Kent County Health Department
Stop It Before it Starts: Using the Spectrum of Prevention Model for Sexual Violence Prevention
The Kent County Health Department (KCHD, accesskent.com/Health/health_department) serves more than 629,000 residents including 193,000 residents of the principal urban center the city of Grand Rapids. Kent County's population is approximately 83% white, 10% African American, and 10% Hispanic/Latino. More than 25% of Kent County residents are under the age of 18 years and about 12% are 65 years or older. Nearly 90% of residents 25 years or older have at least a high school diploma, and more than 30% of the population 25 years and older have a bachelor's degree or higher. The median household income in Kent County is $52,716 (US Census, 2010-14).
Describe public health issue: Sexual violence (SV) impacts all segments of society. The U.S. National Intimate Partner and Sexual Violence Survey, conducted in 2010, reported that nearly 1 in 5 women and 1 in 71 men were raped in their lifetime; 80% of female victims experienced their first rape before age 25 and almost half before age 18. Fifty-one percent of female victims reported being raped by an intimate partner and 40% by an acquaintance; 52% of male victims reported being raped by an acquaintance and 15% by a stranger. SV often leads to chronic physical and mental health consequences across the lifespan, causing immense societal costs. These costs include the physical and emotional burden of victims, costs to the criminal justice system, health care costs and lost workplace productivity.
KCHD, together with its partners from the Kent County Sexual Assault Prevention Action Team (SAPAT), implements the Spectrum of Prevention (Spectrum) for addressing SV in the community among youth 12 to 24 years of age. KCHD is the only local health department that receives Rape Prevention and Education Program (RPE) funding from the Michigan Department of Health and Human Services to provide sexual violence prevention (SVP) programming. All RPE grantees design their SVP interventions utilizing the Spectrum model.
KCHD commits a full-time equivalent Health Educator to coordinate the department's SVP efforts with SAPAT. The overall goal of SAPAT is to employ the Spectrum model to reduce dating and SV perpetration and victimization among children, teens and young adults. The Spectrum was developed by Larry Cohen, and has been promoted by the Prevention Institute as a comprehensive prevention strategy involving diverse sectors of the community. The Spectrum recognizes that SV originates out of a complex interplay of individual, relationship and community and societal factors. Prevention of SV therefore requires a comprehensive prevention strategy and participation from multiple sectors and stakeholders. Spectrum strategies are based on six levels of intervention:
Level 1. Strengthen individual knowledge and skills about SV prevention (SVP) and healthy relationships
Level 2. Promote community education
Level 3. Educate professional providers
Level 4. Foster coalitions and networks
Level 5. Change organizational practice
Level 6. Enhance policy-makers' knowledge and awareness of SV as a public health issue
KCHD/SAPAT Spectrum strategy outcomes for 2015-16 included: Teaching 68 Safe Dates/Love Notes educational sessions involving 373 youth and young adults (Level 1); distribution of over 400 educational and social media messages reaching more than 50,000 county residents for Teen Dating Violence and Sexual Assault Awareness Months (Level 2); presentation of Coaching Boys Into Men, Not Even One Child Sexual Abuse Prevention, and Adverse Childhood Experience trainings to more than 300 professionals (Level 3); collaboration and 6-month follow-up with 4 after-school programs in policy development for impacting SV risk and protective factors (Level 5); the SAPAT's Young Leaders Against Violence (YLAV) advisory council presented to the Kent County Community Health Advisory Committee (formerly the Board of Health) and Kent County Board of Commissioners on teen dating and SV risks. YLAV members also completed a training session on how the legislative process works and how to effectively communicate with legislators (Level 6).
Statement of problem: Sexual violence is a pervasive public health problem. Victimization often begins at an early age and leads to negative health consequences with significant societal costs. SV is the most under-reported crime, and even when reported to law enforcement, prosecution is infrequent and conviction is rare. Hence, SV is not an issue that the criminal justice system can or should address alone.
