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. 2026 Jul 1;39(5):884–896. doi: 10.1002/jts.70100

Pilot trial of THRIVE: A peer‐delivered sexual and intimate partner violence prevention program for women in substance use treatment

Heidi M Zinzow 1,✉, Lauren Smalls 1, Irene Pericot‐Valverde 1, Meghan Shank 1, Madelyn Brancato 1, Greyson Chapman 1, Allison Smith 1, Caroline Greco 1, Kacey Eichelberger 2, Kimbley Smith 3, Alain H Litwin 1,2
PMCID: PMC13639203  PMID: 42383404

Abstract

High rates of interpersonal violence exposure and trauma‐related mental health concerns among women in substance use treatment underscore the need for violence prevention services in these settings. Peer support specialists can play a crucial role in increasing access to trauma‐focused services and overcoming barriers, such as stigma and mistrust in formal systems. We tested the feasibility, acceptability, and preliminary efficacy of a peer‐delivered sexual and intimate partner violence prevention program for women in substance use treatment (THRIVE: The Healthy Relationships and Interpersonal Violence Education program). We conducted a single‐arm trial with 90 women recruited from outpatient and residential substance use treatment centers. Self‐report surveys assessed risk and protective factors and violence exposure over four assessment points from baseline (T1) to 3‐month follow‐up (T4). Exit interviews and survey data examined feasibility and acceptability outcomes. Results from linear mixed models indicated that participants improved on knowledge of consent (M T1 = 4.37, M T4 = 4.52), p = .004, and resources (M T1 = 2.09, M T4 = 2.63), p < .001; increased sexual self‐efficacy (M T1 = 4.90, M T4 = 5.29), p < .001; and decreased risky dating (M T1 = 3.37, M T4 = 2.87), p < .001, and physical and psychological intimate partner violence victimization (T1: 73.9%, T4: 42.0%), p < .001. Participants reported high satisfaction and acceptability and highlighted the strengths of peers as facilitators. In sum, THRIVE offers promise as an effective, scalable violence prevention program.

Sexual violence (SV) and intimate partner violence (IPV) are significant public health problems associated with both acute and long‐term psychosocial sequelae, including posttraumatic stress disorder (PTSD), depression, and substance use disorders (SUDs; Overstreet et al., 2017; White et al., 2024). Individuals with SUDs are at particularly high risk of violence exposure, with 60%–90% of people in SUD treatment reporting a history of interpersonal violence (Dworkin et al., 2017; Goodrum et al., 2022). Notably, women are at greater risk than men for SV/IPV victimization (Hines, 2007; Leemis et al., 2022). Substance use is a widely documented coping mechanism for managing the psychological effects of violent victimization, as well as a risk factor for future violence exposure (Hines, 2007; Ruback et al., 2014). For women in substance use treatment, victimization can lead to an escalation in substance use and interfere with recovery (Bishop et al., 2017). Given the significantly elevated risk of victimization and its harms in this population, there is a pressing need for violence prevention services to prevent and mitigate the effects of SV and IPV among women in substance use treatment.

Despite the recent emphasis on trauma‐informed care and the integration of trauma‐focused services in substance use treatment settings, less than half of substance use treatment facilities have adopted this model (Capezza & Najavits, 2012; Spivak et al., 2022). Barriers to adoption include difficulties offering integrated programs within existing timeframes and service delivery formats, minimal provider training, limited availability of mental health providers, and complexity of case management needs in this population (Killeen et al., 2015; Spivak et al., 2022). Beyond these challenges, women with a history of SV/IPV and SUDs also face multiple barriers to engaging in formal care, including stigma toward violence survivors and persons with SUDs, nonacknowledgment and nondisclosure of SV/IPV, fear of reprisal or legal repercussions, limited knowledge of resources, and concerns about negative reactions from peers and providers (Agterberg et al., 2020; Zinzow et al., 2022). Innovative strategies are needed to surmount these challenges and ensure that trauma‐focused and violence prevention services can be optimally integrated in substance use treatment settings.

