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Abstract

Female survivors of sexual assault may be at greater risk of cervical cancer than those with no such experience but are less likely to attend their cervical screening. This feasibility study evaluated a novel self-help intervention delivered via mobile app, designed to make cervical screening more accessible by addressing barriers commonly experienced by this group. Participants accessed the intervention immediately (n = 15) or were allocated to a control group (n = 15). Measures of shame, self-compassion, self-efficacy related to cervical screening, and progress toward attendance were completed at baseline and after 7 weeks. Significantly more participants in the intervention group booked and completed a cervical screening compared to controls. A significant group × time interaction was found for self-efficacy with a large effect size. No significant interactions were found for shame or self-compassion. Feedback was generally positive. The app appeared to be a feasible and acceptable way of providing self-help materials and was successful in increasing some participants’ confidence in their ability to attend a cervical screening, and in some cases led to attendance. Further evaluation is needed.

Keywords

cervical screening cervical cancer trauma women's health compassion-focused therapy‌

Introduction

Females and people with a cervix with experience of sexual assault are at increased risk of developing cervical cancer but are less likely to attend and complete a cervical screening than the general population.^1-3 Survivors are often traumatized, experience high levels of shame and may have low self-efficacy in relation to cervical screening, meaning that they lack confidence in their ability to complete the procedure.^3-6 Despite this, there is little support available to them in accessing cervical screening or making the experience more tolerable. In the United Kingdom, the voluntary organization My Body Back³ offers a specialist clinic, but routine provision is lacking. Public health campaigns have been criticized for being insensitive to survivors’ needs⁷ and those from backgrounds that may have traditionally been marginalized, such as individuals from ethnic and cultural minorities and people with disabilities or mental health conditions, may face additional barriers to accessing routine care following sexual violence.⁸

Mobile applications (“apps”) are a cost-effective and accessible way of providing health information and promoting behavior change. Apps are available to support the management of various health conditions, including sexual health, with an emerging, though limited, evidence base.^9-11 Digital interventions may be a helpful option for individuals who struggle to access traditional services.¹²

This study aimed to fill a significant gap in research evidence and clinical provision by evaluating the feasibility of a mobile app self-help intervention offered to people with experience of sexual assault, developed in partnership with My Body Back³ clinicians and experts by experience. The intervention aimed to promote behavior change by targeting established psychological barriers to cervical screening attendance, namely low levels of self-efficacy and high levels of shame.^4-6 Target behaviors were booking, attending, and completing a cervical screening. A step-by-step approach to behavior change was adopted, in line with the self-efficacy literature.¹³ The intervention also aimed to improve psychological well-being through increasing individuals’ understanding of their difficulties and providing self-help techniques. The app provided practical information about cervical screening and skills for managing trauma-related symptoms which may be triggered by preparing for the procedure, such as flashbacks and panic attacks. Intervention materials were informed by Compassion-Focused Therapy,¹⁴ an effective and acceptable transdiagnostic psychological intervention intended to reduce shame, self-criticism, and avoidant coping, and to help individuals build compassion toward themselves and their difficulties.¹⁵ It is therefore appropriate for survivors of sexual assault.^5,16 In addition, self-compassion has been linked to health-promoting behaviors.¹⁷ Compassion-Focused Therapy is transferrable to self-help formats, including apps.^18-21 Information and self-help exercises were presented in written, audio, and visual form (topics are summarized in Supplementary File 1, along with sample pages from the app).

Method

Design

The study used an independent groups (intervention group vs control group) and repeated measures design. It was a feasibility study of a novel intervention with random allocation to conditions.

Participants

Participants were recruited online, primarily using social media. Individuals with self-reported experience of sexual assault, within the age range for cervical screening in the UK (25-64), and due to attend a screening were invited to participate. Being a resident in the UK and having access to the Internet on a private device were requirements.

Ethical Considerations

Ethical approval was granted by the local research ethics committee. The nature of this research meant that it required the recruitment of potentially vulnerable participants. Those reporting being in a mental health crisis or having frequent thoughts of self-harm or suicide in the absence of professional and/or social support were unable to participate. The intervention included signposting to additional sources of support, including instructions for action to take in the event of a mental health crisis, services providing psychological therapy, and organizations offering support specifically for survivors of sexual violence. Additionally, participants were offered the opportunity for the research team to contact their General Practitioner to inform them of their participation, but this was optional to preserve confidentiality.

Measures

Behavioral measure

Questions to Assess Action Toward Cervical Screening: Participants were asked whether they had booked and/or attended a screening and whether they had completed the procedure.

