ces in sexual assault risk perception based on victimiza-
tion history.25,26
There is evidence that emotion-related variables could
play a role in the association between sexual victimiza-
tion history and sexual assault risk detection. In the pre-
viously mentioned study by Walsh and colleagues,23 the
researchers found several facets of emotion dysregula-
tion, including identification of one’s own emotions, to
be related to sexual assault victimization history and sex-
ual assault risk detection in a vignette. However, no
known research has examined whether accuracy in
detecting and differentiating others’ emotional expres-
sions relates to sexual assault risk detection. Sexual
assault survivors may be less accurate at gauging risk in
social situations if they are less accurate in processing
emotions in others. Social situations, including those
which involve sexual assault risk detection, represent a
complex interplay of environmental, psychological, and
sociocultural considerations that may not be fully cap-
tured in a controlled laboratory study. Thus, the present
study represents a first step in understanding the rela-
tionship between victimization history, risk detection,
and a facet of social information processing. The current
study aims to contribute to the literature on the preven-
tion of sexual assault by incorporating facial emotion
recognition as a moderator between victimization history
and risk detection.
Current study
To inform prevention efforts to reduce sexual assault
incidence, we aimed to enhance our understanding of
risk for sexual assault by incorporating facial emotion
interpretation as an aspect of social information
processing ability, which could relate to risk detection
for both male and female college students. While sev-
eral studies have examined the relationship of prior
sexual victimization and risk perception (see Gidycz
et al1 for review) and Walsh et al23 examined emotion
dysregulation (one’s own emotions), victimization his-
tory, and sexual assault risk perception, no known
study to date has also examined additional facets of
nonverbal social communication ability. Previous
mixed findings related to sexual victimization history
and sexual assault risk detection could be related to a
failure to consider how one processes others’ emo-
tions.27 Therefore, the current study focuses on whether
emotion recognition moderates the relationship
between sexual assault victimization history and risk
detection. First, we expected that ratings of risk detec-
tion in a hypothetical sexual assault scenario would be
lower for those who have been a victim of sexual assault
(since age 14) compared to nonvictims. Further, it was
hypothesized that the association between victimization
history and risk detection would be moderated by facial
emotional expression recognition such that those who
had experienced previous victimization and were less
accurate in identifying others’ emotions would have the
most difficulty detecting risk in the sexual assault sce-
nario. Though most previous work focused on women,
men are also victimized and both men and women may
be in a position to intervene as a bystander in a sexual
assault scenario.28 As such, this study adds to the litera-
ture by examining both men and women.
Participants and general procedures
Participants were 225 college students aged 18–28 years
(Mage D 19.12, SD D 1.44; 66% women; 86% Caucasian)
recruited from a large southern university’s undergradu-
ate psychology courses in 2013–2014. See Table 1 for a
demographic summary. Participants provided anony-
mous responses on an online study administered
through Qualtrics for course credit. Participants were
presented with informed consent electronically. Upon
providing an electronic signature to indicate informed
consent, participants completed self-report question-
naires, an emotion identification task (ie, identify one of
five emotions depicted in facial images), and a sexual
assault vignette task (ie, reading a vignette ending in sex-
ual assault followed by providing ratings of their inter-
pretation of the behavior in the scenario) in randomized
order. Participants were provided with debriefing infor-
mation online. All procedures were approved by the Uni-
versity’s Institutional Review Board.
Measures and stimuli
Participants reported age, gender, race, and ethnicity.
Sexual victimization history
Sexual victimization history was assessed using the Sex-
ual Experiences Survey—Short Form Victimization
(SES-SFV29). The SES-SFV is a commonly used brief
measure that includes items related to the occurrence
and frequency of multiple types of unwanted sexual
experiences since the age of 14 years. Previous versions
of the SES have displayed good reliability and validity.30
Participants were included in the victimization history
group based on scoring recommendations of the SES-
SFV if previous unwanted sexual contact was reported as
a result of force or coercion [n D 56 (25% of sample;
31% of women, 14% of men)] and were included in the
nonvictimization history group (n D 169) if no sexual
contact as a result of force or coercion was reported.
Emotion identification
Emotion recognition was assessed with a series of images
of male and female portrayals of one of four facial emo-
tions (anger, happiness, sadness, and disgust) or no emo-
tion. Although surprise and fear are also outlined as
universally identifiable emotions, we chose to exclude
these emotions as past research shows poor reliability in
identifying these expressions.31,32 Each image shown to
participants was a composite image based on Ekman and
Friesen’s33 facial stimuli created by combining multiple
images of varying strength of expression (ie, a face dis-
playing 50% emotion expression strength is a composite
image exactly halfway between no emotion being shown,
and 100% expression). Strength of expression was varied
to include 10 images each shown at 30%, 50%, and 70%
strength of expression to simulate the variability of emo-
tion expression in a social situation.31 Participants were
shown 30 total digital images (one male and one female
portrayal of 5 different expressions, shown at the three
strengths of expression) and asked to identify the emo-
tion being depicted in each by selecting their choice from
a list of possible responses (ie, angry, happy, sad, dis-
gusted, neutral). Overall accuracy scores were computed
based on the total number of correct identifications of
each emotion image (M D 21.11, SD D 3.34).