One emerging mechanism for overcoming barriers to care in SUD treatment settings is to embed peer support specialists (PSS) as trusted advocates who can both educate and serve as a bridge to formal care. The Substance Use and Mental Health Services Administration (SAMHSA) estimates that approximately two thirds of all substance use treatment facilities offer peer services (SAMHSA, n.d.). Engaging PSS to provide trauma‐focused services may represent a readily available and effective means of addressing the complex needs of individuals with co‐occurring SUD and trauma history. PSS are individuals with lived experience and specialized training in facilitating SUD recovery, including training in advocacy, ethics, motivational interviewing, and trauma‐informed care (SAMHSA, 2009). With their emphasis on a nonhierarchical, empathic, and empowering relationship, these individuals represent ideal candidates for reducing barriers to care in SUD treatment settings (Mead et al., 2001; SAMHSA, 2009). They can also broaden the continuum of care in underresourced environments, while serving as a warm handoff to formal care. However, the effectiveness of involving certified PSS or addiction recovery coaches as violence prevention educators remains an unexplored area.

In addition to gaps in the literature regarding the roles of PSS in violence prevention, little work has focused on how to deploy evidence‐based SV/IPV prevention strategies in substance use treatment and health care settings. Most prior studies have focused on college populations and have been conducted within school‐based contexts. Many previously examined programs include components that focus on dispelling rape myths, providing education on risky alcohol use and dating behavior, fostering healthy relationships, and teaching bystander intervention skills (Banyard, 2015; Coker et al., 2015; Orchowski et al., 2023; Zinzow et al., 2018). Meta‐analytic findings indicate that campus SV programs have a significant impact on SV knowledge and attitudes, including knowledge of consent and rape myth acceptance (Graham et al., 2021; Kettrey et al., 2023). Of note, research on one program that focuses on risk reduction via enhancing self‐efficacy, risk detection skills, and protective behaviors (i.e., Enhanced Assess, Acknowledge, Act) reported a significant reduction in sexual assault victimization over long‐term follow‐up in a randomized controlled trial with college women (Senn et al., 2017). However, findings indicated that participants desired more focus on substance use (Leone et al., 2025), and most prior violence prevention programs have generally had limited focus on IPV. Promoting healthier relationships, sexual assertiveness, and protective behaviors via violence prevention programs is important not only in terms of preventing victimization but also in terms of achieving a direct positive impact on mental health (Fanslow et al., 2025; Quinn & Fromme, 2010).

To extend these evidence‐based violence prevention practices into broader health care settings, including an expanded emphasis on IPV and substance use, we developed an SV and IPV program for women in substance use treatment, THRIVE (The Healthy Relationships and Interpersonal Violence Education program). We implemented a PSS‐delivered model as a means of overcoming barriers to care, as well as to maximize the feasibility and scalability of the intervention. The purpose of the current study was to conduct a pilot trial of THRIVE. The first aim was to determine the feasibility and acceptability of the program, and the second aim was to assess the preliminary efficacy of the program on SV/IPV risk factors, protective factors, and exposure.

METHOD

Participants and procedure

Study procedures and sample description

Participants were recruited from three substance use treatment facilities: an outpatient clinic offering behavioral and medication‐assisted treatment, a residential facility for pregnant women and mothers, and an outpatient clinic offering counseling and medical services to pregnant women with SUDs. Participants were recruited via flyers and referrals from health care providers and PSS at each clinic. Eligible participants included adults (18 years of age and older) who identified as women, were currently enrolled in substance use treatment, and did not have a medical or psychiatric condition that impaired participation in the study (e.g., active suicidality, acute psychosis). After providing informed consent, participants completed baseline self‐report surveys prior to beginning the first THRIVE session. Participants also completed assessments immediately following the second session and at 1‐month and 3‐month follow‐ups. A subsample of 10 program completers and two noncompleters was recruited for exit interviews. Participants received $30 (USD) for each of four assessments, plus $30 for exit interviews. Participant characteristics are reported in Table 1. This study was approved by the Institutional Review Boards at Prisma Health and Clemson University, the two overseeing institutions, and registered with ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT06608979).