Primary psychological measures

The Experience of Shame Scale (ESS):²² The ESS measures shame related to self (character and body) and performance (behavior). Respondents rate their agreement with 25 items on a scale ranging from 1 (not at all) to 4 (very much). The subscales have good internal consistency (α = .90 for characterological shame, α = .87 for behavioral shame, and α = .86 for bodily shame) and an overall test–retest reliability of .83. The ESS has demonstrable construct validity in a nonclinical sample.²² Given the short-term nature of this research, instructions were adjusted to ask respondents to rate experiences over the previous month rather than the previous year.

The Compassionate Engagement and Action Scales — Compassion for Self Scale:²³ The Compassion for Self scale is a measure of self-compassion, defined as an awareness of one's own suffering, with a commitment to easing it. It comprises 2 subscales: compassionate engagement and compassionate action. The full CEAS consists of 3 scales that have been validated against established compassion measures.²³ Instructions were adjusted to ask participants to focus on distress specifically related to cervical screening. In the present context, booking and attending a screening may be conceptualized as compassionate actions.

Questions to Assess Self-efficacy Relating to Cervical Screening: Participants rated their confidence in their ability to attempt various stages of a cervical screening. Twelve statements were rated on a scale of 0 (cannot do at all) to 100 (highly certain can do). This scale was adapted from a previous study which found it to have a high alpha level (α = .88) and factor loadings (.63-.86).⁶ Adaptations were made to maximize relevance. There remained a high level of agreement between items (α = .93).

Secondary psychological measures

The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5):²⁴ The PCL-5 requires respondents to rate how often they have been bothered by 20 symptoms within the last month, on a scale of 0 (not at all) to 4 (extremely). The PCL-5 has good internal consistency (α = .94) and test–retest reliability (r = .82) and strong convergent (rs = .74-.85) and discriminant (rs = .31-.60) validity.²⁵ The suggested clinical cutoff indicating a potential diagnosis of PTSD is 33; the maximum score is 80.

The Patient Health Questionnaire-2 (PHQ-2),²⁶ a screen for major depression. Respondents rate 2 statements depending on how often they have experienced them over the previous 2 weeks, using a scale of 0 (not at all) to 3 (nearly every day). Scores of 3 or above indicate major depression.

Generalized Anxiety Disorder Scale-2 (GAD-2):²⁷ The GAD-2 asks respondents to rate 2 statements depending on how often they have experienced them over the previous 2 weeks, using a scale of 0 (not at all) to 3 (nearly every day). Scores of 3 or above indicate clinical levels of anxiety.

Questions relating to intervention use and acceptability

Participants completed an 8-item questionnaire regarding acceptability of the app and were asked how often they had used it.

Procedure

Potential participants were invited to read the study information sheet online and to complete the consent form. Those providing consent answered screening questions. Those eligible to participate were asked to complete baseline questionnaires. Participants provided an email address to enable the researcher to contact them and to match together their baseline and postintervention measures.

Participants were randomized to either the intervention group or the waiting list control group. Those in the intervention group were given access to the app.

The intervention period lasted for 7 weeks. A comparable pilot study²⁸ used a one-month intervention period, however, additional time was added to allow for participants to book and attend a cervical screening, should they decide to. Participants in the intervention group were sent a weekly supportive email to supplement app use.

At the end of the intervention period, all participants were asked to repeat the questionnaires, with additional questions regarding app usage and feedback for the intervention group. Participants in the control group were able to access the app after completing their final questionnaires. Participants were provided with debrief including signposting to further sources of support.

Data Analysis

Results relating to the behavioral outcome of interest — progress toward completing a cervical screening within the intervention period — were analyzed using Fisher's exact test to check for differences between the intervention and control groups. Initial descriptive statistics (means and standard deviations) were used to visually analyze outcomes on all psychological outcome measures, followed by a series of t tests which were used to assess for differences in scores between completers and noncompleters.

A series of group (intervention and control group) × time (baseline and postintervention) mixed model ANOVAs were calculated for all psychological outcome measures using the completers sample only (per-protocol analysis). Intention-to-treat analysis was not used because there was no way to ascertain whether participants who dropped out had received any part of the intervention.²⁹ Follow-up ANCOVAs were used to control for differences in scores between groups at baseline when analyzing postintervention scores, where required. The Statistical Package for Social Sciences version 21.0 was used for all statistical analyses.

Results

Sixty-nine people completed the study consent form. Of these, 64 answered the screening questions; 24 were excluded because they did not meet criteria for participation and 10 did not go on to complete the baseline measures. Thirty participants were randomized; the intervention and control groups each contained 15 participants. Demographic information is provided in Supplementary File 2.

Nine participants in the intervention group and 12 in the control group completed postintervention measures, a completion rate of 70%. Participants’ flow through the study is illustrated in Supplementary File 3.

All data were checked for normality with no significant skewness, kurtosis, or outliers found. There were no missing data at baseline. All participants completing postintervention measures completed the full data set, with one exception. This participant completed most outcome measures, so their data were included. Nine participants (intervention group n = 6; control group n = 3) did not complete any postintervention questionnaires so were considered dropouts.