Sexual assault risk detection
Participants read a brief vignette used in prior research35
that portrays a situation involving unwanted sexual con-
tact between a male perpetrator and female victim. The
story follows a college-aged woman being introduced to
a man by a mutual friend with whom she gets along well.
As the gathering concludes, the woman agrees to return
to the man’s house to continue talking and have a drink.
The woman begins to kiss the man for a short time
period before deciding she would like to end the interac-
tion and asks the man to stop. The man ignores her
request, and instead begins to engage in increasing levels
of sexual acts despite the lack of consent. Items were
selected based on previous vignette research to assess
participant perceptions regarding the scenario, including
responsibility of the man (reverse coded) and woman,34
approval of the man’s behavior (reverse coded),35 degree
of consent provided, the woman’s desire for sex,35 and
the degree to which the scenario could be considered a
rape.35 Each item was rated on a 7-point Likert-type
scale. A sum score was calculated to create an overall
index of risk perception, with higher scores reflecting
greater detection of risk (possible range D 6–42,
M D 30.36, SD D 4.8, Cronbach’s alpha D .68). Items
used were based on related research examining risk
detection in a sexual assault scenario26 and situational
rating25 scores to high degrees of reliability.
Preliminary analyses
Data were examined for violations of assumptions for the
analyses conducted. There were no missing data (all par-
ticipants completed all study measures, despite having
the option to skip over items) and no violations of nor-
mality. Results of independent samples t-tests indicated
that there were no gender differences in vignette risk
detection rating sum scores [Mmen D 30.28, SD D 5.23;
Mwomen D 30.40, SD D 4.6; t(223) D 0.17, p D .87] or
emotion identification scores [Mmen D 20.63, SD D 3.41;
Mwomen D 21.35, SD D 3.30; t(223) D 1.50, p D .14]. As
shown in Table 1, victimization history groups did not
significantly differ in race and ethnicity, emotion identi-
fication scores, or sexual assault vignette rating scores.
Victimization groups differed by gender, with women
more likely to be victimized than men. Finally, emotion
identification scores and sexual assault vignette risk
detection ratings were significantly positively correlated,
r D .20, p < .01. Moderation The Hayes PROCESS macro36 was used to test emotion identification as a moderator of the association between victimization history and sexual assault risk detection. The overall model including victimization history, emo- tion identification, and their interaction accounted for a significant amount of the variance in risk detection scores, R2 D .063, F (3,222) D 4.96, p < .01. Main effects of victimization history {B D 0.67 [95% confidence inter- val (CI) D ¡0.77, 2.10], t D 0.91, p D .36} and emotion identification score [B D 0.16 (95% CI D ¡0.61, 0.38), t D 1.42, p D .16] on risk detection score were nonsignif- icant. The victimization history X emotion identification interaction [B D 0.47 (95% CI D 0.06, 0.89, t D 2.25, p D .03)] accounted for significant variance in sexual assault risk detection [DR2 D .022, p D .03]. As shown in Figure 1, emotion identification moderated the associa- tion between victimization history and sexual assault risk detection such that individuals with a history of victimi- zation showed a significant positive relationship between Table 1. Demographic summary. Total sample (N D 225) Victimization history (n D 56) No victimization history (n D 169) Gender x2 (1, N D 225) D 8.45, p D 0.01 Male 76 (33.8%) 10 (17.9%) 66 (39.1%) Female 149 (66.2%) 46 (82.1%) 103 (60.9%) Race and ethnicity x2 (5, N D 225) D 5.37, p D 0.37 Caucasian (non-Hispanic) 194 (85.8%) 49 (87.5%) 144 (85.2%) African American 5 (2.2%) 2 (3.6%) 3 (1.7%) Hispanic/Latino 10 (4.4%) 0 (0%) 10 (5.9%) Asian 6 (2.7%) 1 (1.8%) 5 (3.0%) American Indian 5 (2.2%) 2 (3.6%) 3 (1.7%) Other/not reported 5 (2.2%) 2 (3.6%) 4 (2.4%) Age 19.12 (SD D 1.44) 19.14 (SD D 1.57) 19.12 (SD D 1.41) t(224) D ¡0.11, p D 0.91 Emotion identification score 21.11 (SD D 3.34) 20.80 (SD D 3.54) 21.21 (SD D 3.27) t(224) D 0.79, p D 0.43 Risk detection score 30.36 (SD D 4.83) 30.71 (SD D 5.51) 30.25 (SD D 4.60) t(224) D ¡0.62, p D 0.53 Figure 1. Sexual assault risk detection score by emotion identifi- cation score and victimization group. JOURNAL OF AMERICAN COLLEGE HEALTH 469 emotion identification and risk detection [B D 0.63 (95% CI D 0.28, 0.99), t D 3.52, p < .01], whereas emotion identification was not related to sexual assault risk detec- tion in nonvictims [B D 0.16 (95% CI D ¡0.61, 0.38), t D 1.42, p D .16]. Furthermore, this association was not significantly moderated by gender [B D .74 (95% CI D ¡0.26, 1.74), t D 1.42, p D .15]. Comment The current study examined the role of nonverbal social communication abilities in the association between sex- ual victimization history and sexual assault risk detection among college students, a population with high rates of sexual assault.5 Results revealed that the association between sexual victimization history and situational risk detection was moderated by emotion identification accu- racy for both men and women. Ability to identify emo- tional expressions in others was positively related to sexual assault risk detection for those with a victimiza- tion history, but emotion identification accuracy was unrelated to sexual assault risk detection for those with no victimization history. Due to previously mixed find- ings regarding the effects of victimization history on risk detection,1 the present findings suggest an important new avenue of study further examining the connection between visual emotion processing and social situation interpretation to better explain conditions under which victimization history may be related to risk detection. Extending previous work connecting emotion identifica- tion related to one’s self and detection of sexual assault risk,23 the present results suggest that identification of others’ emotions may also be an important factor related to risk detection. Discussion The results of the current study suggest that sexual assault risk detection did not differ based on victimiza- tion history alone. Although some researchers have found a significant relationship between victimization history and situational risk recognition,13,14,24 others have not found support for differences by victimization history.14,26 The present study revealed those who experi- enced victimization and showed less accuracy in identify- ing facial emotions also rated lower levels of risk in the sexual assault scenario, suggesting that social informa- tion processing may be an important variable related to further understanding differences in detecting sexual assault risk. Sexual assault survivors who are less accu- rate in decoding nonverbal cues may also be more likely to misidentify potential risk in social situations. Con- versely, sexual assault survivors who are more accurate may be more attuned to risk cues and therefore have reduced risk for revictimization and a greater likelihood of intervening as a bystander to prevent to stop a sexual assault. These findings may be explained by variable levels of hyperarousal among victims. Previous research has found increased reported levels of posttraumatic stress disorder-related arousal, such as hypervigilance, increased startle response, and irritability, among sexual assault victims was related to increased risk detection compared to victims with lower levels of reported arousal symptoms.37 Thus, while some survivors may experience a higher threshold for risk recognition, others may expe- rience enhanced attention to risk and social information processing. Future research examining how and why sex- ual assault survivors might have differential responses to risk cues and social information cues, as well as how these differential responses are related to meaningful health and behavioral outcomes, is warranted. Furthermore, results suggesting differences in sexual assault risk detection and social information processing for those with a history of victimization are relevant for practice settings as well as experimental research to improve intervention and prevention efforts. Emotion recognition accuracy may be considered a relatively sta- ble yet malleable factor; research supports that with spe- cific training, emotional awareness can be improved.38 Thus, practitioners could consider assessing emotional awareness in survivors of sexual assault to understand how they process social information and embed emo- tional awareness of others into interventions focusing on empowering survivors. Further understanding of the implications of these social processing differences can also be used to enhance bystander behavior to reduce sexual assault incidence. Recent evidence supports the efficacy of bystander intervention programs targeting reduction in victimization, reduction in perpetration, and increase in bystander intervention.39 Adding a com- ponent of training in nonverbal communication recogni- tion may further increase the likelihood of identifying a situation in need of intervention to enhance program effectiveness on college campuses. Other programs have targeted increasing empathy to enhance bystander inter- vention behavior.40 Given emotional awareness has been connected to empathic responding,41 enhancing emo- tional awareness of bystanders through direct training may provide an added benefit to empathy-based bystander intervention training to prevent sexual assault. Accuracy of facial emotion identification has been found to be enhanced through training, which includes feed- back on emotional expressions displayed.38 Thus, practi- tioners or bystander interventions aiming to increase empathic responding may include an emotional expres- sion feedback training. 470 A. J. MELKONIAN ET AL. Limitations A primary limitation of the current study is that it was correlational; thus, no assumptions regarding causality can be implied. Additionally, it is possible that the lack of a significant relationship between victimization history and risk ratings could be due to the methodol- ogy employed. There are numerous approaches to studying the assessment of a nonconsensual situation, all of which may reveal differences in findings; Gidycz et al1 discuss the potential for differences as a result of varying vignette items and individual sexual assault experiences. Thus, it is possible different results may be found based on individual victimization experiences (the setting, context, and relationship to perpetrator), the situation detailed in the vignette used (how similar or dissimilar is it to the victimization experience), and the way in which risk detection is measured (eg, rat- ings versus behavioral response). Of note, the internal consistency of our risk detection measure (a D .68) fell just below the conventional cutoff of acceptability. However, measures with this Cronbach’s alpha may be considered moderately reliable, and acceptable for use in preliminary research such as the current study.42,43 Furthermore, victimization history was only measured from the age of 14 years, and perpetration history was not measured. Given the scope of the study, childhood sexual assault experiences were not examined; there- fore, it remains unknown how childhood victimization may influence the relationships examined in the pres- ent study. Additionally, though a strength of the study was the inclusion of both men and women, it is possi- ble that the lack of gender moderation was due to low power to detect the effect. Future studies should con- tinue to examine the role of gender in the relationship between social information processing and risk detec- tion. Follow-up studies may also consider use of vignettes that vary the depiction of the gender of the perpetrator and victim. Additionally, given that in nearly 50% of all college sexual assault situations alcohol is present in either the perpetrator or the victim, future research should con- sider examining this relationship within the context of alcohol intoxication.44 Research