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VIOLENCE AND GENDER Volume 4, Number 2, 2017 ª Mary Ann Liebert, Inc. DOI: 10.1089/vio.2017.0004

Acceptability, Feasibility, and Effectiveness of Interdisciplinary Group Education Sessions for Women Veterans with a History of Sexual Trauma Veronica Ades, MD, MPH,1,2 Erica Sedlander, MPH,3 Melanie Jay, MD,1,4 Laurie Zephyrin, MD,1 and Joanna Dognin, PsyD1,5

Abstract

Women with a history of sexual violence may face obstacles to obtaining preventive health services. Group education models have been used in other settings to improve knowledge and uptake of care. Focus groups were conducted to solicit the concerns and input of the subject population. Interdisciplinary group education sessions (GESs) were designed specifically to address concerns voiced in focus groups. GESs were conducted, addressing mammograms, pelvic examinations, and menopause, and emphasized preventive health education, as well as shared decision-making. GESs were audio recorded and qualitative feedback was collected immediately after each GES. Surveys were administered before and after each GES to evaluate attitude and knowledge change. A total of 18 women attended the focus groups, and 27 women attended at least one GES, with 12 women attending both. GESs were well received, and participants cited the education, group support, and healing dynamic as benefits of participation. Content knowledge improved after all three GESs. Attitude change showed a trend toward improvement, but the sample size was not large enough to detect statistical significance. Group education is an acceptable and feasible model among survivors of sexual violence. GESs improved knowledge among this small group of participants. GESs could be made available in a wide range of topics, as requested by our participants. Larger studies are warranted to examine long-term knowledge and attitude change after GESs. Keywords: sexual violence, preventive health, patient education

especially for women who have experienced sexual trauma (Department of Veterans Affairs 2015). Furthermore, female veterans obtaining care at the Veterans Health Administration (VHA) report lower satisfaction in areas of overall coordination of care and education and information. (Kimerling et al. 2011) Offering information to patients can help overcome barriers to care by empowering women through education ( Jotterand et al. 2016; WHO 1998). A female-only group setting can be a supportive low-stress environment to both gain knowledge and discuss concerns in a nonthreatening context (Grella et al. 1999; Kimerling et al. 2015). Group prenatal care (GPC) is a similar model, in which prenatal care is administered to a group of women as a 90–120-minute educational session, with clinical care administered during the educational visit (Reid 2007). GPC

Introduction

W

omen with prior sexual violence not only face psychological and logistical obstacles to obtaining preventive care but are also at increased risk for numerous health problems (ACOG 2012; Cronholm and Bowman 2009; Farley et al. 2002; Kimerling et al. 2007, 2011; Mengeling et al. 2015; Suris and Lind 2008). Women who report safety concerns are less likely to obtain reproductive preventive health services, and women who have experienced childhood sexual abuse are less likely to obtain cervical cancer screening (Cronholm and Bowman 2009; Farley et al. 2002). A report from the Veterans Affairs Women’s Health Office found that gender sensitivity, mental health stigma, and perceptions of safety and comfort present barriers to care,

1

VA New York Harbor Healthcare System, New York, New York. Department of Obstetrics and Gynecology, NYU School of Medicine, New York, New York. 3 Department of Prevention and Community Health, The Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia. Departments of 4Medicine and Population Health and 5Psychiatry, NYU School of Medicine, New York, New York. 2

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participants gain group support and knowledge from each other (Heberlein et al. 2016; Kennedy et al. 2009). GPC has been found to be effective in achieving different pregnancy outcomes, including improvements in gestational diabetes screening and management, and pregnancy and postpartum weight management (Magriples et al. 2015; Mazzoni et al. 2016). GPC also has a positive impact on psychosocial outcomes for high-stress women during pregnancy and postpartum (Ickovics et al. 2011). In addition, GPC offers camaraderie, community, and improved education (Heberlein et al. 2016) and also increases understanding of medical information and improved self-advocacy (Liu et al. 2017). In addition, GPC for military women helped women feel less alone, but they still voiced a need for more privacy and individual time with the provider (Kennedy et al. 2009). Shared medical visits (SMVs) in primary care have shown improvement in several health outcomes (Geller et al. 2015; Housden et al. 2013; Jaber et al. 2006a, 2006b; Khan et al. 2015; Sabatino et al. 2012). The SMV combines elements of healthcare, such as vital signs, history taking, and physical examination, with educational or discussion formats ( Jaber et al. 2006a). SMVs have been shown to improve outcomes in a wide range of conditions, including diabetes, heart disease, and pediatric obesity (Geller et al. 2015; Housden et al. 2013; Yehle et al. 2009). The purpose of this pilot study was to design and evaluate group education sessions (GESs) for preventive health interventions for women with prior sexual violence. We explored the barriers and needs of the population in a sensitive and nuanced manner and designed the GESs according to qualitative feedback solicited in focus groups. Materials and Methods Ethical approval and subject recruitment