Behavioral Outcomes

Participants reported their progress toward attending a cervical screening at baseline and postintervention. Results are given in Table 1 and demonstrate a greater success rate in the intervention group than in the control group. At postintervention:

Three members of the intervention group had booked, attended, attempted, and completed a screening.

Two participants in the intervention group had booked an appointment for a future date.

One member of the control group booked and attended an appointment but did not complete the procedure. No other control participants had made a booking.

Table 1.

Progress Toward Completing a Screening.

	Intervention group (n = 15)		Control group (n = 15)		Difference between groups at postintervention (Fisher's exact test)
	Baseline (n = 15)	Postintervention (n = 8)	Baseline (n = 15)	Postintervention (n = 12)
Booked appointment	Yes n = 5	Yes n = 5	Yes n = 3	Yes n = 1	P = .018^a
Attended appointment	Yes n = 0 Appointment booked for future date n = 5	Yes n = 3 Appointment booked for future date n = 2	Yes n = 2	Yes n = 1	P = .255
Attempted procedure	Yes n = 0	Yes n = 3	Yes n = 1	Yes n = 1	P = .255
Completed procedure	Yes n = 0	Yes n = 3	Yes n = 1	Yes n = 0	P = .049^a

Significant at <.05 level.

Psychological Outcomes

Mean scores on all outcome measures are provided in Table 2. On average, both groups reported clinical levels of PTSD symptoms and generalized anxiety at baseline and postintervention.

Table 2.

Scores on Outcome Measures at Baseline and Postintervention.

	Intervention group (n = 15)		Control group (n = 15)
	Baseline (n = 15) M (SD)	Postintervention (n = 12) M (SD)	Baseline (n = 15) M (SD)	Postintervention (n = 9) M (SD)
ESS
Characterological	28.60 (9.85)	26.67 (8.63)	32.33 (12.41)	36.25 (8.34)
Behavioral	26.13 (7.02)	21.00 (7.14)	28.07 (7.67)	29.83 (9.13)
Bodily	12.07 (4.08)	11.33 (3.94)	12.33 (3.74)	13.83 (2.52)
Total	66.80 (18.83)	59.00 (17.66)	72.73 (22.14)	79.92 (17.40)
Compassion for self
Engagement	33.60 (9.90)	36.89 (11.24)	33.00 (6.13)	30.83 (5.89)
Action	21.93 (8.28)	24.00 (9.03)	18.47 (5.24)	16.25 (6.10)
Total	55.53 (16.87)	60.89 (19.80)	51.47 (8.72)	47.08 (11.76)
Self-efficacy	47.33 (25.55)	78.00 (32.01)	29.93 (19.03)	26.08 (20.92)
PCL-5	35.73 (18.65)	35.44 (20.40)	33.93 (17.11)	44.58 (16.49)
GAD-2	3.47 (1.55)	3.67 (2.12)	3.40 (2.23)	4.50 (1.51)
PHQ-2	2.00 (1.56)	2.33 (1.94)	2.27 (1.94)	3.58 (1.44)

There were no significant differences at baseline between groups on any measure, except the self-efficacy scale where the intervention group scored significantly higher than the control group (t(28) = 2.12, P = .043).

When looking at baseline scores of completers alone:

The control group scored significantly higher on the ESS (t(19) = −2.62, P = .017) and its 3 subscales;

The intervention group scored significantly higher on the action subscale of the Compassion for Self scale (t(19) = 2.65, P = .016);

The intervention group scored significantly higher on the self-efficacy scale (t(19) = 2.98, P = .008).

There were no significant differences between completers and noncompleters on any baseline measures (see Supplementary File 4).

Per-Protocol Analysis

As shown in Table 3, there was a highly significant interaction of time and group (F(1,18) = 15.99, P = .001, η_p² = .32) on the self-efficacy scale, indicating that self-efficacy differed significantly between the intervention and control groups, with a large effect size.

Table 3.

Results of Completers Sample ANOVAs.