TABLE 1.

Baseline characteristics of participants in the THRIVE pilot study

Variables M SD
Age (years) 35.0 9.87
n %
Race/ethnicity
White 79 88.8
Other 6 6.7
Black 4 4.4
Hispanic/Latino/a 1 1.1
Treatment site
Outpatient clinic 45 50.0
Residential facility 42 46.7
Outpatient clinic for pregnant/postpartum individuals 3 3.3
Recent substance use (past 3 months)
Tobacco 53 58.9
Amphetamines 38 42.2
Cannabis 30 33.3
Opioids 20 22.2
Alcohol 18 20.0
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Note: N = 90.

THRIVE program

THRIVE is a program we developed based on the information–motivation–behavioral (IMB) skills theoretical model (Fisher et al., 2003), evidence‐based strategies from prior interventions (Orchowski et al., 2023; Senn et al., 2015, 2017; Zinzow et al., 2018), and feedback from key stakeholders (Zinzow et al., 2025). THRIVE was delivered by PSS who were Certified Peer Support Specialists and Certified Assertive Community Engagement Specialists under the National Association of Alcohol and Drug Abuse Counselors. PSS received at least 10 hr of training on the THRIVE protocol by the principal investigator, a licensed clinical psychologist, and attended weekly supervision sessions. The THRIVE program consisted of two 1‐hr sessions delivered in person by a PSS. Sessions were conducted in a group format at the residential site and in an individual format at the outpatient sites. Each session included both informational and interactive exercises along with handouts summarizing key information and a comprehensive list of resources tailored to interpersonal violence survivors. THRIVE sessions provided information and skills training exercises related to the intersection of SV, IPV, and substance use; healthy versus unhealthy relationships; sexual assertiveness; risk recognition; and protective behavior. More information about the research design, program development and content, and methods has been published elsewhere (Zinzow et al., 2025).

Measures

Demographic characteristics

All participants completed a demographic questionnaire to assess age, ethnicity, and race.

Feasibility and acceptability

Adherence

A 16‐item measure created for the protocol assessed whether core THRIVE elements were completed during each session (Zinzow et al., 2025). The project coordinator was trained on the protocol and attended each session to complete the adherence scale (eight items for each of two sessions). Item response format was “yes” or “no” to indicate whether an intervention component was addressed. The principal investigator attended approximately 15% of the sessions, and codes were reviewed for accuracy. The project coordinator and principal investigator met regularly to resolve discrepancies, address comments, and discuss feedback for PSS to improve adherence when drift was observed.

Satisfaction and engagement

At the postintervention assessment, participants responded to four items from our prior SV prevention study (e.g., “How engaging did you find the program?”; Orchowski et al., 2023), with response options ranging from 1 (not at all) to 5 (extremely). Two qualitative items assessed program strengths and areas for improvement; these items were included on the postintervention survey.

Exit interviews

A total of 24 semistructured interview question prompts assessed program feasibility (e.g., “How easy was it to take the surveys and complete the assessments?”), acceptability (e.g., “How appropriate does the program seem for women who are in substance use treatment?”), strengths and weaknesses (e.g., “What are your thoughts on the strengths of this program?”), what participants learned or changed (e.g., “What changes do you think you'll make [or have you made] in your life based on this program [if any]?”), areas for improvement (e.g., “If change was possible, what would you like us to change about this program?”), and alliance with PSS (e.g., ʻʻHow did you feel about your interactions with the peer support specialist who delivered the program?). A member of the research team conducted the interview in person or virtually, and interviews lasted 15–30 min.

Knowledge, attitudes, and behavioral intentions

All measures assessing knowledge, attitudes, and behavioral attentions were completed at all four time points, and mean item scores were calculated and used in the analyses.

Rape myth acceptance

The Illinois Rape Myth Acceptance Scale–Short Form (Payne et al., 1999) is a 20‐item scale with responses ranging from 1 (not at all agree) to 7 (very much agree). Prior scale validation has indicated good internal consistency (Cronbach's α = .87) and construct validity, correlating with related constructs (e.g., hostility towards women) and the full 45‐item scale (r = .97). We used mean item scores for each measure. Cronbach's alpha at baseline in the current study was .87.