According to currently available local data, the priority populations for our SVP programs bear a significant SV burden. Sexual assault in Michigan is classified by several levels of criminal sexual conduct (CSC). The 2015 Michigan Incident Crime Report indicated 924 CSC offenses and 157 arrests by Kent County law enforcement agencies. (A CSC offense is an act which has been reported to a law enforcement agency; an arrest may follow.) Of the CSC arrests, 45% were committed by youth ages 10-24. The 2015-16 Michigan Profile for Healthy Youth, a behavioral health survey administered to middle and high school students, reports that among high school age youth in Kent County, 14.6% of females and 4.9% of males reported having been forced to do sexual things by a dating partner. And 8% reported being physically hurt by a dating partner including 6.4% of African American, 10.7% of Hispanic/Latino and 7% of White students. In the same survey, 15.5% of high school students who reported having sexual intercourse reported that their first partner was 3 or more years older than them.
Target Population affected
The KCHD SVP program provides education to 4 priority populations, including the number of each population reached in 2015-16: 1) At-risk and under-served middle and high school students, with an emphasis on at-risk Hispanic/Latino students and detained youth (unduplicated reach: 373); 2) Young adults (age 18-26) with cognitive and developmental disabilities transitioning to work and independent living, in both urban and suburban environments. (unduplicated reach: 150); 3) Social service, education and public health service providers (unduplicated reach: 347), and; 4) Policy makers in Kent County (unduplicated reach: 19 county commissioners, 10 Community Health Advisory Committee members).
Increasingly, public health interventions are addressing the population and policy level factors that contribute to or discourage healthy behaviors. In the past, KCHD SVP efforts focused primarily on Level 1 activities through classroom education. The Spectrum of Prevention encourages addressing SV by also focusing efforts on changing social norms and behaviors of communities, professional providers, and institutions, and educating leaders who are responsible for setting policy that will impact risk and protective factors of vulnerable populations. Prior to the formation of SAPAT, 5 local agencies involved in SAPAT today taught healthy relationship education in the schools and in programs that serve at-risk youth. Previously, there was little or no communication between these agencies on which schools and programs were receiving SVP education and the impact of the efforts upon participants. This led to an overlap of services and no agreement on common curricula or their effectiveness. Organizing KCHD SVP efforts under SAPAT has enhanced creativity for project development, ensured collective energy and impact, and increased available program data for evaluation purposes. Examples of successful SAPAT partnerships include the production of a professional quality video addressing SV myths and facts that SAPAT agencies post on their social media sites, partnering to write and disseminate an annual Sexual Assault Awareness Month newsletter (https://www.accesskent.com/Health/HealthPromo/pdfs/2016_SAAM_newsletter.pdf) to community leaders and stakeholders, and recruiting student volunteers from local high schools and colleges (YLAV) to organize Teen Dating Violence Awareness Month events targeting students with healthy relationship and bystander intervention messages.
Evidence of effectiveness
KCHD SVP strategies align with the Centers for Disease Control and Prevention's (CDC) National Center for Injury Prevention and Control STOP Sexual Violence: A Technical Package to Prevent Sexual Violence. The Technical Package, released in 2016, represents a select group of strategies based on the best available evidence to help communities plan SVP activities. The strategies and approaches in the Technical Package are intended to work in combination and reinforce each other to influence both individual and environmental factors related to SV. While individual level and skill-based programs like Safe Dates, Love Notes and Coaching Boys Into Men are evidenced-based (Safe Dates, Love Notes) or promising practices (Coaching Boys Into Men) for reducing SV, comprehensive approaches that address providers, educators, workplaces, leaders and social norms of the community are equally important and will have the greatest impact on reducing SV, supporting victims and holding offenders accountable.
The SV Technical Package strategy Promote Social Norms that Protect Against Violence is applied in the Coaching Boys Into Men program and in the Real Hero video series produced by SAPAT for social media. The SV Technical Package strategy Teach Skills to Prevent SV is applied in KCHD's Safe Dates and Love Notes programs for adolescents and young adults. The Create Protective Environments strategy is applied in KCHD strategies to establish workplace policies that protect against SV and through education about risk and protective factors for SV that is provided to professional providers and community leaders. The strategy to Support Victims/Survivors to Lessen Harm is applied through the involvement of KCHD's SVP program in the community Adverse Childhood Experiences work group and our efforts to provide education and referral resources to professional providers working with at-risk children and families and provide referrals and resources for trauma informed care.