		Time × Group	Time	Group
ESS	Characterological	F(1,19) = .03, P = .877, η_p² = .00	F(1,19) = .03, P = .877, η_p² = .00	F(1,19) = 5.79, P = .026^a, η_p² = .23
	Behavioral	F(1,19) = .83, P = .375, η_p² = .04	F(1,19) = 3.78, P = .067, η_p² = .17	F(1,19) = 7.68, P = .012^a, η_p² = .29
	Bodily	F(1,19) = .01, P = .916, η_p² = .00	F(1,19) = .08, P = .784, η_p² = .00	F(1,19) = 3.29, P = .086, η_p² = .15
	Total	F(1,19) = .55, P = .466, η_p² = .03	F(1,19) = 1.70, P = .209, η_p² = .08	F(1,19) = 7.54, P = .013^a, η_p² = .28
Compassion for self	Engagement	F(1,19) = 1.19, P = .288, η_p² = .06	F(1,19) = .01, P = .918, η_p² = .00	F(1,19) = 1.46, P = .242, η_p² = .07
	Action	F(1,19) = .00, P = .972, η_p² = .00	F(1,19) = .28, P = .604, η_p² = .01	F(1,19) = 6.71, P = .018^a, η_p² = .26
	Total	F(1,19) = .59, P = .451, η_p² = .03	F(1,19) = .03, P = .869, η_p² = .00	F(1,19) = 3.92, P = .063, η_p² = .17
Self-efficacy		F(1,18) = 8.62, P = .009^a, η_p² = .32	F(1,18) = 10.23, P = .005^a, η_p² = .36	F(1,18) = 15.99, P = .001^b, η_p² = .47
PCL-5		F(1,19) = 1.88, P = .186, η_p² = .09	F(1,19) = 1.88, P = .186, η_p² = .09	F(1,19) = .81, P = .380, η_p² = .04
GAD-2		F(1,19) = .62, P = .442, η_p² = .03	F(1,19) = 1.06, P = .317, η_p² = .05	F(1,19) = .44, P = .514, η_p² = .02
PHQ-2		F(1,19) = .07, P = .791, η_p² = .00	F(1,19) = 2.89, P = .106, η_p² = .13	F(1,19) = 3.58, P = .074, η_p² = .16

^a Significant at <.05 level.

Significant at <.001 level.

Post hoc independent samples t tests showed that the groups differed significantly at both baseline (t(10.93) = 2.72, P = .020) and postintervention (t(18) = 4.41, P ≤ .001). Paired samples t tests showed a significant increase in self-efficacy between baseline and postintervention for the intervention group (t(7) = 2.88, P = .024) while there was no significant effect of time for the control group (t(11) = −.316, P = .758).

An additional ANCOVA confirmed that the effect of group membership on self-efficacy scores at postintervention remained significant when differences in baseline scores were controlled for (F(1,17) = 6.99, P = .017, η_p² = .29), with participants in the intervention group scoring significantly higher than those in the control group, with a large effect size.

Mean total scores on the ESS and Compassion for Self scale and their subscales improved for the intervention group but not for the control group; this improvement was statistically significant for the behavioral subscale of the ESS (t(8) = 2.86, P = .021) and showed a trend toward significance for the ESS overall (t(8) = 2.04, P = .075). There were no significant interactions of time and group. There were significant effects of group membership for:

The ESS total scale (F(1,19) = 7.54, P = .013, η_p² = .28);

The characterological shame subscale (F(1,19) = 5.79, P = .026, η_p² = .23);

The behavioral shame subscale (F(1,19) = 7.68, P = .012, η_p² = .29);

The action subscale of the Compassion for Self scale (F(1,19) = 6.71, P = .018, η_p² = .26).

In all cases, these were due to significant differences between scores at both baseline and postintervention. Follow-up ANCOVAs were therefore used to ascertain whether differences in baseline scores impacted on the interaction:

The effect of group membership on scores on the ESS at postintervention remained insignificant (F(1,18) = .491, P = .492, η_p² = .03) when baseline ESS scores were controlled for.

The effect of group membership on scores on the Action subscale of the Compassion for Self scale at postintervention remained insignificant when baseline scores were controlled for (F(1,18) = .10, P = .757, η_p² = .01).

As shown in Table 3, there were no significant interactions of time and group, nor were there any significant effects of group or time, on the 3 secondary outcome measures: the PCL-5, PHQ-2, and GAD-2. Paired samples t tests found no significant pre-post changes on these measures for the intervention group. For the control group, scores on the PCL-5 significantly increased (t(11) = −1.33, P = .043) and showed a trend toward significantly increasing on the GAD-2 (t(11) = −1.89, P = .085).

App Usage and Acceptability

Eight participants from the intervention group answered questions regarding app usage and acceptability.

Four (50%) indicated that they had opened the app several times a week, 3 (37.5%) once a week and one (12.5%) less than once a week.

Eight participants (100%) stated that they were initially interested in the app and intended to use it.

In response to the statement “I liked the app”, 5 (62.5%) agreed, while 3 (37.5%) neither agreed nor disagreed.

Six participants (75%) agreed that using the app had a positive impact on them, while one (12.5%) neither agreed nor disagreed and one (12.5%) disagreed.

Seven (87.5%) agreed that an app is a good way to help people like them; one (12.5%) neither agreed nor disagreed.

Five (62.5%) agreed that they were satisfied with the app, while 2 (25%) neither agreed nor disagreed and one (12.5%) disagreed.