This study was approved by the institutional review board of the New York Harbor Healthcare System of the Department of Veterans Affairs. Potential subjects were included if they (1) identified as having an unwanted sexual experience (including military or nonmilitary sexual trauma) in their lifetime; (2) were female veterans enrolled within the VHA; and (3) spoke English. Participants were excluded if they were unwilling or unable to provide informed consent. Subjects were counseled that the focus groups and GESs would not address their specific history of trauma to avoid emotional distress. Recruitment

We recruited participants for the focus groups and GESs from the Department of Veterans Affairs New York Harbor Healthcare System, which includes both the Manhattan and Brooklyn campuses. Recruitment efforts included the following: flyers at the VA, requests that providers and staff refer patients, discussions about the study with potential participants at a VA Women’s Health Day event and at the weekly women veterans-only clubhouse, and snowball sampling (Krueger and Casey 2009). We offered a $10 gift card and a $5 metro card for participation in each session.

ADES ET AL.

can help overcome these barriers. Women were eligible to participate in one of two focus groups and any or all GESs. The focus group guide incorporated open-ended semistructured questions about pelvic examinations, mammograms, and birth control (Supplementary Appendix A; Supplementary Data are available online at www.liebertpub .com/vio). Focus groups were led by an experienced facilitator; two additional research team members observed the groups. Focus group analysis

Focus groups were audio recorded, transcribed verbatim by a third-party vendor, reviewed for accuracy, and read and reread to identify emerging themes. An initial consensus codebook was created following independent review of a subset of transcripts. Transcripts were analyzed using Applied Thematic Analysis, an inductive approach designed to identify and examine emerging themes from conceptual data (Guest et al. 2012). Each transcript was independently coded, the codebook was modified as new themes emerged, and researchers met to discuss and reconcile discrepancies for each transcript until a final coded transcript was agreed upon. Themes from focus groups were organized and analyzed using descriptive matrix analyses wherein the range of responses related to each theme was visually displayed and codes were condensed into discrete themes (Averill 2002). Nvivo qualitative software, v.8, (NVivo, 2009) was used for data management and retrieval. Group education sessions

We used focus group findings to design the GES. Interdisciplinary GESs were conducted between August and September 2015 and taught collaboratively by both a gynecologist and a psychologist. The goals of the GES were to (1) provide information, (2) spark discussion, (3) encourage shared decision-making, and (4) empower the women in their healthcare experiences. GESs were created using PowerPoint. The scientific content (e.g., the biological process of menopause) was written in conversational language, and this was reviewed and agreed upon by the study team. The GES emphasized shared decision-making as well as how to handle conflict or difficult situations with a healthcare provider and how to address issues of avoidance of preventive healthcare. Subjects were encouraged to ask questions and to offer their own experiences and opinions. We collected demographic information before each GES. We administered knowledge and subjective preference pre- and post-tests immediately before and after the GES. Subjective preference surveys (Supplementary Appendix B) contained 7–10 questions to elicit the participants’ opinions regarding the preventive health topic. Knowledge tests (Supplementary Appendix C) contained six to seven questions assessing the participants’ understanding of facts regarding the preventive health activity, commensurate with expected patient-level knowledge. Before initiating each session, we obtained informed consent for participation and for audio recording. Analysis

Focus groups

Focus groups were conducted to better understand barriers to care faced by women veterans at the VA and how the GESs

GESs were analyzed using the same methods as the focus groups. Seven additional codes were added to the codebook created for the focus groups with a total of 41 codes. There

GROUP EDUCATION FOR SEXUAL TRAUMA SURVIVORS

were 699 passages coded across five transcripts. Codes were used on average 17.6 times (range 4–63). Pre- and post-tests from the GESs were analyzed using Stata, v.13. To increase the validity of the collected and analyzed data, we conducted two external reviews. First, we used member checking, and in October 2015, we invited all participants back to present the focus group findings to ensure they reflected their opinions and beliefs (Guest et al. 2012). Additionally, in October 2015, we presented our findings to VA researchers and clinicians not involved in either data collection or analysis to examine the rigor of the analytic process and probe for potential biases. Results Participant demographics

In June 2015, 18 women participated in two focus groups, with nine participants in each group. Between August and September 2015, 27 women participated in the GESs; participation ranged from 9 to 14 women in each session.