The overall goal of the Spectrum implementation is to deliver initiatives developed to increase SVP awareness, knowledge, skills, collaboration, and policy change. This includes a positive change in community beliefs regarding the primary prevention of SV, resulting in widespread acceptance of social norms that support the belief that SV is a serious but preventable public health problem. Research supports that communities which view SV as preventable increase their support for programs that promote protective factors and address risk factors for perpetration, victimization, and victim blaming.
The KCHD SVP triennial Work Plan and objectives are developed and carried out through the collaboration of SAPAT partners. SAPAT acts as an advisory council for the development of members' SV primary prevention strategies. Strategies fit within the Spectrum framework, target priority populations, and are based on the needs and gaps as determined by data collected and professional experiences of SAPAT member agencies. Our SVP Work Plan is fluid and democratic in its development. Current and timely local SVP issues influence its development. All SAPAT members participate in the Work Plan's development and key partners also implement the activities. SAPAT members also sign SVP Partner Commitment Forms that specify member responsibilities regarding SVP planning, meeting attendance and sharing of program outcome data.
Specific objectives of the 2014-17 SVP Spectrum Work Plan that support the larger Level 1-6 objectives (Overview section) include:
Level 1: Strengthening Individual Knowledge & Skills: SVP youth education, Safe Dates and Love Notes
Activities: 68 educational sessions provided to 337 at-risk Latino youth in the Yo Puedo program and young adults with cognitive/emotional disabilities in the Kent Vocational Options program.
Key Measures: Attitudes, skills, and intentions for risk and protective factors for SVP measured through Safe Dates and Love Notes pre- and post-tests.
Level 2: Promoting Community Education: Educational Material Distribution and Social Media Analytics
Activities: 441 educational and social media messages created/distributed; SVP media messages were heard/viewed 57,199 times.
Key Measures: Quarterly data collection of Reach, Amplification Rate, Likes, Views, Shares specific to SVP grantee social media efforts at YLAV.org blog, Facebook, YouTube.
Level 3: Educating Professionals and Providers: SVP Professional Provider Trainings
Activities: 13 SVP trainings provided to 347 professional providers including SVP trainings, Coaching Boys Into Men, gender identity, Adverse Childhood Experiences (ACE).
Key Measures: Knowledge, skills for understanding signs of SV and ACEs including risk and protective factors, and increased confidence in teaching SVP for professionals and other health workers measured through training post-surveys.
Level 4: Fostering Coalitions and Networks: SVP Team Community Coalition Assessment Tool (CCAT) Survey
Activities: Facilitated 6 SAPAT meetings.
Key Measures: CCAT Survey administered to 23 SAPAT members.
Level 5: Changing Organizational Practice: SV policy education; Follow-up interviews for professional education
Activities: SVP practices and policy education was conducted with 13 organizations, including 347 staff from schools, after-school programs, licensed childcare facilities and the KCHD WIC, Clinics and Nurse Family Partnership programs.
Key Measures: Knowledge, attitude, and behavior changes regarding organizational practices and policies supportive of SVP. Administer follow-up survey 6 months after education with organization administrators and staff to monitor whether SVP practices and policies are adopted.
Level 6: Informing Policy & Education: SVP education for policy makers
Activities: SVP policy education activities were conducted for 2 groups of policy makers: 10 Community Health Advisory Committee members and 19 Kent County Commissioners.
Key Measures: Knowledge, attitude, and behavior changes regarding policies supportive of SVP.
Carrying out the SVP Work Plan, and other SVP efforts throughout Kent County, owes much to the collaboration among various agencies on the Sexual Assault Prevention Action Team. SAPAT is a multidisciplinary team of representatives from local agencies that work in the fields of higher education, youth services, domestic and sexual violence prevention, intervention and advocacy, criminal justice and law enforcement. SAPAT also acts as an advisory council for the development of KCHD and the YWCA of West Central Michigan's (YWCA) sexual violence primary prevention strategiesâ€”both agencies are recipients of Rape Prevention and Education Program funding from the Michigan Department of Health and Human Services. SAPAT members, and their respective agencies, have operated a professional speaker's bureau, hosted conferences and educational events, expanded evidenced-based sexual violence prevention education in Kent County schools, organized many community awareness events, and have been integral to the compilation of local SV data through community resources and needs assessments, focus groups, and stakeholder interviews. In 2015, the Grand Valley State University School of Criminal Justice partnered with SAPAT in releasing the Kent County Sexual Violence Program Resource and Needs Assessment. The information collected from the SVP needs assessment led to formation of the Kent County Human Trafficking Task Force and a local human trafficking hotline.