Four (50%) agreed that they intended to continue using the app; 2 (25%) neither agreed nor disagreed and 2 (25%) disagreed.

Six (75%) agreed that they would recommend the app to others with similar difficulties; one (12.5%) neither agreed nor disagreed and one (12.5%) disagreed.

Discussion

Access to and use of the app appeared to increase the likelihood of participants accessing cervical screening. At postintervention, 3 participants in the intervention group had completed their cervical screening and a further 2 had arranged appointments for a future date, while no participants in the control group had completed a screening. In addition, participants in the intervention group showed significantly higher levels of self-efficacy at the end of the study compared to the control group, a significant improvement from baseline. This finding is consistent with general health behavior models such as the Health Action Process Approach.³⁰ It also supports previous research⁶ which identified self-efficacy as a key factor in intention to attend cervical screening, and in the translation of intention to action, and contrasts with recent data which does not suggest a link between self-efficacy and screening attendance.³¹ It is notable that self-efficacy was the only outcome measure to show a significant time × group effect. This may have been due to participants’ engagement with the intervention content but could also have been linked to motivation; at baseline 5 participants in the intervention group had already booked a screening so were clearly motivated to attend. Baseline levels of self-efficacy were significantly higher for those in the intervention group; it is unclear why this difference occurred, as participants were randomly allocated to conditions, and scores between groups at baseline did not significantly differ on any other measure. However, when this was statistically controlled for the intervention group still showed a significant improvement on the self-efficacy scale, suggesting that exposure to the intervention had an effect.

The intervention group improved on measures of shame and self-compassion, but these improvements were not statistically significant and the difference between groups at postintervention on these measures was nonsignificant. Participants may have required a higher-intensity intervention to make significant improvements. However, given the positive trend in shame scores for the intervention group, it is possible that the sample size lacked the power to detect significant changes and differences between groups. It is also possible that participants focused more on sections of the app related to the practicalities of completing their screening than those aimed at building self-compassion, so made less progress in this area. Additionally, participants may have required more time for significant changes to occur, particularly given the pervasive nature of shame following trauma.³² Shame is understood to be strongly associated with psychological distress, particularly that linked to trauma,^5,32,33 and it is possible that continued engagement with the compassion-focused exercises within the intervention over a longer period may lead to further reduction in shame and therefore potentially improved psychological well-being. Increased self-efficacy over time may also have a positive impact on mental health beyond the end of the study.³⁴

Participants also completed measures of PTSD, depression, and anxiety. On average, participants reported clinically significant PTSD symptoms and anxiety at baseline. The intervention group did not show any significant improvement in anxiety, depression, or PTSD symptoms and the control group showed a significant increase in PTSD symptoms and an increase in anxiety approaching significance. However, the intervention did not aim to treat PTSD, but to provide coping strategies, so an improvement in scores was not necessarily expected. It is possible that the increased focus on a triggering event, namely cervical screening, increased trauma symptoms for participants across groups, and the lack of coping skills supplied to the control group may have contributed to the worsening of their scores. In addition, given the clinically significant levels of PTSD symptoms and anxiety reported by the sample overall at baseline, it may be unrealistic to see an improvement in symptomatology using a brief, self-guided intervention. Again, a more intensive psychological intervention may be required for improvements to be seen in these measures.

Participants in the intervention group who completed the study generally provided positive feedback about the app. However, a proportion of participants dropped out and did not complete postintervention measures, reducing the generalizability of the results. Invitations to complete measures were sent by email, followed by regular reminders. One individual contacted the researcher to explain that they had been unable to complete the measures for personal reasons; otherwise, the reasons for noncompletion are unknown. There were no significant differences between completers and drop-outs in scores on any of the psychological measures at baseline, so noncompletion cannot be attributed to these factors. There were fewer drop-outs in the control condition; it is probable that participants in the control group were motivated by the chance to access the app following completion of the postintervention measures, while there was no such inventive for those who had already accessed it. It is also possible that the length of the assessment battery deterred some individuals from completing their final measures.

Limitations

The study recruited a small sample and some participants dropped out. It was therefore underpowered, so smaller effects of the intervention may not have been detected, and equally, per-protocol analysis may have overestimated effect sizes, although this was expected in a feasibility study.³⁵ Scores on outcome measures, reports of app usage, and progress toward screening may have been influenced by demand characteristics and reflect the views of those who remained in the study but not those who discontinued, which introduces the potential for further bias. The sample is unlikely to be representative of the broader population of survivors of sexual assault which limits the generalizability of the results.

Future Research

The findings of this feasibility study support further evaluation of the app using a second cohort of participants to achieve a larger sample size and therefore increase the statistical power, certainty of the findings, and generalizability of the results. This could be done with the current prototype or a more sophisticated version. Further research could explore whether an association exists between scores on baseline outcome measures, particularly self-efficacy, and subsequent use of the intervention, which could provide an avenue for increasing future engagement. Follow-up data would also be useful in establishing the potential longer-term benefits of the intervention. It may be helpful to gather detailed qualitative feedback from participants to support further development of the app and to understand aspects which are experienced as helpful or less helpful.

