Integrating Alcohol and Cannabis Risk Reduction Into Sexual Assault Resistance Programming: Findings From a Pilot of EAAA+

Abstract

Objective:

One in five college women experiences sexual assault. Feminist scholars have called for the use of programming that empowers women by increasing their ability to recognize and resist sexual assault. One such program, the Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Education Program (EAAA), has demonstrated lower rates of sexual assault up to 24 months. EAAA could be further enhanced by directly targeting women's risky alcohol and cannabis use, two known risk factors for sexual assault, within an integrated framework. This study evaluated the acceptability and preliminary efficacy of an integrated version of EAAA with enhanced alcohol and new cannabis content.

Method:

College women (n = 14) ages 18–24 who reported engaging in past-month heavy alcohol use, cannabis use, and simultaneous alcohol and cannabis use participated in the adapted program. Women completed a baseline assessment, measures of acceptability at strategic points during the program, and a post-program assessment.

Results:

Women rated the program very high in likability, quality, organization, relevance, and usefulness and were likely to recommend it to other women. Overall, acceptability and usability ratings for EAAA+ were high. Content analysis of open-ended questions indicated that some women wanted more cannabis and/or alcohol content included.

Conclusions:

Results indicate that the adapted content is acceptable for the target population and has promising pre–post changes on alcohol, cannabis, and sexual assault–related outcomes.

One in five college women experience sexual assault (Muehlenhard et al., 2017). Although primary prevention programs are a crucial part of a comprehensive approach to stop sexual assault (Orchowski et al., 2020), women's sexual assault resistance programs are also essential given that rates of sexual assault have remained stable across time (Koss et al., 1987; Muehlenhard et al., 2017). Sexual assault resistance programs are designed to increase a woman's ability to recognize and resist sexual assault by providing knowledge, affirmation (trust yourself and your judgment), and skills to assert and defend their boundaries against acquaintance sexual assault (for a review, see Orchowski et al., 2020). Although many of these programs include substantial content on the elevation of sexual assault risk when alcohol is present (no matter who is imbibing it), they rarely provide content to help women reduce risky alcohol use. Further, they do not include content related to cannabis use, nor have they been adapted for women who regularly engage in heavy alcohol and cannabis use. Targeting alcohol and cannabis within sexual assault programs is important given that these substances are known risk factors for sexual assault victimization (e.g., Koss et al., 2022; Resnick et al., 2013), and using alcohol and cannabis at the same time so that their effects overlap (hereafter referred to as simultaneous use) increases sexual assault risk over and above the use of either substance alone (Egan et al., 2019; Read et al., 2021). The aim of this study was to test the acceptability and preliminary outcomes of an adaptation of the Enhanced Assess, Acknowledge, and Act Sexual Assault Resistance Education Program (EAAA;¹ Senn et al., 2015), a program that has decreased sexual assault victimization for at least 24 months after completion of the program (Senn et al., 2017, 2022), for college women who engage in heavy episodic drinking (HED; 4 or more drinks in 2 hours), cannabis use, and simultaneous use.

To our knowledge, there are currently no brief evidence-based programs for college students that address both alcohol and cannabis use in tandem, although a few exist for adolescent populations (Amaro et al., 2010; Blevins et al., 2018). Brief interventions that include personalized normative feedback (PNF), either alone or with other components (e.g., BASICS; Dimeff et al., 1999), hold the majority of empirical support for reducing HED (Dotson et al., 2015; Miller et al., 2013; Prestwich et al., 2016; Reid & Carey, 2015; Walters & Neighbors, 2005). PNF interventions correct misperceptions of peers' heavy alcohol use and are often paired with skills training, including the use of protective behavioral strategies (PBS) such as alternating non-alcoholic beverages with alcohol (Riggs et al., 2018; Walters & Neighbors, 2005). Compared with alcohol, research on cannabis brief PNF interventions is limited (Gex et al., 2024; Halladay et al., 2019), with only one PNF intervention that incorporates cannabis PBS (e.g., avoiding mixing with alcohol), leading to minimal reductions in use among heavy cannabis users (Riggs et al., 2018). Training in PBS for cannabis may be an especially important program component because these strategies are associated with reduced frequency of consumption and fewer cannabis-related consequences (Pedersen et al., 2016; Prince et al., 2020).