SAPAT publishes an annual newsletter for Sexual Assault Awareness Month addressing local and timely SV issues. The newsletter, written by SAPAT members and other subject area experts for distribution to local leaders and stakeholders, provides a platform for important insights and views into SVP issues like rape culture and victim-blaming, teens and sexting, consent laws, and child sexual abuse prevention. In addition, SAPAT has produced 4 short videos debunking SV myths and increasing bystander intervention skills. The videos, titled Real Hero (https://www.youtube.com/watch?v=1Qm_rvLG0Fk) , are meant to show that anyone can be a hero when they intervene in situations they know are not appropriate. Real Hero is meant to be shown at high schools and colleges, as well as posted to social media and SAPAT partner agency websites. KCHD and SAPAT have also worked with a local graphic designer to create 2 comic books for teens on the dangers of sexting. The latest version, Ink and Syrup (https://www.ylav.org/wp-content/uploads/2015/pdf/Ink_Syrup_Comic.pdf), an update of the first comic bookâ€”Message Sent, was created with input from YLAV participants. It focuses on empowering bystanders to intervene and show positive characteristics of healthy dating relationships, especially by counteracting popular culture by portraying males in a positive light.
Two recent, significant accomplishments of SAPAT are the formation of the Teen Dating Violence Planning Committee (TDVPC) and creation of Young Leaders Against Violence. TDVPC was formed to improve the reach and coordination of the 5 SAPAT organizations that provide SVP and healthy relationship education to students in Kent County middle/high schools and after-school/risk reduction programs. TDVPC members share curriculum objectives, educational materials and activities to ensure consistent messaging to students. In 2017, the TDVPC will begin collecting uniform post-test evaluation data for two objectives from all agencies providing Level 1 SVP education. This data will be useful to educators and parents for understanding how Kent County youth compare with other areas in protective factors for SVP and attaining healthy relationships.
YLAV is a coalition of high school and college students that are interested in increasing SVP awareness, knowledge and bystander skills for intervention. Youth and young adults are recruited from schools and colleges by members of SAPAT and TDVPC. Youth who are passionate about gender equity and SVP serve a 7 month school-year term. YLAV members commit to work as SVP agents of change in their school and community and to maintain a youth voice on the YLAV.org website, blog and social media platform (YLAV is on Facebook and YouTube). KCHD and the YWCA provide mentorship, training, technical assistance and funding to support YLAV initiatives. In 2016, YLAV hosted a community screening of the documentary The Hunting Ground, promoted adoption of SVP policy among county leadership, organized school events for Diversity Week, sponsored a nationally recognized speaker for anti-bullying week, hosted several Love is Sweetâ€ and Steps to a Healthy Relationshipâ€ events in their schools, and produced Chalk the Talk (https://www.youtube.com/watch?v=NB-zOdesqvw) for Sexual Assault Awareness Month..
The KCHD SVP coordinator also looks for opportunities to partner with other Kent County departments to maximize the interdepartmental reach of SVP practices. These efforts include providing Safe Dates programming to youth housed in the county's Juvenile Detention Facility and educating WIC, Clinics and Nurse Family Partnership staff on family and gender-based violence and tolerance and acceptance of violence.
KCHD and the other recipients of Michigan Department of Health and Human Services SVP-related funding work with the Michigan Public Health Institute to evaluate outcomes for Safe Dates and Love Notes (Spectrum Level 1: Strengthen individual knowledge and skills about SV prevention (SVP) and healthy relationships). Outcome and participant satisfaction data is used to guide program planning, refinement and promotion. An example of successful program refinement based on participant feedback is the addition of an extra session to Safe Dates to address the inappropriate use of electronics by youth engaging in sexual harassment and sexting.