Additionally, it would be useful to develop and evaluate training packages for healthcare staff to become more aware of, and confident in responding to, the needs of survivors of sexual assault when conducting gynecological examinations. The use of a self-help intervention alone arguably places the responsibility solely on patients; however, there is also a duty for healthcare providers to offer sensitive, compassionate, and trauma-informed services.

Conclusion

A self-help mobile app appears to be a feasible and acceptable way of supporting survivors of sexual assault to access cervical screening in routine care, thus potentially improving health outcomes and patient experience. The results of this study, while encouraging, should be treated with caution, and further evaluation is warranted with a larger sample before the app can be recommended more widely.

Supplemental Material

sj-docx-1-jpx-10.1177_23743735251343581 - Supplemental material for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault

Supplemental material, sj-docx-1-jpx-10.1177_23743735251343581 for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault by Jane Smallwood, Stuart Gibson, Jill Zelin, Dawn Langdon and Jane Vosper in Journal of Patient Experience

Supplemental Material

sj-docx-2-jpx-10.1177_23743735251343581 - Supplemental material for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault

Supplemental material, sj-docx-2-jpx-10.1177_23743735251343581 for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault by Jane Smallwood, Stuart Gibson, Jill Zelin, Dawn Langdon and Jane Vosper in Journal of Patient Experience

Supplemental Material

sj-docx-3-jpx-10.1177_23743735251343581 - Supplemental material for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault

Supplemental material, sj-docx-3-jpx-10.1177_23743735251343581 for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault by Jane Smallwood, Stuart Gibson, Jill Zelin, Dawn Langdon and Jane Vosper in Journal of Patient Experience

Supplemental Material

sj-docx-4-jpx-10.1177_23743735251343581 - Supplemental material for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault

Supplemental material, sj-docx-4-jpx-10.1177_23743735251343581 for Making Cervical Screening More Accessible: A Compassion-Focused Self-Help Intervention for Survivors of Sexual Assault by Jane Smallwood, Stuart Gibson, Jill Zelin, Dawn Langdon and Jane Vosper in Journal of Patient Experience

Footnotes

Acknowledgments

The authors wish to thank the app development team at Founders and Coders, experts by experience, and My Body Back volunteers for their contributions to this project.

Author Contributions

All authors contributed to the preparation of the manuscript and approved the final version.

Data Availability Statement

The data that support the findings of this study are not publicly available due to ethical restrictions.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

Ethical approval was granted by the London City and East Research Ethics Committee on 10/09/2019, reference 263183. Participants gave written consent to participate in the research via the completion of an online consent form. No individual data are included in this paper.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Jane Smallwood

Dawn Langdon

Supplemental Material

Supplemental material for this article is available online.

Appendix 1

Intervention Content

• Understanding the brain's response to trauma: explaining why cervical screening can be difficult for people with experience of sexual assault, including an introduction to the “threat system” and the fight or flight response. Within compassion-focused therapy, the activation of the threat system is understood as an evolutionary response to perceived danger. This section aimed to normalize and reduce the shame that many survivors feel about their experiences and about their difficulties with cervical screening by emphasizing that this response is natural.

• Grounding skills and self-help techniques for coping with anxiety, panic, flashbacks and dissociation.

• Breathing and imagery exercises to promote self-soothing and ideas for increasing self-compassion and directly challenging self-criticism, particularly in response to difficulties with cervical screening. These exercises were designed to be used at each stage of preparing for the process of screening, and during the appointment.

• Practical advice for before, during, and after an attempt to complete a cervical screening, emphasizing the value of breaking the task down into stages and seeing each attempted stage as an achievement. This was intended to support the development of greater self-efficacy around the screening process.

• Supportive messages from other survivors and supporters, also targeting shame and building compassion.

• Crisis information and signposting to additional sources of support.