Attitudes toward dating violence

The Attitudes Towards Dating Violence Scales (Price et al., 1999) measure acceptance of dating and partner violence myths. Three items that were highest loading on the physical and psychological scales in validation studies assessed participants’ level of agreement with each statement. Response options ranged from 1 (not at all agree) to 7 (very much agree). The scale has demonstrated good construct validity (i.e., correlation with other forms of dating violence) and internal consistency (Cronbach's αs = .75–.87). Cronbach's alpha for the three items used in the current study was .77 at baseline.

Consent

The ARC3 Consent Scale (Swartout et al., 2019) is a seven‐item scale assessing understanding of consent in sexual situations. Item responses range from 1 (not at all agree) to 5 (strongly agree). Prior research has established good internal validity (Cronbach's α = .76) and model fit (Tilley et al., 2020). In the present study, Cronbach's alpha was .88 at baseline.

Barriers to resistance

This 13‐item self‐report scale (Norris et al., 1996) is used to assess sexual self‐efficacy and perceived barriers to resisting when in sexually coercive situations, including substance use. Participants indicated the significance of each barrier on a scale of 1 (not at all significant) to 4 (very much significant), with total scores ranging from 13 to 52. Prior research has established construct validity via correlations to sexual victimization (r = .41), concern about embarrassment (r = .47), and concern about rejection (r = .45). Cronbach's alpha in the current study was .90 at baseline.

Risky dating behavior

The Dating Behavior Survey (Breitenbecher, 2008) was used to assess intentions to engage in risky and protective behavior while meeting with an intimate partner. Studies have established convergent validity with measures of self‐protective dating behavior, risk perception, and sexual victimization. We added six items to directly assess strategies covered by the THRIVE program (e.g., “If I'm on a date, I will try to limit my drug and alcohol use,” “If a dating partner controls where I go or what I do, I will stop dating him or her”), resulting in 17 items. Response options ranged from 1 (not at all agree) to 7 (very much agree). Protective behaviors were reverse‐scored to reflect higher risk as scores increased. Cronbach's alpha in the current study was .83 at baseline.

Resistance responses and sexual self‐efficacy

The 16‐item Resistance Responses to Sexual Aggression scale (Macy, 2007) measures the perceived likelihood of engaging in verbal and physical resistance responses in sexually aggressive situations (e.g., “Tell them I like them, but I'm not ready”). Items are scored on a scale of 1 (not at all agree) to 7 (strongly agree). Prior studies have established convergent validity with measures of sexual risk and victimization (Nurius et al., 2004). In the present sample, Cronbach's alpha was .92 at baseline.

Knowledge of resources

The Knowledge of Resources Scale (Swartout et al., 2019) is a 13‐item scale adapted from local and national resources for trauma‐focused care that was used to assess participants’ level of familiarity with these resources. Items are scored on a scale of 1 (not at all aware) to 5 (extremely aware). The scale has demonstrated good construct validity and high internal consistency in prior research with college samples (Cronbach's αs = .87–.91; Swartout et al., 2019; Tilley et al., 2020). Cronbach's alpha was .80 at baseline in the current study.

Trauma‐related service use

The 16‐item Trauma‐Related Service Use scale was created for this study based on local and national resources for interpersonal violence. For each item, participants indicated whether they accessed the resource in the past 30 days (“yes” or “no”), and positive responses were summed. Cronbach's alpha was .89 at baseline in the present sample.

SV/IPV

For all measures of SV/IPV, participants reported on past 3‐month victimization at baseline and 3‐month follow‐up and reported on past‐month victimization at 1‐month follow‐up.

Sexual victimization

The Sexual Experiences Survey Short Form (SES‐SFV; Koss et al., 2007) is a seven‐item measure assessing a range of unwanted sexual experiences, including unwanted sexual contact; sexual coercion; attempted rape and rape that occur as a result of verbal coercion, incapacitation, or force/threat of force. The SES‐SFV has demonstrated validity and reliability in samples of women (Johnson et al., 2017). SV was scored as a dichotomous variable, representing any form of sexual coercion or assault endorsed.