Class participants' matched pre- and post-tests indicate student knowledge acquisition and changes in attitudes as a result of Safe Dates and Love Notes instruction. As mentioned above, research indicates that this knowledge builds long-term protective factors against victimization or perpetration of SV. Students are surveyed in 10 topic areas. Topic areas include bystanding in the presence of violence, dating violence, gender equality, gender victimization, media influence, sexual consent, bullying and victim blaming. Student participants ranged in age from 12-18 years old. During the October-December 2015 sessions, 80% of the students were African American or Latino and 7% identified as White. Pre- to post-test evaluations for these sessions demonstrated positive changes in SVP attitudes, skills and intentions in 7 of 10 outcome measures. Three of 10 outcome measures remained unchanged from pre- to post-intervention. Selected survey questions and responses follow:
Dating violence is personal and family, friends, and others should not get involved.â€
Agree or Strongly Agree: Pre 65% Post 89%
The media shows healthy ways for men and women to act in relationships.â€
Agree or Strongly Agree: Pre 42% Post 42%
If my partner is drunk or high, my partner cannot legally consent to sexual activity.â€
Agree or Strongly Agree: Pre 40% Post 65%
Constantly texting a partner about what she or he is doing is controlling behavior,â€
Agree or Strongly Agree: Pre 35% Post 48%
I am not afraid to speak up or get help when someone is being intimidated by another person.â€
Agree or Strongly Agree: Pre 78% Post 87%
Selected evaluation results for other Spectrum Levels include:
Level 4 Foster coalitions and networks
The Community Coalition Assessment Tool administered to SAPAT 2015-16 coalition participants demonstrated 81.5% in overall value of member/team efforts in the following categories: team performance, synergy, leadership, coordination and administration, decision-making and capacity. Responses to categories of coalition value follow:
Area of Development Average Subtotal Possible Score % of Maximum
Performance 23.6 28 84.3 %
Synergy 22.4 28 79.9 %
Leadership 19.8 24 82.4 %
Coordination and Administration 16.3 20 81.5 %
Decision-Making 16.2 20 80.8 %
Capacity 12.5 16 77.9 %
Total 110.8 136 1.5 %
Level 5 Change organizational practice
Follow-up interviews with after-school staff in attendance at SVP organizational policy training reported increased administrative and staff support for more education on healthy relationships for students. Staff also reported very positive feedback from their students that received healthy relationship education. After the SVP training, 1 participating school increased the number of days their social worker was on site from 1 day a week to 3 days a week.
KCHD depends on external funding to commit full-time staff to implement the SVP Spectrum of Prevention programming. We have been successful since 1998 in securing funding from the Michigan Department of Health and Human Services. KCHD has also consistently used Kent County general fund revenue to supplement SVP programming. We are well-positioned from past successes to receive future MDHHS funding. In the event that this funding is not available to KCHD in the future, we could seek other non-governmental funding sources, and/or charge a fee for educational programs to cover any future budget shortfalls.
Sustained SVP efforts are also supported through our history of successful SAPAT partnering. For instance, the Safe Dates program is now an embedded program in the Cherry Health Yo Puedo program implemented in select Grand Rapids Public School classrooms. Cherry Health Yo Puedo staff is trained to teach Safe Dates and has co-facilitated the classes with KCHD for the past 15 years. SAPAT partner D.A. Blodgett-St. John (child foster care and child abuse/neglect prevention agency) has co-facilitated professional provider trainings with KCHD to educate childcare providers on workplace policies and mandated reporter requirements to prevent child sexual abuse for the past 4 years and is able to continue this education without KCHD involvement. Kent Vocational Options (KVO) for young adults with cognitive and emotional disabilities has received SVP education for its students through a partnership between KCHD and SAPAT for nearly 15 years. Should KCHD no longer be able to provide SVP education to KVO, the Kent County 17th Circuit Court staff is aligned to fulfill these requests. YLAV activities are also sponsored by SAPAT members. Partners contribute staff time as well as cover all YLAV related expenses such as activity supplies, fees for services and room rental, travel, food and incentives for youth participation. YLAV sponsors have signed partner agreement contracts to support the continuation of YLAV without KCHD supporting funds. The YWCA has agreed to co-facilitate SAPAT and YLAV in 2017 and to host the meetings at their facility.
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