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Demographics of the focus groups and the three GES participant groups are displayed in Table 1. The mean age of participants in the three groups was similar, with the pelvic examination group at 54.0 years (range 35–63), mammogram group at 51.6 years (range 32–64), and menopause group at 56.3 years (range 41–68). The participants were predominantly single, African American, and most had attended or graduated from college. Almost none were employed. Most self-rated their health as fair or good, with few describing it as very good or excellent. Focus groups

Focus groups took an average of 65 min (range 64–66). Many women reported lacking basic information about reproductive health, such as the reason behind specific examinations (e.g., a Pap smear or pelvic examination), how their bodies change over time (e.g., menopause), and expressed a desire for more basic education on women’s reproductive health. Quotations and themes from the focus groups that influenced the GES design can be seen in Table 2. Themes

Table 1. Demographics of Group Education Session Participants

Age–mean (range, SD) Race/ethnicity Black/African American Black + American Indian Black/Indian/White Hispanic/Latina White Other Education Eighth grade or less Some high school High school graduate GED Associate’s degree Some college 4-year college graduate or higher No answer Current health Poor Fair Good Very good Excellent No answer Employed Yes No No answer Relationship status Single Boyfriend/girlfriend Partner Spouse Widow

Focus groups (N = 18)

Pelvic examination (N = 9)

Mammogram (N = 10)a

Menopause (N = 13)a

53.1 (28–68, 10.4)

54.0 (35–63, 7.9)

51.6 (32–64, 10.0)

56.3 (41–68, 6.0)

13 1 1 2

2 1 5 9 1

(72.2%) (5.6%) (5.6%) (11.1%) 0 0

6 (66.7%) 0 0 3 (33.3%) 0 0

0 0 (11.1%) 0 (5.5%) (27.8%) (50.0%) (5.6%)

0 0 (11.1%) 0 (11.1%) (33.3%) (44.4%) 0

1 1 3 4

5 (55.6%) 0 0 2 (22.2%) 2 (22.2%) 0

2 1 4 3

0 0 (20.0) 0 (10.0) (40.0) (30.0) 0

8 (61.5%) 2 (15.4%) 0 1 (7.7%) 1 (7.7%) 1 (7.7%)

1 1 6 4

0 0 (7.7%) 0 (7.7%) (46.2%) (30.8%) 1

0 5 (27.8%) 7 (38.9%) 5 (27.8%) 0 1 (5.6%)

0 5 (55.6%) 2 (22.2%) 2 (22.2%) 0 0

1 (10.0) 4 (40.0) 4 (40.0) 0 0 1 (10.0)

0 6 (46.2%) 6 (46.2%) 0 0 1 (7.7%)

3 (16.7%) 14 (77.8%) 1 (5.6%)

1 (11.1%) 8 (88.9%)

1 (10.0) 9 (90.0) 0

0 13 (100%)

11 1 1 3 1

6 (75.0%) 0 0 2 (25.0%) 0

7 (70.0) 1 (10.0) 0 2 (20.0) 0

12 (92.3%) 0 0 1 (7.7%) 0

(61.1%) (5.6%) (5.6%) (16.7%) (5.6%)

a In the mammogram group, one participant did not fill out a demographic questionnaire, but completed the other assessments. In the menopause group, one participant did not fill out any of the questionnaires/surveys. GED, General Education Diploma.

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It’s not that . you have a choice, but a lot of times, it’s what you have to go through to get the choice.

So I’ve been on birth control [pills] since I joined the military and they put you on it in like boot camp. You don’t have a choice.. And so like there was a period of time where I was having like high blood pressure. and my doctor . he like stopped my birth control.I think that it’s you know, knowing your options and being able to advocate. I think people who’ve had . maybe sexual trauma in their lives are less likely to speak up sometimes, you know? So I told him ‘‘Don’t stop my birth control.’’ But he just still did. And it’s like so you almost feel victimized over again when people don’t listen to you. c

a The other thing I was thinking about is the way, just you talking about the way that doctors treat women.. Again, like women being treated in the military. We’re like castoffs. We’re not complete people. You know? We’re not people who have a separate identity from a man. We’re not people who have a penis. We’re just this sort of byproduct of the medical profession. b

1. Agency

A lot of our complaints are centered around not having compassionate you know, doctors, who actually listen and take into account your needs.

c

.Some people are not as strong and need more help. You’re supposed to ask questions, but some people don’t even know what to ask. Sometimes you need a liaison. A liaison would be especially helpful for a first-timer.

c

b I feel like as a younger person when you go to the gynecologist, you don’t know what you’re going for. Like I don’t really exactly fully know what gynecologists do besides pelvic exams.So you kind of have an idea of what to expect and what to pay attention to. What not to pay attention to. I think that would be helpful. Instead of just going in there blind

b Because of my trauma, if somebody’s groping at my breast, I tend to tense up and almost be aggravated. Male or female. And then it’s like flashes back to the groping as a child and it kind of follows me. You know, but it’s always a feeling of ‘‘Oh, stop doing that. That’s not cool.’’ And I know that it’s part of the exam cause they put the little tape there and then the nipple, and I tend to tense up because I’m thinking ‘‘Wow. This feels like the bad touch.’’

a So what you probably need is a person, I would say the terms they use, mental health, you would need like a mentor, but like a person—she’s a mentor but she deals with women.

4. Requests for additional knowledge/peer support

b

a It’s like I’m playing Russian roulette whenever I light a cigarette. I know I’m not supposed to but it’s like a compulsion. And I think for me, that’s probably why I smoke . I play Russian roulette with my life cause there’s nobody there to keep me from playing Russian roulette.. I still do that sometimes—I play Russian roulette in bed with a man [unprotected sex].