suggests intoxication is related to impaired risk detection,10 and thus future research should consider the impact of intoxication on emotional awareness as well. Finally, all emotions dis- played in a social interaction such as events leading to sexual assault may not always be authentic or clearly dis- played. Given these limitations, the current study repre- sents the first step in a line of research further understanding the role of emotional awareness under controlled conditions. Future research should next target the more nuanced display of emotions in a complex social situation. Conclusions This study incorporated emotion recognition, a compo- nent of social information processing, into the current understanding of sexual assault risk detection and sexual victimization history. Results provide evidence for differ- ences in processing of social information and risk detec- tion between victims and nonvictims of sexual assault, with the least successful sexual assault risk detection being observed among survivors of sexual assault and less accuracy in emotion recognition. The present results, if replicated, have implications for improving prevention programs by incorporating emotional awareness strate- gies, particularly for men and women who are sexual assault survivors. However, future research is needed to further study unique differences in risk for victimization based on history and social information processing. Conflict of interest disclosure The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethi- cal guidelines, including adherence to the legal requirements, of the United States and received approval from the Institu- tional Review Board of the University of Arkansas. Funding No funding was used to support this research and/or the prep- aration of the manuscript. References 1. Gidycz CA, McNamara JR, Edwards KM. Women’s risk perception and sexual victimization: A review of the literature. Aggress Violent Behav. 2006;11(5):441– 456. doi:10.1016/j.avb.2006.01.004 2. Turchik JA. Sexual victimization among male college stu- dents: Assault severity, sexual functioning, and health risk behaviors. Psychol Men Masculin. 2012;13(3):243–255. doi:10.1037/a0024605 3. Coker … Research Article Testing a Model of How a Sexual Assault Resistance Education Program for Women Reduces Sexual Assaults Charlene Y. Senn 1,2 , Misha Eliasziw 3 , Karen L. Hobden 1 , Paula C. Barata 4 , H. Lorraine Radtke 5 , Wilfreda E. Thurston 6 , and Ian R. Newby-Clark 4 Abstract The Enhanced Assess, Acknowledge, Act (EAAA) program has been shown to reduce sexual assaults experienced by university students who identify as women. Prevention researchers emphasize testing theory-based mechanisms once positive outcomes related to effectiveness are established. We assessed the process by which EAAA’s positive outcomes are achieved in a sample of 857 first year university students. EAAA’s goals are to increase risk detection in social interactions, decrease obstacles to risk detection or resistance with known men, and increase women’s use of effective self-defense. We used chained multiple mediator modeling to assess the combined effects of the primary mediators (risk detection, direct resistance, and self-defense self-efficacy) while simultaneously assessing the interrelationships among the secondary mediators (perception of personal risk, belief in the myth of female precipitation, and general rape myth acceptance). The hypothesized multiple mediation model with three primary mediators met the criterion for full mediation of the intervention effects. Together, the mediators accounted for 95% and 76% of the reductions in completed and attempted rape, respectively, demonstrating full mediation. The hypothesized secondary mediators were important in achieving improvements in personal and situational risk detection. The findings strongly support the benefit of cognitive ecological theory and the Assess, Acknowledge, Act conceptualization underlying EAAA. This evidence can be used by administrators and staff responsible for prevention policy and practice on campuses to defend the implementation of theoretically grounded, evidence-based prevention programs. Online slides for instructors who want to use this article for teaching are available on PWQ’s website at Keywords sexual assault, sexual violence, prevention, resistance, women For at least 40 years, people and communities affiliated with feminist, health, and educational organizations and institu- tions have been working to prevent sexual assault (e.g., Morrison et al., 2004; Women Against Rape, 1980), and since the early 2000s, there has been increased interest in evidence-based program development and evaluation to rig- orously assess interventions’ successes and failures. Much of this work has been accomplished on university campuses. A number of qualitative and quantitative review articles and meta-analyses have summarized the state of the field and made recommendations for promising directions for aca- demics and practitioners (Basile et al., 2016; DeGue et al., 2012; DeGue et al., 2014; Ellsberg et al., 2015; Gidycz et al., 2002; Lonsway et al., 2009; Schewe, 2002). As well, promi- nent researchers have called for resources to be focused on evidence-based, theory-driven, effective programs within a comprehensive approach to sexual violence prevention (e.g., Banyard, 2013; Banyard & Potter, 2017; Orchowski et al., 2010; Orchowski et al., 2018). This approach includes, and extends beyond, student programming to changing entire campuses and communities. Included in current recommen- dations by a consortium of independent sexual violence pre- vention researchers and the Centers for Disease Control are bystander-based interventions for students of all genders, resistance education for female students, and continued development of programming for male students related to a 1 Department of Psychology, University of Windsor, Ontario, Canada 2 Women’s and Gender Studies Program, University of Windsor, Ontario, Canada 3 Department of Public Health and Community Medicine, Tufts University, Boston, MA, USA 4 Department