Health and wellbeing of sexual abuse survivors attending sexual assault referral centres in England: the MESARCH mixed-methods evaluation

Abstract

Background: One million people in England and Wales experience sexual violence and abuse each year with around half experiencing serious sexual offences; 55,000 survivors access Sexual Assault Referral Centres (SARCs). Objectives: Our research was commissioned by NIHR to evaluate access, interventions and care pathways for survivors, specifically those provided through SARCs. Design, setting, participants: The SARC care pathway was investigated through six sub-studies. We conducted two Cochrane Reviews (4,274 participants). A process evaluation of SARCs interviewed 72 providers and 5 survivors at 8 sites; our children and young people (CYP) study involved 12 CYP from 2 SARCs. A cohort study with three waves of data collection over one-year (21 SARCs, 2,602 service users screened, 337 recruited) used a multilevel-modelling framework to explore risk factors for burden of post-traumatic stress disorder (PTSD) symptoms at baseline and change at one-year. We analysed costs and outcomes, and conducted an embedded narrative analysis (42 survivors). We prioritised the safety/welfare of participants and researchers and embedded lived expertise across the project lifecycle. Results: The Cochrane Reviews identified large effects from psychosocial interventions for PTSD and depression. SARCs delivered a high-quality frontline service for adult and young survivors, functioning as a gateway to onward services. Groups underrepresented at SARCs include those experiencing domestic abuse and some ethnic and cultural minorities. The research emphasised inter-agency/sector collaboration for survivor benefit. Supported by our qualitative research with minoritised groups, the cohort study showed a risk ‘triad’ with adverse childhood experiences, chronic mental health problems and economic deprivation. The research evidenced important improvements in trauma symptoms. These were unrelated to different SARC models and persisted for half of people a year later. Health-related quality of life was below population norms at baseline and high levels of service use were reported. Over the 12 month period, costs and outcomes were similar across SARC models and no significant differences were identified. Harmful encounters occurred in relation to police and justice practices/procedures for 25% of participants and our qualitative studies emphasised the vital interactions between experiences of justice and wellbeing. Good practice largely concerned enhanced communication (e.g. trauma-competent interviewing techniques; regular/timely updates; conveying case decisions with care). Limitations: The cohort study lacked a comparison group, reducing confidence in the finding that access to SARC and other health/therapeutic care explained the reduction observed in PTSD. Conclusions and future work: The risk ‘triad’ underscores the value of screening at SARCs and timely access to therapies/advocacy as part of multi-sectoral approach to supporting recovery. Poor mental health was the main barrier to service access beyond SARCs, suggesting the value of Independent Sexual Violence Advisors with mental health specialisation. The persistence of trauma symptoms supports calls for tackling wait-lists, expanding therapy options and commitment to lifelong care. Cohesive commissioning strategies can promote a whole pathway approach by supporting greater collaboration across providers. Access gaps at the population-level and for specific groups call for concerted efforts to support people to reach care early, for example, through outreach, campaigns and implementing trauma-informed universal health services. MESARCH provides a foundation for advancing trauma-informed practices when supporting people exposed to the effects of sexual violence and abuse. Study registration: MESARCH is registered with ISRCTN registry ISRCTN30846825 https://doi.org/10.1186/ISRCTN30846825