3. Self-care and triggers

As a veteran, I expect, I have high expectations of the Veteran’s Administration. And there’s just some things that we as women just should not have to go through.

a I choose to be my own advocate. I ask question after question. I was with Dr. X for an hour. I personally feel we should take responsibility for our own healthcare. Everyone has a smartphone nowadays—google it. Don’t just take what your doctor says.

2. Individual empowerment vs. systematic change

Table 2. Focus Group Findings Used in Creating Group Education Sessions

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GESs, group education sessions.

c (Menopause GES) We learned that we’re not going alone by ourselves and information we receive here we can pass onto other people and can contact them.

b (Mammogram GES) I was saying I’d like sharing the knowledge especially with this particular subject since I had the parents and other people in here that have people their family directly. They had it themselves and then we get to share this knowledge and be a light so we can move on and have better ways to you know, make proper decisions.

a (Menopause GES) I found that I didn’t know a lot about menopause. I mean besides going through it, you know, I went through that stuff and so forth but there is a lot of stuff that I didn’t know which was interesting.

1. Improved knowledge

d (Mammogram GES) We like to talk a lot, and I’ve found that men talk just as much as we do but they talk to each other about things. But women like to bring it out in the open cause it’s healing for us. We talk a lot about different things, you know, we get to help each other cause we hear each other’s comments. You had one of those back in the early part of the year.

c (Menopause GES) I have a well it’s my summary [sic] but groups are very good. They should not stop. Some people can’t read, some people don’t like to read, some people don’t have time to ready, you know. And you have these groups and I mean listening is nothing best it’s better than reading because you listen and then you have these questions or you’re hearing people and what they went through is the best medicine. It’s the best education so don’t stop the groups.

c (Pelvic examination GES) But I think that would be nice to have a session for the older ladies so we can talk about things like because we have difficulty with losing weight because our metabolism slows down. So menopause is some of the reasons why. We need to know what to expect or what to still expect because premenopause, there’s menopause and then there’s post. And I think a group of ladies that are in that stage or going through that would like to come to a session like that and I could even help you with some ladies that would love to come for that, you know, specifically for that.

b (Pelvic examination GES) For instance two main things that I would say that I see and hear a lot of in women and I don’t see enough information out there mostly is like heart disease because you hear a lot about men. You hear that men go through this, that and the other but to me I find that women maybe go through it a little bit differently and maybe be nice to have a bit more information on that with women, focusing on women. And then also diabetes like with women, you know, just focusing on how it affects women and the issues.

a (Pelvic examination GES) I think some of us older ladies would like to have a session on menopause because there’s a lot of ladies that I speak to who come to the VA and they’re so afraid to talk about it with GYN. They say my God what am I going to tell him about my hot flashes. I said you should be able to just talk about it. They’re not comfortable talking about it. They can talk about other stuff but menopause seems like keep it to yourself. A lot of women feel like don’t tell anybody you got hot and cold flashes.

a (Pelvic examination GES) I think you’re more comfortable in a group and willing to share because you’re not the only person. And hearing other people have the same issue, you kind of feel more comfortable about sharing and be more open about it. Some things I still held back on so there’s some things that I can generalize on, other things no. b (Pelvic examination GES) It’s more like I feel like I’m not doing it alone like I’m not the only person going through it and then it kind of makes me feel better to kind of open up when you realize that there are other people probably going through the same thing you are and have the same questions.

3. Future topics

2. Feelings on group participation

Table 3. Quotations and Themes from Qualitative Feedback of Group Education Sessions

60

ADES ET AL.

include agency, individual empowerment versus systematic change, self-care and triggers, and requests for additional peer support or advocacy. Agency touched on both military service and perceptions of the medical establishment. Examples include not having control over birth control choices while in the military (Table 2, Comment 1b) and that even when choices are present, they may be accompanied by obstacles (Table 2, Comment 1c). Another participant felt that women in particular are considered secondary to men when in the military, and this leads to being overlooked among the medical community at the VA (Table 2, Comment 1a). Women debated individual empowerment and systematic change; specifically, whether they should expect the Veteran’s Health Administration to provide a certain level of care (Table 2, Comment 2b) or whether they had personal responsibility to advocate for themselves (Table 2, Comment 2a). Additionally, participants emphasized that having individual doctors who are compassionate is an important factor in the expected quality of care (Table 2, Comment 2c). Clinical care can serve as a trigger for emotional distress in the process of obtaining care (Table 2, Comments 3a and 3b), and having peer support would be helpful (Table 2, Comments 4a and 4c). Having a better understanding of the reasons for and process of the gynecologic examination can be helpful (Table 2, Comment 4b). Group education sessions