Present study

The reviewed research suggests that EAAA (Senn et al., 2015, 2017) would benefit from the inclusion of alcohol and cannabis content for women who use these substances. Content is needed that aligns with the ethos of EAAA by encouraging women to consider their substance use, use-related experiences, changes they might want to make, and strategies for safer use in situations where a coercive man may be present while reinforcing that he is entirely responsible for his actions, as well as increasing confidence and skills to successfully engage in sexual assault resistance when intoxicated.

Using mixed methods to assess implementation outcomes (Aschbrenner et al., 2022; Proctor et al., 2011), the aim of this open pilot study is to assess the acceptability of an adapted version of EAAA—hereafter termed EAAA+—that integrates evidence- and theory-based content on alcohol, cannabis, and the original program. It was hypothesized that program content would have high levels of acceptability via positive qualitative feedback and at least an 8 out of 10 (with 10 indicating highly acceptable) on quantitative measures.

Method

Participants

Participants were 14 college women from a large university in the Southeastern United States recruited through flyers and emails. Eligible participants were between ages 18 and 24; reported engaging in HED, cannabis use, and simultaneous use at least once in the past month with intentions to use in the future; and had to be available to attend the in-person program on one of the available dates. See Table 1 for participant characteristics.

Table 1.

Participant demographics and baseline characteristics

Variable	n (%)	M (SD)
Age		20.43 (1.28)
Sexual identity
Lesbian	1 (7.1%)
Bisexual	3 (21.4%)
Straight/heterosexual	9 (64.3%)
Pansexual	1 (7.1%)
Racial identity
American Indian or Alaska Native	1 (7.1%)
Asian	2 (14.3%)
Black or African American	6 (42.9%)
White	5 (35.7%)
More than one race	0 (0%)
Ethnicity
Non-Hispanic/non-Latinx	12 (85.7%)
Hispanic/Latinx	2 (14.3%)
College class standing
Freshman	3 (21.4%)
Sophomore	3 (21.4%)
Junior	2 (14.3%)
Senior	6 (42.9%)
Relationship status
Single, not dating	5 (35.7%)
Single, dating	2 (14.3%)
In a relationship (less than 6 months)	2 (14.3%)
In a relationship (more than 6 months)	5 (35.7%)
First-generation college student
No	9 (64.3%)
Yes	5 (35.7%)
Alcohol use
Drinks per week		7.64 (4.78)
Drinking days per week		2.79 (1.37)
Cannabis use
Grams per week		6.65 (8.13)
Hours high per week		17.11 (12.49)
Cannabis use days per week		4.43 (1.74)
Prior sexual assault	13 (93%)

Measures

Demographics. Participants reported their age, sexual identity, racial identity, ethnicity, college class standing, relationship status, and whether they were first-generation students.

Program acceptability. Program acceptability was assessed after each program unit, as well as after the final program.

Quantitative measures. After each of the five EAAA+ units (see EAAA+ Program Content, below), participants responded to the following 10 items assessing the unit's acceptability: likeability, comfort, material quality, material organization, extent of interesting content, relevance, knowledge gained, usefulness, satisfaction, and likelihood to recommend. At the end of the program, overall knowledge gained, likelihood to recommend, facilitator warmth, facilitator knowledge, facilitator credibility, and facilitator trustworthiness were assessed. Participants responded to all items on a 1 (e.g., not at all comfortable) to 10 scale, with high scores reflecting greater acceptability of program content.

Open-ended questions. After each unit, participants responded to open-ended questions provided by the SARE Center (sarecenter.org) for session evaluation. These items asked about the participant's motivation during the session, ability to concentrate, whether there was enough time to cover content, how easy it was to understand the program material, participants' favorite things about the session, any improvements or changes that should be made to the material, and whether they experienced any negative feelings during the session.