Physical and psychological IPV

The six‐item ARC3 Dating Violence Victimization Scale (Swartout et al., 2019) and five items from the Safe Dates Psychological Victimization Scale (Foshee et al., 1996) assessed both physical and psychological IPV. Response options ranged from 1 (never) to 5 (many times). Both scales have demonstrated validity and reliability (Foshee et al., 2013; Swartout et al., 2019). Because internal consistency reliability was high in the present sample, Cronbach's α = .97, we combined both scales into one measure of IPV. We calculated both a mean score and a dichotomous variable representing any experiences of physical and/or psychological IPV.

Data analysis

To examine feasibility outcomes, we calculated descriptive statistics for the adherence, satisfaction, and engagement scales. We conducted a thematic analysis of qualitative interview and survey data (Braun & Clarke, 2006). This entailed three independent coders conducting a line‐by‐line analysis of transcripts to identify inductive codes that emerged from the data. The coders met to achieve consensus on the codes, grouped by themes organized by the research questions, and to develop a codebook. Each coder proceeded to code all transcripts, assign codes to the data, and meet regularly with the other coders to resolve discrepancies.

To analyze pilot trial outcomes, we first examined correlations between demographic variables and study outcomes to identify any potential covariates for subsequent analyses. Given that there were no significant associations between demographic variables and study outcomes, no demographic variables were included as covariates in subsequent analyses. We then examined associations between all baseline variables and completer status at each time point, indicating no significant associations and upholding the missing completely at random (MCAR) assumptions of linear mixed models (LMM) and generalized estimating equations (GEE). Given the sample size (45 participants per site), power to detect site differences was 80% for medium effect sizes (d = 0.6, F = 0.30, estimated via G* Power 3.1 [Faul et al., 2007], one‐way analysis of variance [ANOVA], α = .05). Even though no differences in outcomes were observed in between‐site comparisons, we elected to include site as a covariate due to its potential confounding effects and the fact that small site differences were unlikely to be detected in our initial comparisons. The two outpatient sites were combined due to the small number of participants (n = 3) at one site. To analyze changes over time on measures of knowledge, attitudes, behavioral intentions, and IPV, we conducted a series of LMM, with site as a covariate. We conducted pairwise comparisons between time points, with a Bonferroni correction for multiple comparisons. For the binary variables of IPV and SV, we conducted GEE using binary logistic models and an autoregressive correlation matrix structure, with site as a covariate. Analyses were conducted with IBM SPSS Statistics (Version 29).

RESULTS

Feasibility and acceptability

We recruited and enrolled 90 women between June 2024 and December 2024, with a total of 71 (78.9%) completing the program (i.e., attending both sessions). Participant characteristics are reported in Table 1, and participant flow is reported in Figure 1. Of program completers, 81.7% were retained at 1‐month follow‐up (n = 58), and 67.6% (n = 48) were retained at 3‐month follow‐up. No noncompleters completed the follow‐up assessments. Adherence analyses indicated that facilitators were 96% adherent to the protocol. Participants indicated high levels of satisfaction (M = 4.42, SD = 0.86) and engagement (M = 4.27, SD = 0.87). Participants also rated the program as very good in quality (M = 4.45, SD = 0.77) and reported it to be very helpful (M = 4.36, SD = 0.86).

FIGURE 1.

FIGURE 1

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Participant flow through the THRIVE pilot study

Note: Participants were women in substance use treatment recruited locally in Greenville (South Carolina, USA).

An examination of open‐ended responses to protocol strengths indicated that all participants who took part in the exit interviews found PSS to be knowledgeable and supportive and did not prefer a different facilitator. Participants highlighted several strengths, including relying on peers as facilitators, noting the fact that PSS could demonstrate empathy; being able to trust peers; and perceiving that they would not feel judged. About half of the interviewed participants preferred group format, half preferred individual format, most found the current length and in‐person format to be preferred, most preferred the locations in which the sessions took place, and most did not perceive barriers to participation.