We designed the GES based on focus group input. Each GES took an average of 80 min (range 74–86). The original

three topics planned for the GES were birth control, pelvic examinations, and mammograms. However, we changed the birth control session to menopause based on focus group feedback. Overall, women were receptive to the GES and provided valuable insight into the group education model. The three main perceptions about the sessions were (1) the groups improved knowledge, (2) women learned from each other’s stories, and (3) group settings can provide healing and a therapeutic place for discussion. Quotations and themes from the qualitative feedback sessions from the three GESs can be seen in Table 3. Themes included improved knowledge, feelings on group participation, and future topics for GESs. Women commented on how much they learned from the sessions and how that knowledge was useful both to themselves and also how they could disseminate knowledge to others (Table 3, Comments 3a–c). The participants enjoyed learning from each other in the group. Many stated that hearing other women’s experiences and stories taught them a great deal and provided insight into their own healthcare (Table 3, Comments 1a and 1c). A sense of camaraderie and connection permeated the groups as women shared stories and discussed their reproductive healthcare experiences (Table 3, Comment 2b and 2d). Participants suggested several topics for future GESs, including aging, heart disease, and diabetes (Table 3, Comments 3b and 3c). In particular, menopause was a popular topic requested (Table 3, Comment 3a) and led to the change of topic for the third GES. The main critiques were about a lack of outreach to additional women in the area who may benefit from the classes and frustration around the same women attending VA events.

FIG. 1. Attitude change after pelvic examination group education session (GES).


FIG. 2.

Attitude change after mammogram GES.

Surveys and knowledge assessment

Attitude change toward each preventive health topic is shown in Figures 1–3. While the samples were too small to comment on statistical significance, we can observe trends among the groups. After the pelvic examination GES (Fig. 1), subjects expressed better receptivity to the importance of Pap

FIG. 3.

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smears, early detection of cancer, obtaining a second opinion, and comfort with pelvic examinations. Marked improvement was observed in the numbers of subjects planning to have a mammogram (Fig. 2) in the next year (six before vs. nine after, with one being under 40 years old) and comfort with asking for a second opinion. After the menopause GES (Fig. 3), participants more strongly agreed that menopause is

Attitude change after menopause GES.

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a natural aging process for women and better understood the etiology and typical symptoms of menopause. Subjects also indicated an increased comfort in discussing menopause with family or friends and a better understanding of the pros and cons of hormone replacement therapy. Interestingly, more participants felt that menopause triggers feelings of trauma after the menopause GES compared with before. Knowledge improved significantly with each GES. The pelvic examination GES mean score increased from 50.0% to 80.0% correct ( p = 0.002), mammogram GES scores increased from 40.0% to 73.3% correct ( p = 0.003), and menopause GES scores increased from 58.3% to 81.7% correct ( p = 0.002). Discussion

This study takes a unique approach in addressing sexual violence survivors’ knowledge and attitudes toward reproductive preventive care through group education. In our trauma-informed approach, we sought to incorporate the voices of women veteran survivors of sexual trauma in designing our intervention and solicited feedback from participants for each element of the program. Furthermore, our program highlights the impact of trauma on obtaining preventive care and seeks to explore and ameliorate the challenges faced by survivors. Focus groups revealed a need for increased comfort and an opportunity to learn more about preventive healthcare. In fact, their main concern was increasing outreach efforts to more women veterans. The intervention was well received and further sessions were requested on subjects, such as mental illness, sex life, heart disease, diabetes, alcohol consumption, diet, bone loss, and dental issues. The GESs improved comfort with sensitive reproductive health topics by encouraging women to consider alternative perspectives on health while engaging in shared decision-making with their providers. Additionally, the GESs substantially improved the participants’ knowledge. One interesting finding was the perception of triggering of each preventive health intervention; after the GES, women were less likely to feel that pelvic examinations triggered trauma, equally likely to feel that mammograms trigger trauma, and more likely to feel that menopause triggered trauma. We interpret these findings to indicate that while pelvic examinations and mammograms are more obvious triggers of trauma, many of the women may have never previously considered how menopause could trigger their trauma, and the GES provided the opportunity to recognize it. Other studies have supported the use of group education to improve healthcare knowledge, access, or uptake. For example, both a systematic review and a randomized controlled trial found that group education improved uptake in breast cancer screening (Sabatino et al. 2012; Seven et al. 2015). GGPC is a relevant example for our GES model, in that it addresses reproductive health topics, is designed for an allfemale audience, and focuses more on education and empowerment than on uptake of specific treatments or health outcomes. One potential disadvantage of GPC is that it requires a major system delivery modification, which can cause logistical challenges and barriers to its full implementation (Novick et al. 2015). Our GES, on the other hand, does not replace any form of medical care; it complements rather than modifies healthcare delivery.

ADES ET AL.