EAAA+ program content

EAAA+ is a 12.25-hour program that includes an inperson component completed over 2 full days or 4 nights and a 15-minute web-based unit in groups of up to 15 women.² EAAA uses a train-the-trainer model, and two female peer facilitators (i.e., young adult college women) lead the inperson content. EAAA+ modifies content from EAAA's four established units detailed in Figure 1 (for a detailed overview of EAAA content and the facilitator training process, see Jeffrey et al., 2022; Senn et al., 2013). The content was modified based on theory and a separate study of focus groups with 15 college women who met eligibility criteria for the present study to determine women's current knowledge of alcohol, cannabis, and sexual assault risk and preferences for program content. In addition, a web-based module named SAFER-U (Substance Use Awareness, Facts, and Education for sexual assault Resistance at the University) was added by adapting web-based BASICS (Dimeff et al., 1999) and Positive Change (Gilmore et al., 2015, 2022, 2024). SAFER-U uses a combination of personalized feedback (including PNF), motivational interviewing principles, and training in PBS.

Figure 1.

Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Education Program (EAAA+) structure and learning objectives. Note: Purple boxes indicate original EAAA material and learning objectives. Teal boxes indicate new alcohol and cannabis content integrated into the original program. SA = sexual assault; HED = heavy episodic drinking; BAC = blood alcohol concentration.

Procedures. Participants provided informed consent, completed a baseline questionnaire on a tablet, and began EAAA+. Acceptability was measured after each unit and at the end of EAAA+, along with a post-program questionnaire that assessed pre-to post-program changes (see Supplemental material). (Supplemental material appears as an online-only addendum to this article on the journal's website.) Participants were compensated up to $60 for completing surveys. The study was approved by the university's institutional review board.

Data analytic plan

Sample characteristics and descriptive statistics of quantitative acceptability data were examined using IBM SPSS Statistics for Windows, Version 28 (IBM Corp., Armonk, NY). NVivo version 14 (Lumivero, Denver, CO) was used to analyze qualitative data and identify themes in the acceptability, relevance, knowledge, content learned from units, and feedback for improvement.

Open-ended responses were content analyzed by two undergraduate research assistants. They independently read the open-ended responses from each EAAA+ program unit's acceptability surveys and created a list of topics that emerged deductively and inductively from participant responses. Research assistants and the first and seventh author met to compare and review topics for consensus, created a codebook, and used the codebook to code the open-ended responses from all five units. After coding, interrater reliability analyses were conducted until a suitable level was achieved (k > .80). Coders developed analytic memos for each topic with major findings and quotations. The first author used those memos and coded quotations to identify the most salient results reported herein.

Results

Program completion

Of the 14 participants who participated in EAAA+, 100% completed the Assess and Acknowledge unit (n = 14), 80% (n = 12) completed the SAFER-U unit, and 71% (n = 10) completed the Act and Relationship & Sexuality units.

Quantitative findings

Quantitative acceptability ratings for each model and the overall program are presented in Table 2. Overall, consistent with hypotheses, unit acceptability ratings were high for each unit and the overall program.

Table 2.