of Psychology, University of Guelph, Ontario, Canada 5 Department of Psychology, University of Calgary, Alberta, Canada 6 Department of Community Health Sciences, University of Calgary, Alberta, Canada Corresponding Author: Charlene Y. Senn, Department of Psychology, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, Canada N9B 3P4. Email: [email protected] Psychology of Women Quarterly 2021, Vol. 45(1) 20–36 ª The Author(s) 2020 Article reuse guidelines: DOI: 10.1177/0361684320962561 mailto:[email protected] bystander and social norms education (Basile et al., 2016; Orchowski et al., 2018). These opinions are strongly supported by the prevention science literature (e.g., Nation et al., 2003), where it has long been recommended that all prevention work be comprehen- sive in having multiple interventions targeted for different audiences within a system and use prevention best practices (e.g., include opportunities for active interaction and appli- cation of skills). Researchers in academia and public health have also recommended improvements to evaluation research in order to answer more precise questions about what works and why (Banyard et al., 2014; DeGue et al., 2014; Orchowski et al., 2018). Published standards for reporting randomized and nonrandomized evaluation trials (Des Jarlais et al., 2004; Schulz et al., 2010) and calls for better reporting of interventions so that they can be understood and imple- mented with findings replicated and improved upon by others (e.g., Hoffmann et al., 2014; Pinnock et al., 2017) have also emerged. Specifically, within the sexual violence prevention field, researchers have argued for more rigorous studies that would allow the testing of theory-based mechanisms once positive outcomes related to their effectiveness are estab- lished (e.g., Norris et al., 2018). Salazar et al.’s (2019) recent analysis of the mechanisms for change in the RealConsent program for university men is a good example of such an analysis. While high attrition in the follow-up period and the short duration of the positive outcomes make the authors’ conclusions tentative, it is an important first attempt to understand how a theory-based sexual assault program works. To our knowledge, no studies of sexual assault resistance education programs for university women have assessed the process by which positive out- comes are achieved (Senn et al., 2018), despite increasing calls for such analyses (Hollander, 2018; Norris et al., 2018). This is our goal. The current article focuses on the first author’s Enhanced Assess, Acknowledge, Act (EAAA) sexual assault resistance education program, which is also known as the Flip the Script TM program. EAAA is the only pro- gram that in a randomized controlled trial (RCT) has been shown to substantially reduce the sexual assaults that women university students experienced over the subsequent year (i.e., 50% reduction in attempted and completed rape as well as reductions in other forms of sexual assault; Senn et al., 2015). In fact, positive outcomes occur for at least 2 years (Senn et al., 2017). A few empowerment self-defense or risk reduction programs for women have also demonstrated positive sexual assault outcomes. Specif- ically, assessment of a 30-hour empowerment self-defense program using a quasi-experimental design indicated signif- icant reductions in sexual victimization for college women for at least 1 year after participating in the program (Hollander, 2014). A shorter, 7.5-hour risk reduction pro- gram, evaluated using an experimental design, also led to significant reductions in sexual victimization for subsets of college women who participated in the program for a few months (e.g., Gidycz et al., 2006; for a review of theory and evidence for the type of program more generally, see Orchowski & Gidycz, 2018). Thus, the benefits of under- standing how these types of programs work extend beyond a single program. We were ideally situated to provide answers to this ques- tion for many reasons. EAAA was evaluated in a multi-site RCT with a large sample of 893 women students. There were prospective data for women who did and did not take the program, which included information about their back- grounds and baseline scores on key variables. Further, we followed them with assessments across more than a year with high retention. Data collection included measurement of potential mediators (mechanisms) 1-week post-intervention and sexual assaults in the 12 months following that assess- ment, which allowed for prospective temporal conclusions regarding the mediators’ influence on post-program sexual assault outcomes. As such, we were able to go beyond the goal of finding out whether a program works to decrease sexual victimization to how and why the program works. This article describes a chained multiple mediation analysis, which allowed us to assess the joint processes that produced treatment outcomes. Through this analysis, we tested the model of theoretically postulated mechanisms that drove the development of the sexual assault resistance education pro- gram. This is important for scientific and practical reasons and has not previously been reported. Theoretical and Empirical Foundation of EAAA The EAAA program’s name acknowledges that it is based in large part on the recommendations of Rozee and Koss (2001), who synthesized decades of theory and rape research to sug- gest a theoretically driven, evidence-based approach for sex- ual violence prevention programming for young women. 