Another model similar to our GES model is the SMV, also sometimes referred to as group medical visit. Both GPC and SMV are modifications to the standard delivery of healthcare. However, some patients may not want to disrupt their individual relationship with their provider, or implementation of group care may involve prohibitive logistical barriers (Heberlein et al. 2016; Jaber et al. 2006a; Novick et al. 2015). In our study, we separated the group education model from provision of care and offered to patients who seek group support and opportunities for additional education. Our study differed from GPC and SMV, in that our groups are specifically designed for women with a history of trauma. This was addressed in several ways. Rather than repeatedly mentioning trauma specifically throughout the focus groups and GESs, each session was introduced in the context of trauma. Issues related to trauma were addressed, such as power, control, triggering, and respect. The presence of the psychologist helped to frame the trauma context and provide support and direction, remain attuned to signals that might be retriggered, and upon occasion, gently remind participants to not reveal specific traumatic material. In working with sexual violence survivors, it is important to consider issues of sensitivity and confidentiality. Despite concerns, we did not encounter any such issues in our discussions. Previous studies have supported this finding; while providers are concerned about confidentiality as the most common reason that patients decline SMV participation, in fact, patients selectively chose, or filtered, what medical information they disclosed during a shared visit and expressed few concerns about confidentiality (Wong et al. 2015). The communal experience allowed them to learn from one another, and participants found the format to be empowering, motivating, and supportive (Wong et al. 2015). Patients with diabetes found that patients describe seeing their peers as change agents through support, role modeling, and encouraging accountability (Thompson et al. 2014). Strengths of our study include its diverse subject population, its study design utilizing both focus groups and surveys, the standardized format of evaluation of all GESs, and the specific tailoring of groups to sexual violence survivors. To our knowledge, no other study has been published evaluating the utility and feasibility of a group educational model in this population. The study design allows us to obtain a quantitative evaluation combined with qualitative feedback, providing more detail and depth to the specific reactions and thoughts of participants, which can often be lost in quantitative-only assessment. Furthermore, GESs were designed only after obtaining direct input from the subject population in the form of focus groups, allowing the content, structure, and presentation style to be better designed and modified for the target group. This study has several limitations. First, this was a pilot study and therefore our sample size was small. While we were pleased to find a statistically significant knowledge increase after each GES, we would still caution that our findings should be replicated and confirmed in larger samples. However, our study does demonstrate that GES is a feasible and acceptable model for imparting health knowledge and increasing engagement among women veterans, even with backgrounds that may be traditionally alienating and present an obstacle to obtaining care. Second, we did not assess knowledge retention in our subjects. Therefore, while subjects’ knowledge increased significantly immediately after


the session, we do not know whether this knowledge increase was retained over time, nor how it affected their health behavior. The demographics of our participants differ somewhat from the demographics of the overall female veteran population. Similarities include age (median 49.2 years in the female veteran population) and education level distribution (NCVAS 2016). However, our study population differs from the larger female veteran population, in that the majority of female veterans are white, while most of our participants were black or Latina, and higher proportion of our veterans were single compared with national data (NCVAS 2016). Last, our groups included women who volunteered to attend and therefore a selection bias cannot be avoided; women who are either too traumatized to attend such sessions or are unable to attend due to work, childcare, or other obstacles are difficult to capture in this type of intervention. Nonetheless, these GESs proved to be popular among women who attended, and more sessions were requested. Conclusions

Women who have experienced sexual violence face many obstacles to obtaining preventive reproductive healthcare, and education can help to improve women’s knowledge and acceptance of preventive health interventions. Group education is acceptable to sexual violence survivors and improves knowledge and attitude about preventive health. We anticipate that this intervention would be well received by the VHA given its commitment to women, survivors of sexual trauma, and quality care. Specifically, the Veterans Administration Center for Innovation (VACI) seeks to identify new approaches to urgent problems faced by veterans with a veteran-centered approach. Further research to verify these findings should concentrate on creating groups on more topics with higher numbers of women and evaluating knowledge and attitude improvement, including knowledge retention and provider training on trauma-informed care, as well as improvements in health outcomes. Health facilities seeking to improve opportunities for patient knowledge could consider creating group education programs. Acknowledgments

This study was funded by the Reproductive Health Office of the Department of Veterans Affairs. The authors would like to acknowledge the New York Harbor Veterans Administration Women’s Research Group, which contributed to the grant application, study design, and implementation, and the study participants who gave their time and effort to this study. Author Disclosure Statement

This study was funded by the Reproductive Health Office of the Department of Veterans Affairs. No competing financial interests exist for any of the authors of this article. References Averill JB. (2002). Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qual Health Res. 12, 855–866. Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists (ACOG). (2012). Committee Opinion No. 547: Health care for women in the military and women veterans. Obstet Gynecol. 120, 1538–1542.