EAAA+ quantitative acceptability findings

Variable	Unit 1: Assess (n = 14) M (SD)	Unit 2: Acknowledge (n = 14) M (SD)	Web-based Unit: SAFER-U (n = 12) M (SD)	Unit 3: Act (n = 10) M (SD)	Unit 4: Relationships & Sexuality (n = 10) M (SD)	Overall Program Acceptability (n = 10) M (SD)
Acceptability of units
Likability	8.93 (1)	9.21 (1.31)	9.08 (1.31)	9.90 (0.32)	9.50 (0.97)
Comfort	8.93 (0.92)	8.14 (1.83)	9.67 (1.16)	9.50 (0.71)	8.40 (1.58)
Material quality	9.5 (0.76)	9.71 (0.47)	9.33 (0.99)	9.90 (0.32)	9.90 (0.32)
Material organization	9.79 (0.58)	9.43 (1.09)	9.08 (1.78)	9.80 (0.42)	9.70 (0.95)
Interesting	9.14 (1.17)	9.07 (1.69)	9.33 (1.16)	9.90 (0.32)	9.80 (0.42)
Relevance	9.57 (0.94)	9.36 (0.75)	9.83 (0.39)	9.90 (0.32)	9.40 (1.58)
Knowledge gained	7.93 (2.34)	8.29 (2.23)	9.33 (1.23)	9.80 (0.42)	8.70 (2.50)
Satisfaction	9.71 (0.47)	9.79 (0.43)	9.5 (1.00)	9.90 (0.32)	9.50 (0.85)
Usability of units
Usefulness	9.64 (0.75)	9.57 (0.85)	9.67 (0.89)	9.90 (0.32)	9.40 (1.27)
Likelihood to recommend	9.14 (1.56)	9.79 (0.58)	9.58 (1.00)	9.90 (0.32)	9.80 (0.63)
Acceptability of overall program
Enjoyment of program						9.70 (0.48)
Knowledge gained						9.30 (1.64)
Usability of overall program
Likelihood to recommend						9.70 (0.68)
Ratings of peer facilitator characteristics
Facilitator warmth						9.90 (0.32)
Facilitator knowledge						9.80 (0.42)
Facilitator credibility						9.90 (0.32)
Facilitator trustworthiness						9.90 (0.32)

Notes: Scores of 8 or higher indicate high levels of acceptability consistent with hypotheses. EAAA+ = Enhanced Assess, Acknowledge, Act Sexual Assault Resistance Education Program.

Qualitative findings (Table 3)

Table 3.