1 They named this conceptualization “Assess, Acknowledge, Act (AAA).” AAA was conceived on a bedrock of theory and feminist research, particularly the cognitive ecological theory proposed by Norris and Nurius (e.g., Norris et al., 1996; Nurius & Norris, 1996) and the evidence of effective sexual assault resistance strategies provided by Ullman (1997, 1998) as well as a long tradition of feminist grassroots activism, advocacy, theory, and self-defense practice (e.g., Bateman, 1978; Rozee et al., 1991; Wen-Do Women’s Self Defence, n.d.; Women Against Rape, 1980). These underpinnings are described in more detail elsewhere (Rozee et al., 1991; Rozee & Koss, 2001; Senn et al., 2015; Senn et al., 2017). Rozee and Koss’s proposed approach challenged past practices that were not theory- or evidence-based, tended to focus primarily on stranger sexual assault, and were largely ineffective (see Morrison et al., 2004, for review of research evaluations of programs conducted prior to this period). They argued that, given the continuing alarming rates of sexual violence expe- rienced by young women, the complete lack of success in Senn et al. 21 reducing perpetration, and the substantial evidence base available, providing women with knowledge and skills to prepare them to detect risk, overcome emotional obstacles to acknowledging the danger, and to resist sexual coercion or sexual assault by men they know was imperative. In response to this call, the first author designed a resis- tance program curriculum to bring the conceptualized pro- gram into reality. The term “resistance” is used in its broadest sense to represent any attitudes women hold or actions they take to refuse to accept or comply with social norms or expec- tations that (a) support woman-blaming explanations for sex- ual violence, (b) undergird societal tolerance of rape culture, and/or (c) undermine women’s sexual autonomy. Resistance includes defensive actions women take to protect their boundaries, their body, and sexual integrity in interactions with others. For survivors, resistance also includes the refusal to accept sexual violence perpetrators’ views of them and what occurred. EAAA reduces the sexual victimization women experience while holding perpetrators entirely responsible for their actions (Senn et al., 2015; Senn et al., 2017) and interrupts messages often perpetuated in a rape culture (Radtke et al., 2020). The program has a gendered framing, focusing on sexual assaults perpetrated by men who are known to young women (i.e., it uses a broad definition of acquaintances that includes family members, intimate part- ners, classmates, neighbors, and other men they know). EAAA is designed and implemented to recognize the diver- sity of experiences of participants who self-identify as women in terms of prior sexual victimization history (i.e., that there will always be survivors in the room), demo- graphics (e.g., race, class, religion), abilities (e.g., physical ability, ability to be loud), sexual identity (i.e., explicitly acknowledges heterosexual, bisexual, lesbian, and asexual identities), and relationship and sexual experience. The goals of the program are to (a) increase the likelihood that empirically supported risk cues in social contexts (e.g., isolation, alcohol) and revealed in men’s behavior (e.g., per- sistence, sexual entitlement) will be detected by women as early as possible in social interactions, (b) decrease women’s emotional or cognitive obstacles to risk detection or resistance in situations involving known men, and (c) increase the like- lihood that women will use defensive actions (e.g., leaving when possible, forceful verbal and physical self defense) that are most likely to lead to better outcomes (i.e., reduced severity of the sexual assault, interruption of rape; Tark & Kleck, 2014; Ullman, 1997) when threats are detected. To accomplish these goals, the curriculum has four 3-hour units. Unit 1, Assess, is designed to help women identify situations and behaviors that signal a higher risk for sexual violence. Unit 2, Acknowledge, was created to assist women to overcome emotional barriers to acknowledging the threat from men they know and provides practice in identifying and resisting verbal coercion. Unit 3, Act, provides empowerment verbal and physical self-defense training (based on Wen-Do Women’s Self Defence) focused on effective strategies for resisting common acquaintance tactics. Unit 4, Relationships and Sexuality, adapted from the Our Whole Lives curriculum (Goldfarb & Casparian, 2000; Kimball & Frediani, 2000), offers high quality sexual information and a context for exploring and talking about their own sexual desires and relationship values. In other words, EAAA gives women evidence-based information, skills, and practice within a pos- itive sexuality framework to empower them to more quickly identify a sexually coercive situation involving a male acquaintance as dangerous and get out or use forceful resis- tance if necessary. More detail on the program content is provided elsewhere (Radtke et al., 2020; Senn et al., 2013). The key findings for the registered, multisite (three uni- versities), RCT (SARE Trial) evaluating EAAA have been published elsewhere (Senn et al., 2015; Senn et al., 2017) but are briefly summarized here. The reductions in sexual vio- lence for young women who were assigned to the EAAA program (Senn et al., 2015) were accompanied by positive program effects on a number of other important outcomes (Senn et al., 2017) measured 1 week after participation and, for most, at 6 and 12 months (and up to 24 months). We measured these additional outcomes because they were hypothesized mediators; that is, they encompassed most of the theoretical mechanisms targeted by the AAA approach to increase women’s safety without limiting their freedom. In this study, we go beyond our previous analysis of the pro- gram’s positive effects on these outcomes to test whether, together, they are mediators of the reductions in the sexual assault across time. In other words, do improved scores on these outcomes at post-test (1-week after participation) com- bine to account for the reductions in sexual assault experi- enced from that point until the 12-month follow-up? In the following section, we explain the hypothesized mul- tiple mediation model (Figure 1) and, specifically, the theory behind our expectations that the possible mediators would combine to lead to reductions in sexual assault. Given that the model was built based on the best evidence available, there are no competing theoretical models to be tested; rather, we are assessing whether the model works as a whole and whether the relationships for any hypothesized elements are not supported. Any