Other key themes regarding program strengths are detailed in Table 2. The most frequent theme was that participants generally found the program informative, helpful, and engaging. They enjoyed learning about definitions of types of IPV, consent, and myths. Many participants commented on the protective strategies that they learned, particularly in the context of situations involving substance use. Participants found the material relatable, appreciated the “real‐world” examples, and indicated that these examples helped them feel validated and like they were “not alone.” The content also helped participants decrease self‐blame and increase acknowledgment of past experiences of assault. Participants appreciated the information about resources and noted that they found it important to have the space to discuss trauma and have a “voice.” Although some participants reported that they appreciated the resources and engaged in more help‐seeking, others indicated that they were already engaged in help‐seeking and, therefore, did not perceive a need for further assistance. Participants mostly indicated no need for change or improvement. However, a few participants requested additional classes and information, as well as more visual aids. Some noted a desire for more follow‐through and reinforcement of information and support beyond the program.

TABLE 2.

Feasibility and acceptability themes from the qualitative survey data and exit interviews

Theme and subthemes Participant quotations
Program strengths
Informative, helpful, engaging “I learned something new every time. It was very informative.”
Definitions, terms, myths vs. facts “[I liked] learning that sexual assault comes in many ways and forms.”
Facilitators (PSS) “The connection with the staff.”
Protective strategies, improved skills “How to better protect myself while going through my personal recovery.”
Space to discuss trauma “We got to talk freely without judgment.”
Decreased self‐blame “Letting us know it isn't our fault.”
Relatable “Real life examples.”
Resources and help‐seeking “Getting ladies resources that they're ashamed to ask for.”
Areas for improvement
None “I think it's great as it is.”
Processing difficult emotions “Make people talk about how they feel.”
More visual aids “More handouts and brochures.”
More sessions “More classes.”
More skills training “More life skills”
More examples “The difference between a gay or straight relationship”
More follow‐up “It stopped abruptly.”
Shorter “It's too lengthy.”
Importance of PSS
Trust, empathy “I think it's important a peer support person does that because of the level that we confide in them.”
“I would prefer someone who has been through it and knows what I'm going through over somebody that has never been through it. I would feel like I'm being judged, and they don't know what it's like. "
Changes since the program
Protective strategies “That had me thinking about ways that I can set boundaries and say no and not be around people like that.”
Help‐seeking Yes: “Had a lot of resources for me.”
No: “I feel like I'm over these things.”
“I am [already] getting good services here.”
Self‐efficacy “I'm gonna be proactive and speak for myself and protect myself.”
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Note: Qualitative survey data: n = 23, exit interviews: n = 12. PSS = peer‐support specialists.

Pilot trial outcomes

Findings from the LMMs examining changes in violence‐related knowledge and attitudes indicated significant changes over time, including increased knowledge of consent, increased intentions of engaging in resistance responses to sexual aggression (sexual self‐efficacy), increased resource knowledge, and decreased risky dating behavioral intentions. Participants reported generally low mean scores on measures of rape and dating violence myths at baseline, with no significant change over time. IPV also declined over time, with significant differences between baseline and 3‐month follow‐up (Table 3).

TABLE 3.

Results from linear mixed models examining changes in attitudes, behaviors, and violence exposure over time