Qualitative themes and example quotes for program acceptability

Topic	Example quotes
	Assess	Acknowledge	SAFER-U	Act	Relationships & Sexuality
Motivation during session	“I felt very motivated because as a woman you're constantly aware of sexual assault, so having identifiable risks helps reduce that chance” “I was very motivated because I fear sexual assault”	“I was very motivated, especially hearing possible ways to be persistent when saying ‘no’ to things I don't want to do” “Very, I felt like I could apply the info to my life”	“It was very interesting!! Especially the part about how much I spend on cannabis yearly” “Very because the data was personalized to me” “I was motivated because the material had graphs and different visuals that were easy to read”	“Very motivated because I have always been interested in learning defense more” “I was very motivated because I wanted to learn how to defend myself without a weapon”	“Very motivated but a bit hesitant because the sexuality part was a bit uncomfortable but relevant” “Very, I felt like it was very important to life and how to build healthy/functional relationships”
Ability to concentrate	“Nope. Everything was engaging and encouraged us to share our own experiences” “No, because I felt like I was always thinking about the material and ways I could apply it to my life”	“No, I was engaged in the material and the format it was presented. I like the semi “lecture” and their activity structure” “No. I felt group interaction was great and kept me engaged on topic”	“No because I was engaged with the material” “No, it was not difficult to concentrate because the information was interesting such as the statistics on [university] women”	“No it was engaging” “No, we were constantly moving and doing things so it was easy to concentrate” “No, being able to act out certain scenarios made me feel more inclined to learn”	“Not really, it was awkward at moments but mostly fun” “Not at all, engaging and easy to follow”
Time to cover content	“Yes, we were on track for getting all the information in on time as well as retaining what was being taught” “I think so! Each topic discussed allowed for retention of the information”	“Yes, there was plenty of time” “Yes, the material was easy to understand and the time duration was great”	Not assessed	“Yes, perfect timing throughout the duration of these sessions”	“Yes there was enough time during the sessions”
Ease of comprehending material	“Yes, because we were given explanations and time to discuss all of the topics in groups” “Yes, it was easy to follow and understand because we had activities and games along with the material”	“Yes and I liked the activities because it gave me things to think about if I was ever in that situation” “Yes, it followed a fluid structure of learning the signs, learning ways to avoid, and then practicing”	“Yes, the material was easy to understand because there was also graphics in the web unit” “Yes. It was personalized for me so it helped me put it into perspective and understand” “Yes. It was well organized just a lot”	“It went very fast, but I think I understood everything fairly well” “Yes, the [self-defense] moves built off of each other which made them easy to follow”	“Yes, we learned about the sex we want to have and how to apply that into our relationships” “Yes, the material was easy to understand the interactive games helped” “Yes, because the researchers provided real-life examples”
Favorite things about session	“[Discussing] the social/behavior cues of men; made me feel confident to identify them and recognize danger in others” “Discussing the topic with other women. I don't usually talk about sexual assault or fears about that so it was nice” “Learning the common thing[s] that could be big warning signs”	“When we acted out the scenarios & practices responses” “Roleplay was both funny and informative” “The part where we got to act as a women in a situation to defend ourselves until success”	“Seeing how much my spending was for marijuana” “That I could compare my typical alcohol and cannabis use to other [university] women” “I liked seeing the statistics on the levels on substance use on campus and how my beliefs were different than reality”	“Practicing the defensive moves to work our muscle memories” “Learning about weak spots I could hit on the perpetrator's body” “I thought the bump [self-defense] move was fun [and] cool to learn”	“Getting comfortable with sexual terms and setting boundaries” “Learning how to communicate what you/I want in a relationship” “The interactive activities & talking through the material with my peers”
Improvements or changes to program content	“Define the difference between coercion/sexual assault/rape [better] because the definitions kept getting mixed up” “Possibly expanding on how to judge cues that an impaired male (cannabis or alcohol) would show” “I would incorporate one more game”	“Talk more about cannabis” “Nothing really, younger presenters interact and tell us personal anecdotes/stories help me to be more willing to share my opinion” “N/A, everything was organized & informational”	“Nothing, it did a good job touching on the specifics”	“No it was very easy to understand” “Can't think of anything other than more moves women could use to defend themselves” “I would bring in a real self-defense instructor/somebody we could actually practice on”	“N/A, presentation was amazing” “Talk about sex ‘slang’ more and how it can affect everything”
Negative feelings experienced during session	“I got uncomfortable with some of the topics of rape, but I think it's just because it's a sensitive topic” “No, I did not have any negative feelings. The session gave a discretion in the beginning that we were open to leave whenever”	“a little when I was told to imagine the coercive guy to be a male in my life” “I didn't feel any negative emotions towards anything except the triggering material but I think that's necessary” “I did not experience any negative feelings”	“No, I did not experience any negative feelings. The session does not need to be changed” “No, just surprised at how much cannabis I use”	“No negative feelings, all positive” “No negative feelings were experienced”	“No, although this is a heavy topic the presenters made sure to keep the mood light” “I was slightly uncomfortable talking about sex and the activity where we had to role play a couple trying to decide what sex to have” “No negative feelings”

Note: SAFER-U = Substance Use Awareness, Facts, and Education for sexual assault Resistance at the University.

Assess. All respondents reported being motivated during Assess; 79% of participants reported being “very” or “highly” motivated because the content was relevant to their lives. Most participants (86%) reported no difficulty concentrating and thought there was enough time. All participants reported that the material was easy to follow and understand.

In terms of participants'favorite content, many appreciated content about the types of danger cues that men exhibit and how to identify these cues early on in situations. Participants reported that the unit also conveyed knowledge that will contribute to behavior change when they are in a situation with a potential perpetrator. Last, participants reported that this unit shifted their attitudes and perspectives on sexual assault and increased their perceived risk of sexual assault, particularly when drinking alcohol and/or using cannabis.

Four participants (29%) suggested adding another interactive or group activity. In addition, one participant stated that they would like more content on how to identify danger cues in potential perpetrators when the situation involves substance use. The remaining participants reported that no improvements or changes were needed. Finally, one participant reported feeling uncomfortable with the topic of rape because it is a sensitive subject.