Sample pages:

Appendix 2

Participant Characteristics

	Intervention group (n = 15)	Control group (n = 15)
Age (years)	Range 27-53 (median = 39)	Range 25-49 (median = 28)
Gender identity	Female = 15	Female = 14, nonbinary = 1
Ethnicity	White = 14, mixed background = 1	White = 10, mixed background = 3, black = 1, Asian = 1
Relationship status	Single = 9, married/cohabiting = 4, in a relationship = 2	Single = 5, Married/cohabiting = 5, in a relationship = 4, Separated/divorced = 1
Employment status	Employed/self-employed = 10, unable to work = 2, unemployed = 1, student = 1, carer = 1	Employed/self-employed = 12, unable to work = 1, student = 1, other = 1
Time of sexual assault	Adulthood = 6, childhood = 6, adulthood and childhood = 3	Childhood = 7, adulthood = 4, adulthood and childhood = 4
Previous experience of cervical screening	Yes = 13, no = 2	Yes = 7, no = 8
Last cervical screening was distressing	Yes = 13, no = 2	Yes = 7, no = 8

Appendix 3

Participant Flow Through the Study

Appendix 4

Differences Between Completers and Noncompleters on Psychological Measures at Baseline

		Completers (n = 21)	Noncompleters (n = 9)	Difference Between Groups at Baseline
		M (SD)	M (SD)	Difference Between Groups at Baseline
ESS	Characterological	32.29 (10.71)	26.22 (11.69)	t(28) = 1.38, P = .177
	Behavioral	28.24 (5.96)	24.44 (9.62)	t(10.73) = 1.10, P = .297
	Bodily	12.57 (3.67)	11.33 (4.33)	t(28) = .80, P = .429
	Total	73.10 (17.97)	62.00 (24.65)	t(28) = .1.39, P = .177
Compassion for Self	Engagement	33.52 (8.58)	32.78 (7.28)	t(28) = .23, P = .822
	Action	20.19 (7.64)	20.22 (5.76)	t(28) = −.01, P = .991
	Total	53.71 (14.35)	53.00 (11.48)	t(28) = .13, P = .896
Self-efficacy		37.14 (25.27)	42.11 (21.09)	t(28) = −.52, P = .610
PCL-5		37.48 (14.69)	28.67 (22.88)	t(10.94) = 1.07, P = .310
GAD-2		3.62 (1.99)	3.00 (1.66)	t(28) = .82, P = .420
PHQ-2		2.24 (1.79)	1.89 (1.69)	t(28) = .50, P = .622

References

Cadman

Waller

Ashdown-Barr

, et al. Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study. J Fam Plann Reprod Health Care. 2012;38(4):214-220. https://doi.org/10.1136/jfprhc-2012-100378

Danan

Brunner

Bergman

, et al. The relationship between sexual assault history and cervical cancer screening completion among women veterans in the veterans health administration. J Womens Health. 2022;31(7):1040-1047. http://doi.org/10.1089/jwh.2021.0237

Zelin

Cadman

Amara

, et al. The ‘my body back’ clinic: a specialist cervical screening and sexually transmitted infection testing clinic for women who have been sexually abused. J Fam Plann Reprod Health Care. 2017;43(4):327-330. doi:https://doi.org/10.1136/jfprhc-2017-101741

Vidal

Petrak

. Shame and adult sexual assault: a study with a group of female survivors recruited from an east London population. Sex Relation Ther. 2007;22(2):159-171. https://doi.org/10.1080/14681990600784143

Dawood

Vosper

Irons

, et al. Exploring the roles of compassion and post-traumatic stress disorder on global distress after sexual trauma. Br J Clin Psychol. 2024;63(3):1-16. https://doi.org/10.1111/bjc.12465

Madden

Vosper

Evangeli

, et al. Understanding the relationship between sexual assault and cervical screening uptake. Eur J Health Psychol. 2022;29(4):196-206. https://doi.org/10.1027/2512-8442/a000109

McCartney

Calls for cervical screening should treat women like adults. BMJ 2023;383:2772. https://doi.org/10.1136/bmj.p2772

Bach

Hansen

Ahrens

, et al. Underserved survivors of sexual assault: a systematic scoping review. Eur J Psychotraumatol. 2021;12(1). doi:https://doi.org/10.1080/20008198.2021.1895516

Eleuteri

Rossi

Tripodi

, et al.

Sexual health in your hands: how the smartphone apps can improve your sexual wellbeing?

Sexologies. 2018;27(3):e57-e60. https://doi.org/10.1016/j.sexol.2018.04.004

10.

Kao

Liebovitz

. Consumer mobile health apps: current state, barriers, and future directions. PM&R. 2017;9(5):S106-S115. https://doi.org/10.1016/j.pmrj.2017.02.018

11.

Huckvale

Nicholas

Torous

, et al. Smartphone apps for the treatment of mental health conditions: status and considerations. Curr Opin Psychol. 2020;36(4):65-70. https://doi.org/10.1016/j.copsyc.2020.04.008

12.

Schueller

Hunter

Figueroa

, et al. Use of digital mental health for marginalized and underserved populations. Curr Treat Options Psychiatry. 2019;6(3):243-255. https://doi.org/10.1007/s40501-019-00181-z

13.

Bandura

Guide to the construction of self-efficacy scales. In: Pajares

Urdan

, eds. Self-efficacy Beliefs of Adolescents. Information Age; 2006. pp. 307-337.

14.