Baseline Postintervention 1 month 3 month
(n = 88) (n = 70) (n = 58) (n = 49)
Variable M SE M SE M SE M SE df F p
Rape myths attitudes and beliefs 1.35 0.09 1.31 0.10 1.40 0.11 1.50 0.11 3, 135 0.75 .522
Dating violence attitudes and beliefs 1.38 0.10 1.36 0.11 1.26 0.13 1.27 0.14 3, 179 0.30 .825
Knowledge/ attitudes toward consent 4.37a 0.07 4.64b 0.08 4.59a,b 0.08 4.52a,b 0.09 3, 132 4.53 .004
Barriers to using resistance responses 2.08 0.08 2.02 0.09 1.83 0.10 1.95 0.11 3, 193 2.03 .112
Behavioral intentions for risky dating 3.37a 0.14 2.52b 0.15 2.77b 0.16 2.87b 0.17 3, 194 11.93 < .001
Resistance responses in sexually aggressive situations 4.90a 0.15 5.83b 0.16 5.56b 0.17 5.29a,b 0.19 3, 185 9.61 < .001
Knowledge of resources 2.09a 0.09 2.35a,b 0.10 2.36a,b 0.11 2.63b 0.11 3, 198 6.61 < .001
Trauma‐related service use 1.67 2.07 1.50 0.31 1.65 0.34 1.51 0.38 3, 191 0.09 .966
Intimate partner violence 2.41a 0.85 N/A 1.91b,c 0.85 1.65b,c 0.85 2, 130 7.81 < .001
% % % % df χ2 p
Intimate partner violence a 73.9 N/A 56.9 42.0 2,196 12.81 .002
Sexual violence a 49.4 N/A 51.7 56.0 2,191 0.44 .802
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Note: N = 90. Means with differing subscripts were significantly different at p < .05 in pairwise comparisons. All analyses controlled for recruitment site.

a

Yes or no; percentages reflect “yes” responses.

Results for dichotomous variables (IPV and SV) were obtained from GEE analyses. The findings indicated a significant decrease over time for IPV. The results for SV did not achieve statistical significance (Table 3). A post hoc examination of SV by site indicated that observed changes in SV over time at the outpatient sites (baseline: 51.1%, 1‐month: 55.2% 3‐month: 44.0%), χ2(2, N = 45) = 0.46, p = .795, versus the residential facility (baseline: 47.4%, 1‐month: 48.3%, 3‐month: 68.0%), χ2(2, N = 45) = 2.66, p = .264, were not statistically significant. The main effects of recruitment site were not significant in any of the models.

DISCUSSION

This single‐arm trial of THRIVE examined the acceptability, feasibility, and preliminary efficacy of a peer‐delivered SV and IPV prevention program for women in substance use treatment. The findings demonstrate expected changes in risk and protective factors from baseline to follow‐up, as well as improvements in the distal outcomes of physical and psychological IPV victimization. Furthermore, the feasibility and acceptability of the program were supported, with high retention rates from baseline to program completion and most participants completing the 1‐ and 3‐month follow‐up assessments. Participants reported high ratings for satisfaction, engagement, quality, and helpfulness. Qualitative data further underscored program feasibility, with participants noting the strengths of the peer support delivery model, the program content, and the importance of knowledge of protective skills gained from the program.

Participants in THRIVE demonstrated improvements in several protective factors, including knowledge of consent, intentions to engage in various resistance responses and assertive behavior when facing potential sexually aggressive situations, and increased knowledge of trauma‐related resources. Moreover, participants decreased their likelihood of engaging in risky dating behaviors, such as using substances on a date, and increased their intent to use protective strategies, such as taking control of plans for a date, arranging their own transportation, and ending encounters during which partners engage in coercive or risky behaviors. These factors reflect direct targets of the education provided within THRIVE and are established risk and protective factors for subsequent violent victimization (Hines, 2007; Spencer et al., 2019). Notably, participants in the THRIVE program reported a decline in exposure over time, with a decrease of more than 30% in past 3‐month exposure at follow‐up. Although it is not possible to directly attribute these effects to the program, a decline in IPV is consistent with completers’ comments regarding their healthier perspectives on intimate partnerships and their increased use of protective strategies.

Although this pilot trial highlights multiple strengths of the current design, the findings suggest areas for improvement and refinement in future controlled trials. First, there were no significant changes on measures of dating and SV attitudes and myths or trauma‐related service use. Participants did not highly endorse problematic attitudes at baseline, leaving minimal room for change. This suggests that program content can minimize focus on components intended to shift these attitudes and instead focus more on skills training and help‐seeking. Although the lack of increased help‐seeking may be due to the fact that some participants were already engaged with care, it is possible that a lack of acknowledgment of trauma‐related symptoms could be a barrier. Many participants described symptoms of PTSD during program sessions, underscoring the need for further psychoeducation on this topic.