Acknowledge. All respondents reported being motivated during Acknowledge; 71% of participants reported being “very” motivated because the content was relatable, informative, or applicable to their lives. Most participants (86%) found it easy to concentrate during the session, and all but one thought there was enough time. All participants found the material easy to comprehend and noted that the real-life examples, activities, and flow assisted comprehension. Participants' favorite part of Acknowledge was acting out the scenarios and interacting with the facilitators. There was little feedback given for improvements; one participant commented that they would want to see more cannabis content. Finally, most participants (86%) reported no negative feelings. Two participants reported some mild negative feelings when watching videos related to coercive men.

SAFER-U. Most participants reported being motivated during SAFER-U (83%) because the unit was personalized to them, and they learned about their alcohol and cannabis use compared with other women's use. All participants reported that it was easy to concentrate and that the material was easy to understand. Participants reported that the graphics, charts, and personalization aided their comprehension of the material. Respondents indicated that their favorite content included statistics about their own cannabis and alcohol use habits, normative feedback, and strategies for decreasing substance use to cope with stress. Only one participant recommended a change and stated it “could be more interactive.” Participants reported no negative feelings.

Act. All participants reported being motivated during Act; 80% stated they were “very motivated” because the unit was fun and hands-on, and they were interested in learning to defend themselves. Participants reported no difficulties concentrating because of the engaging content; the unit was presented in an acceptable time frame, and they would not recommend any changes. Favorite content included the practice of self-defense techniques and learning body contact points. There was no feedback given for improvement, with one exception that bringing in a “real self-defense instructor” with whom to practice would be helpful. Participants reported no negative feelings.

Relationships & Sexuality. All respondents reported being motivated during Relationships & Sexuality. Two participants noted that discussing sex can be “awkward” or “uncomfortable,” and one reported “a little” difficulty concentrating for this reason. Overall, respondents found the unit informative, specifically focusing on their sexuality and desires in sex and relationships. Respondents reported that the time spent on the unit was appropriate, and the content was easy to understand. Most (90%) of the participants indicated that no changes were needed, although one participant shared that they would want to expand more on the sexual “slang” activity. Favorite content included setting sexual boundaries, communicating what they want in relationships, and interactive activities. There was no feedback for improvement. Two participants reported feeling uncomfortable discussing sex, and the remaining participants reported no discomfort.

Discussion

EAAA+ integrates alcohol, cannabis, and sexual assault content into an education program for high-risk college women. Women who completed EAAA+ found the program highly acceptable. Women reported being very motivated to complete the program and being able to concentrate on the program content. This is notable given the length of the program. In addition, 71.4% of women completed the full program, compared with 76.1% in the SARE trial (Senn et al., 2015), suggesting good completion rates. Women reported liking the content as designed but also provided suggestions for improvement. Although few changes were recommended, some women suggested including more alcohol and/or cannabis content in the first two units of the program.

This study had a small sample size of college women. We included racially and sexually diverse college women from an urban, predominantly Black university in the Southeastern United States in the study, which is a strength. However, these findings may not generalize to predominantly White institutions. As this pilot trial had no long-term follow-up, a large randomized controlled trial is needed to evaluate whether EAAA+ results in reductions in alcohol, cannabis, and sexual assault–related outcomes over time.

Findings suggest that EAAA+ is promising and warrants future evaluation. Importantly, despite potential challenges of integrated substance use and sexual assault programs (e.g., concerns of victim blaming; see Leone et al., 2022), the program was well liked, with one woman stating, “Every woman should take this.” Of course, women are not responsible for sexual assault, and programs are needed to also target potential perpetrators (Orchowski et al., 2020). EAAA (Senn et al., 2015) is being used globally (see sarecenter.org) and has demonstrated efficacy in real-world implementation (Senn et al., 2023). Should this additional content prove effective, it could be easily integrated into current implementation efforts for widespread reach.

Conflict-of-Interest Statement

Kevin Gray has provided consultation to Indivior and Jazz Pharmaceuticals and has received research support from Aelis Farma. The authors have no other conflicts to disclose.