variable that is hypothesized to explain a portion of the EAAA program’s effect on sexual assault vic- timization through a direct link to the outcome, we refer to as a “primary mediator.” These are the primary elements of the AAA model. Any variable that is hypothesized to have an indirect link to the outcome through its influence on a pri- mary mediator, we refer to as a “secondary mediator.” Mediators of Reductions in Sexual Assault Risk detection is a key element of the primary appraisal pro- cess outlined in Nurius and Norris’s (1996) cognitive ecolo- gical model and hence also the theoretical underpinning of the first unit (Assess). The program is designed to undermine socialization processes about “stranger risk” that direct 22 Psychology of Women Quarterly 45(1) women to use a wide range of precautionary strategies involving restrictions on their freedom without protecting them from sexual violence (e.g., not walking alone at night; Gordon & Riger, 1989; Stanko, 1990). The curriculum pro- vides information and practice in identifying empirically sup- ported risk factors for acquaintance sexual assault and encourages women to trust their own instincts and judgments when they identify risk cues in social situations. Based on past research (e.g., Marx et al., 2001) and theory, better risk detection (i.e., more accurate, earlier) at post-test, which was a positive outcome of participation in EAAA (Senn et al., 2017), should be directly linked to reductions in sexual victimization in the subsequent 12 months and hence a primary mediator. The EAAA program also addresses obstacles women encounter at secondary appraisal stages (i.e., after risk has been detected and when they are making “determinations of coping resources, options, and outcomes”; Nurius & Norris, 1996, p. 130) in interactions with coercive men. Content and activities in the second unit of the EAAA program focus on strengthening women’s belief in their own sexual and rela- tionship rights and undermine the belief that relationships must be preserved at all costs. Young women are provided with a context in which they can practice asserting their needs and confronting common verbal and physical acquaintance perpetrator tactics. In the third unit, facilitators present evidence that direct forceful verbal and physical resistance strategies and leaving lead to better outcomes in sexual assault situations. In any given situation, participants are then able to select their own toolbox of effective strategies from among the many techniques taught. Nurius and Norris (1996) summarize the goal of intervention to improve the situation for women as follows: Thus, the extent to which a woman is prepared to see assertive behavior as a reasonable resistance stance and is assisted to gain assertiveness skills and habits may have an indirect effect mediated through a woman’s cognitive structures operating at the time of the coercion. (p. 122, emphasis added) Thus, both increases in self-defense self-efficacy, that is, confidence that she could assert and defend herself across a range of situations, and the ability and willingness to use more direct resistance strategies in a hypothetical situation should be related to one another and be primary mediators of the EAAA program’s effects on sexual assault. Notably, in our previously published analysis, we found both variables to be positively impacted by program participation (Senn et al., 2017). Based on the research evidence (e.g., Vitek et al., 2018), risk detection was a primary mediator expected to be influ- enced by secondary mediators (i.e., other specific attitudes Figure 1. Hypothesized Multiple Mediation Model. Note. Primary mediators are variables that are hypothesized to explain a portion of the Enhanced Assess, Acknowledge, Act program’s (Group) effect on sexual assault victimization and have a direct link to the outcome (Sexual Assault). Secondary mediators are variables that are hypothesized not to have a direct link to the outcome themselves but rather are expected to influence the primary mediators. OwnRisk ¼ perceived risk of acquaintance rape; FPrecip ¼ belief in female precipitation of rape; RapeMyth ¼ rape myth acceptance; RiskDet ¼ risk detection; DResist ¼ direct resistance; SDSE ¼ self-defense self-efficacy. Senn et al. 23 and beliefs directly affected by the EAAA program). Three hypothesized secondary mediators that were included in the RCT were (a) women’s perceptions of their own general risk of sexual assault, (b) acceptance of rape myths, and (c) the belief that women play a causal role in sexual assault. All were affected in the desired direction by program participa- tion at the post-test, and these effects were maintained for at least 2 years (Senn et al., 2017). These attitudes and behaviors were not expected to have direct effects on sexual victimiza- tion (i.e., changes in attitudes and beliefs alone have never been sufficient to reduce the incidence of sexual assault; Morrison et al., 2004). Instead, they were included in the trial precisely because any improvements in these attitudes and beliefs were hypothesized to facilitate risk detection. Thus, we hypothesized that in combination these three factors would be related to each other and would lead to better out- comes in sexual assault through their relationships with risk detection. Each is described in more detail below. An optimism bias, which is the belief that while others are at risk of experiencing a particular negative outcome, we are not ourselves at risk, can in some circumstances be protective (e.g., against depression; Conversano et al., 2010). However, “unrealistic optimism” (Nurius & Norris, 1996) is an obstacle to detecting acquaintance sexual assault risk (Norris et al., 1996). Unsurprisingly, an optimism bias is present in women’s estimates of their sexual assault risk (Gidycz et al., 2006). The problematic piece of this perception is not the judgment of risk for other women who are similar to us—this tends to be rela- tively accurate (i.e., there is a possibility the bad event could occur)—but rather judgment for one’s self (i.e., it is unlikely to occur to me). The RCT analyses showed that the EAAA pro- gram increased women’s perceptions of their own general risk of sexual assault (Senn et al., 2017). 