Gilbert

. Introducing compassion-focused therapy. Adv Psychiatr Treat. 2009;15(3):199-208. doi:https://doi.org/10.1192/apt.bp.107.005264

15.

Craig

Hiskey

Spector

Compassion focused therapy: a systematic review of its effectiveness and acceptability in clinical populations. Expert Rev Neurother. 2020;20(4):1-16. https://doi.org/10.1080/14737175.2020.1746184

16.

McLean

Steindl

Bambling

Compassion-focused therapy as an intervention for adult survivors of sexual abuse. J Child Sex Abus. 2017;27(2):161-175. https://doi.org/10.1080/10538712.2017.1390718

17.

Holden

Rollins

Gonzalez

Does how you treat yourself affect your health? The relationship between health-promoting behaviors and self-compassion among a community sample. J Health Psychol. 2020;26(12):135910532091244. https://doi.org/10.1177/1359105320912448

18.

Beaumont

Dagnall

Masse

Irons

Evaluating the impact the self-compassion app has on levels of compassion, psychological distress and well-being. Couns Psychother Res. 2024;25(2):1-11. https://doi.org/10.1002/capr.12841

19.

de Krijger

Bohlmeijer

Geuze

, et al. Compassion apps for better mental health: qualitative review. BJPsych Open. 2023;9(5):e141. doi:https://doi.org/10.1192/bjo.2023.537

20.

Linardon

Can acceptance, mindfulness, and self-compassion be learnt by smartphone apps? A systematic and meta-analytic review of randomized controlled trials. Behav Ther. 2019;51(4):646-658. https://doi.org/10.1016/j.beth.2019.10.002

21.

Schaab

Cunha

Silveira

, et al. A pilot study of a new app based on self-compassion for the prevention and promotion of mental health among Brazilian college students. Front Psychol. 2024;15:1414948.

22.

Andrews

Qian

Valentine

JD.

Predicting depressive symptoms with a new measure of shame: the Experience of Shame Scale. Br J Clin Psychol. 2002;41(1):29-42. https://doi.org/10.1348/014466502163778

23.

Gilbert

Catarino

Duarte

, et al. The development of compassionate engagement and action scales for self and others. J Compassionate Health Care. 2017;4(1). https://doi.org/10.1186/s40639-017-0033-3

24.

Weathers

Litz

Keane

, et al. The PTSD Checklist for DSM-5 (PCL-5) Published 2013. Accessed April 28, 2024. www.ptsd.va.gov

25.

Blevins

Weathers

Davis

, et al. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-498. doi:https://doi.org/10.1002/jts.22059

26.

Kroenke

Spitzer

Williams

JBW.

The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):284-292. https://doi.org/10.1097/01.MLR.0000093487.78664.3C

27.

Kroenke

Spitzer

Williams

JBW

, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317. https://doi.org/10.7326/0003-4819-146-5-200703060-00004

28.

Miner

Kuhn

Hoffman

, et al. Feasibility, acceptability, and potential efficacy of the PTSD coach app: a pilot randomized controlled trial with community trauma survivors. Psychol Trauma: Theory, Res, Pract Policy. 2016;8(3):384-392. doi:https://doi.org/10.1037/tra0000092

29.

Obermeier

. Intention-To-Treat (ITT) vs. Per Protocol (PP) analysis in clinical trials. CliNFo.EU - ideas, tools, knowledge & best practices in clinical research. Published. 2018. Accessed April 28, 2024. https://www.clinfo.eu/itt-vs-pp/

30.

Schwarzer

Modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors. Appl Psychol. 2008;57(1):1-29. https://doi.org/10.1111/j.1464-0597.2007.00325.x

31.

Bengtson

Lynch

. Trauma, PTSD, and self-efficacy: predictors of cervical cancer screening in sexual violence survivors. J Interpers Violence. 2024;40(7-8):1865-1887. https://doi.org/10.1177/08862605241265431

32.

Lee

Scragg

Turner

. The role of shame and guilt in traumatic events: a clinical model of shame-based and guilt-based PTSD. Br J Med Psychol. 2001;74(Pt 4):451-466. https://doi.org/10.1348/000711201161109

33.

Harman

Lee

The role of shame and self-critical thinking in the development and maintenance of current threat in post-traumatic stress disorder. Clin Psychol Psychother. 2010;17(1):13-24. https://doi.org/10.1002/cpp.636

34.

Soysa

Wilcomb

. Mindfulness, self-compassion, self-efficacy, and gender as predictors of depression, anxiety, stress, and well-being. Mindfulness (N Y). 2015;6(2):217-226. https://doi.org/10.1007/s12671-013-0247-1

35.

Bowen

Kreuter

Spring

, et al. How we design feasibility studies. Am J Prev Med. 2009;36(5):452-457. https://doi.org/10.1016/j.amepre.2009.02.002

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