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Address correspondence to: Veronica Ades, MD, MPH New York Harbor Veterans Administration Hospital 423 East 23rd Street, 11066-AS New York, NY 10010 E-mail: [email protected]

Appendix A: Focus group guide

Topic 1: Pelvic Exams 1. When you go to the gynecologist, do you expect to have a pelvic exam (by pelvic exam, we mean when you put on a gown and put your feet into stirrups and slide down the examination table for a physical exam of your female organs)? If so, what do you think is the purpose of this exam? 2. What has been your experience in getting pelvic exams? Have you had negative experiences? Have you had positive experiences? 3. What kind of information might be helpful to you in preparing for a pelvic exam? 4. Here are some teaching tools that a provider could use in explaining the pelvic exam. Would this be helpful and if so, how could they be used? 5. What strategies have you used to help you prepare for a pelvic exam? 6. How do you think having had an unwanted sexual experience might affect whether a) a woman chooses to get a pelvic exam; and, b) their experience of it?

Topic 2: Birth Control 1. We would like to know about your experience in preventing an unwanted pregnancy. Can you think of some reasons that women don’t use birth control even when they don’t want to get pregnant? 2. What factors do women consider when they are choosing between different types of birth control? 3. Here are some teaching tools that providers could use to discuss birth control options. Do you think that these tools are helpful and if so, how can they be used? 4. What are some barriers to accessing birth control? 5. What strategies have you used to help you prepare for a birth control visit? [i.e. looking up information online; talking to supportive people; relaxation/meditation or other emotional strategies] 6. How do you think having had an unwanted sexual experience might affect whether a) a woman chooses to use birth control; and, b) their experience of it?

Topic 3: Mammograms 1. You may or may not have had a mammogram in the past. What is your opinion of mammograms, and why do you think they are recommended? Who should have mammograms? 2. There has been some controversy about who should get mammograms, and how often. What have you heard about this? How has it affected your feelings about whether or not to get a mammogram? 3. What information would be helpful to you in deciding when and how often to get a mammogram? 4. Here is a model of the breast that can be used for explaining breast screening. Do you think this would be helpful, and how should it be used? 5. What strategies or techniques have you used to help you prepare for a mammogram? [i.e. looking up information online; talking to supportive people; relaxation/meditation or other emotional strategies] 6. How do you think having had an unwanted sexual experience might affect: a) a woman’s choice to get a mammogram; b) their experience of it?

Appendix A: Focus group guide

Topic 4: Environment of Care/Wrap-up 1. We would like to know about how the VA health care environment as a whole affects women veteran’s experiences of birth control, gynecologic visits and mammograms? 2. Based on this discussion, we are going to create three group education sessions on each topic: gynecologist exams, birth control visits and mammograms. What advice would you give us?

Appendix B: Attitude Surveys

Mammograms Circle one answer for each:

Study ID #____

1. It is important for women to have regular mammograms to detect early cancer Strongly Agree Agree

Neither agree nor disagree

Disagree

Disagree Strongly

Disagree

Disagree Strongly

Disagree

Disagree Strongly

Disagree

Disagree Strongly

2. I feel comfortable getting a mammogram Strongly Agree Agree


3. I plan to get a mammogram in the next year Strongly Agree Agree


4. Getting a mammogram triggers my feelings of trauma Strongly Agree Agree


5. This discomfort of getting a mammogram is not worth the health benefits Strongly Agree Agree


Disagree

Disagree Strongly

6. I wouldn’t/don’t get mammograms because I would rather take a chance Strongly Agree Agree


Disagree

Disagree Strongly

7. I don’t get mammograms because I am afraid to get bad news Strongly Agree Agree


Disagree

Disagree Strongly

8. It is important to me to detect cancer early so that it can be treated Strongly Agree Agree


Disagree

Disagree Strongly

9. I feel reassured when I get a mammogram and the result is normal Strongly Agree Agree


Disagree

Disagree Strongly

10. I feel comfortable asking to get a second opinion after I meet with my doctor Strongly Agree Agree


Disagree

Disagree Strongly

Menopause Circle one answer for each:

Study ID #____

1. I feel comfortable with the idea of discussing menopause symptoms with my doctor Strongly Agree Agree


Disagree

Disagree Strongly

2. Menopause is a natural process that women go through as they age Strongly Agree Agree


Disagree

Disagree Strongly

Disagree

Disagree Strongly

3. Menopause triggers my feelings of trauma Strongly Agree Agree


4. I feel comfortable talking about menopause with my family or friends Strongly Agree Agree


Disagree

Disagree Strongly

5. I understand why some women might choose to take Hormone Replacement Therapy Strongly Agree Agree


Disagree

Disagree Strongly

Disagree

Disagree Strongly

Disagree

Disagree Strongly

6. I understand why menopause happens Strongly Agree Agree


7. I know what the normal symptoms of menopause are Strongly Agree Agree


Pelvic exam Circle one answer for each:

Study ID #____

1. It is important for women to have Pap smears to detect early cancer Strongly Agree Agree


Disagree

Disagree Strongly

Disagree

Disagree Strongly

Disagree

Disagree Strongly

Disagree

Disagree Strongly

2. I feel comfortable getting a pelvic exam Strongly Agree Agree


3. I plan to see a gynecologist in the next year Strongly Agree Agree


4. Getting a pelvic exam triggers my feelings of trauma Strongly Agree Agree


5. This discomfort of getting a pelvic exam is not worth the health benefits Strongly Agree Agree


Disagree

Disagree Strongly

6. I wouldn’t/don’t get pelvic exam because I would rather not know if there is a problem Strongly Agree Agree


Disagree

Disagree Strongly

7. I don’t get pelvic exams because I am afraid that the doctor will find something wrong Strongly Agree Agree


Disagree

Disagree Strongly

8. It is important to me to detect cancer early so that it can be treated Strongly Agree Agree


Disagree

Disagree Strongly

9. I feel reassured when I get a Pap smear and the result is normal Strongly Agree Agree


Disagree

Disagree Strongly

10. I feel comfortable asking to get a second opinion after I meet with my doctor Strongly Agree Agree


Disagree

Disagree Strongly

Appendix C: Knowledge Surveys

Mammograms – VA Group Discussion

Study ID #_____

1. What is a mammogram? (circle the best answer) a. An X-Ray b. An ultrasound c. A CAT Scan d. An MRI e. None of the above f. Don’t know 2. Who should have regular mammograms? (circle the best answer) a. Everyone over 30 years old b. Starting between 40-50 years old c. Everyone under 60 d. Only women who have felt a lump or mass on their breast e. None of the above f. Don’t know 3. Why should you get a mammogram? (circle the best answer) a. It will prevent me from getting breast cancer b. To drain fluid from a cyst c. To detect cancer at an early stage d. There is no reason e. None of the above f. Don’t know 4. Shared Decision Making is appropriate when…. (circle the best answer) a. There are multiple good medical options and there is no “best choice.” b. There is a clear medical recommendation c. A 25 year old women wants a mammogram “just in case.” d. A patient has an aggressive cancer and the doctor makes a recommendation e. None of the above f. Don’t know 5. What is one problem with getting a mammogram that you don’t need? (circle the best answer) a. It will cause thyroid cancer b. A false positive result can lead to stress and too much testing or surgery c. It will make your next mammogram look abnormal d. It could affect your medication e. None of the above

f.

Don’t know 6. The amount of radiation from a mammogram is… a. The same as a CT scan b. Enough to cause breast cancer c. Less than background radiation over 1 year d. The same as an MRI e. None of the above f. Don’t know

Mammograms – VA Group Discussion

Study ID #_____

1. What is menopause? (circle the best answer) a. No period for 12 months (1 year) b. Hot flashes c. Lighter period d. Irregular periods throughout life e. None of the above f. Don’t know 2. Why does menopause happen? (circle the best answer) a. Poor diet b. Ovaries stop producing estrogen and progesterone c. Happens at a specific age d. Not enough exercise e. None of the above f. Don’t know 3. Which of these is NOT an effect of menopause? (circle the best answer) a. Higher risk of heart disease or stroke b. Weight gain c. Bone thinning d. Pelvic pain e. None of the above f. Don’t know 4. When talking to your doctor about menopause, Shared Decision Making can … a. Help you better understand the risks and benefits of taking hormone replacement therapy b. Be avoided altogether since everyone can always take hormone replacement therapy c. Be used by your doctor to convince you to follow their recommendations d. Be avoided since you are the patient and you know best e. Don’t know 5. Which of these is NOT an acceptable treatment for hot flashes in a woman with high blood pressure? (circle the best answer) a. No treatment b. Hormone replacement therapy c. Anti-depressants (SSRI or SNRI) d. Exercise

e. None of the above f. Don’t know 6. If a woman in menopause has some very light vaginal bleeding, she should… (circle the best answer) a. Wait and see if it happens again b. See her gynecologist as soon as possible c. Take an herbal supplement d. Not worry about it e. None of the above f. Don’t know

Pelvic Exams – VA Group Discussion

Study ID #_____

Circle the best answer. 1. What is a Pap smear? a. When the doctor examines a woman’s vagina b. A test of the cervix for sexually transmitted diseases c. A blood test d. A test for abnormal cells of the cervix that can lead to cancer e. None of the above f. Don’t know 2. Why do doctors do pelvic exams? a. For no reason b. To detect problems like fibroids or ovarian cysts c. To detect colon cancer d. To test for infertility e. None of the above f. Don’t know 3. Which sexually transmitted diseases (STDs) can be detected in a pelvic exam? a. Hepatitis B b. HIV c. Chlamydia and Gonorrhea d. Lupus e. None of the above f. Don’t know 4. Shared Decision Making is appropriate when…. a. There are multiple good medical options and there is no “best choice.” b. There is a clear medical recommendation c. A woman complains of severe bleeding d. A patient has an aggressive cancer and the doctor makes a recommendation e. None of the above f. Don’t know 5. Every woman should have a pap smear every year a. True b. False c. Don’t know 6. What is the follow up test to an abnormal pap smear?

a. b. c. d. e.

Ultrasound Colonoscopy EKG Colposcopy Don’t know