2 We hypothesized that this should be related to women’s risk detection in specific situa- tions by making “danger cues” relevant and worthy of attention as they arose in those situations. Similarly and relatedly, commonly held myths about the characteristics of rape, rape perpetrators, and rape victims (e.g., that rape is most likely to be perpetrated by strangers) may be psychologically self-protective (e.g., “only women who do X, wear Y, or go to Z are raped and I would never do those things”) but may also have negative consequences, such as impairing perceptions of one’s own risk of sexual assault (e.g., Bohner et al., 2009; Yeater et al., 2010). Victim-blaming beliefs are thought to be particularly perni- cious in this regard. We therefore hypothesized that the pro- gram’s positive effects in reducing rape myths in general and the specific incorrect belief that women cause rape by their own actions (Senn et al., 2017) would be related to improved risk perception. Further, we expected that reducing the belief that women cause rape by their own actions, a belief that when applied to the self can give one false sense of security (e.g., If I don’t go there or do that, then it can’t happen to me), would be related to increases in women’s perceptions of their own personal risk because reducing these beliefs makes sali- ent that any woman is potentially at risk. The theory and evidence upon which EAAA was built emerges from many different, primarily correlational studies often focused on a single domain (e.g., risk perception or self-defense strategies) that were related to positive outcomes (Norris et al., 2018; Tark & Kleck, 2014; Vitek et al., 2018). Although changes in individual domains can occur and can be important in their own right (e.g., more high-quality informa- tion about a phenomenon or more skill is usually better than less), our focus is on how the combined domains of the whole model are implicated in achieving the reductions in attempted and completed rape 3 affected through participation in the EAAA program. We focused on the 1-year data from the SARE Trial RCT, because a drop in effect sizes after 1 year and a decrease in the sample size across 2 years reduced our ability to test these relationships beyond this period. 4 We assessed mediation prospectively using participants’ scores on the hypothesized primary and secondary mediators that were measured 1-week post-program and their experience of sexual assault in the subsequent 12 months after the post-test. Given our large sample size, we were able to test the mediation effects for completed and attempted rape separately. It should be noted that rape is broadly and behaviorally defined to include oral, vaginal, and anal penetration by a man without the woman’s consent through a range of perpetrator tactics including threats, force, and taking advantage of or inducing women’s incapacitation from drugs or alcohol (Koss et al., 2007). Method Participants Eight hundred and ninety-three first-year undergraduate stu- dents who identified as women were recruited at three uni- versities and enrolled in the SARE RCT. The full trial protocol has been published (Senn et al., 2013), as have the 1- and 2-year primary and secondary outcomes (Senn et al., 2015; Senn et al., 2017). The prospective analysis in the present study required valid responses on potential mediators measured post-intervention at a 1-week post-test and sexual assault outcomes measured beyond that point. A total of 871 (97.5%) women completed the 1-week post-program survey. Among these, 857 (98.4%) completed one or both of the 6- and 12-month follow-up surveys (i.e., not lost to follow-up) and were included in this study. The 36 partici- pants who were excluded were not characteristically different from the 857 who were retained in the present study (all ps ns). The average age of the included women was approxi- mately 19 years, almost all were heterosexual or bisexual, one-quarter were women of color, one-half lived in a univer- sity residence, one-third had previous self-defense training, and approximately one-quarter had experienced the previous victimization (see Table 1). 24 Psychology of Women Quarterly 45(1) Intervention EAAA. This small group (�20 participants) intervention was led by pairs of highly trained, slightly older peer (<30 years) women facilitators. Women attended an average of 3.62 (SD ¼ 0.82) of four sessions, with most (91%) attending three or four sessions. Curriculum fidelity was high (average 94%) as measured by the assessment of randomly selected audio recordings. Control. To match the standard of care common to all univer- sity campuses at the time, brochures on sexual assault were available for participants to take and read, with a friendly and knowledgeable person available to answer any questions that arose about sexual assault or available resources from the group of participants. Brochures chosen were specific to the campuses but had common elements, including the provision of general sexual assault information, date rape drug facts, legal and medical information for survivors, and local resources. Procedure The detailed RCT protocol and procedures are published else- where (Senn et al., 2013), but we provide a brief overview here. Participants were recruited through a variety of means, including posters, emails, tabling, and advertising in research participant pools. Interested students made contact by phone or email, were screened by a research assistant and given a detailed explanation of the purpose of the study, the longitu- dinal survey process and timing, and the randomization pro- cedure. They then chose the timing of the baseline and EAAA intervention sessions that matched their schedule without yet knowing to which condition they would be randomly assigned. All participants attended a baseline session to complete sur- veys in a computer lab, were …

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