Although the results from this trial indicated significant positive outcomes regarding exposure to physical and psychological IPV over time, we did not observe similar declines in SV exposure. Prior research on brief SV prevention programs has often demonstrated a shift in attitudes and norms, but findings frequently fail to exhibit a significant impact on future victimization (Porat et al., 2024). However, more intensive interventions with a concerted focus on skills training and experiential components have led to successful reductions in SV victimization over long‐term follow‐up (Senn et al., 2017). In addition, literature suggests that increasing the dosage of violence prevention programs is important to ensuring a long‐term impact (Anderson & Whiston, 2005; Nation et al., 2003). In the context of the current program, this could include enhanced role‐playing exercises, booster or follow‐up sessions to reinforce skills application and address implementation barriers outside of the treatment setting, and/or supplemental peer phone coaching. A longer follow‐up period may also be required to observe meaningful changes in violence exposure. Finally, it is also possible that education on SV and increased acknowledgment of SV incidents led to higher endorsement of SV items postintervention (Kolivas & Gross, 2007). As such, it is important to consider multiple potential outcomes of SV prevention programs, such as impacts on risk and protective factors, in examining the broader impacts of these interventions.

Given that the current study was a pilot trial focused primarily on feasibility and preliminary efficacy, there were several inherent limitations. First, the lack of a control group inhibits the ability to draw causal conclusions about program effects. Participants’ changes over time could be due to enrollment in substance use treatment rather than the prevention program itself. Furthermore, many participants were assessed while being monitored in a controlled environment (i.e., residential treatment), which could have minimized exposure to violence, particularly during the initial assessment periods. This could potentially explain the lack of any observed decline in SV outcomes, as some participants may have had an increased risk of exposure when they exited treatment programs and reintegrated into the community. For example, studies suggest that individuals have a decreased risk of victimization while in residential treatment and experience a significant risk of victimization after discharge (Hawke et al., 2003; Segal et al., 2019). In our residential treatment sample, all participants were in residence during baseline, postintervention, and 1‐month follow‐up, with most exiting the program by 3‐month follow‐up. Similarly, our assessment of IPV was constrained by whether a participant was currently in an intimate relationship. Though most participants reported recent IPV at baseline, a change in partnerships while in treatment could account for decreased reports of IPV exposure. A related limitation of the measures was that risky and protective dating behavior assessments were more pertinent for individuals who were not in existing long‐term relationships and who were likely to date. Further studies are needed to examine the potential moderating effects of relationship status and to assess healthy relationship behaviors in the context of long‐term partnerships. Finally, despite using validated methods of assessing SV and IPV, the instruments are limited by their self‐report format and lack of fine‐grained analysis of tactics, relationship to perpetrators, and chronicity of exposure. Future research should consider whether the THRIVE prevention program impacts are moderated by these factors.

Although one of the strengths of the current program was its positive effects across outpatient and residential settings and modalities (individual and group), the heterogeneity of populations and treatments received at each site could introduce confounding effects that should be considered in future trials. On the other hand, offering alternative formats can enhance feasibility and scalability. For example, a group format was suitable for the residential site, which had institutionalized group meeting times, whereas groups were not feasible in the outpatient clinics, where transportation and logistical barriers posed challenges to convening more than one individual at a specified time. Another concern with the current study was generalizability, given the limited racial/ethnic diversity in the sample and the sole focus on female participants. Future research should also broaden assessments to include more rigorous measures of behavioral change that measure both intentions and behaviors over longer follow‐up periods. Finally, retention methods could be strengthened in this particularly transient population, specifically at 3‐month follow‐up. Especially in the residential facility, where many participants did not have a phone when transitioning back into the community, gold‐standard methods of collecting multiple alternate contacts, providing additional attendance incentives, and providing phones and transportation to participants will be important to ensure successful data collection in longitudinal studies (Kim et al., 2014).

In sum, the findings from the pilot trial of THRIVE are promising and have also identified areas for refinement. These include reinforcement of skills training, with particular focus on SV and trauma‐focused help‐seeking. The THRIVE study is novel in its inclusion of PSS as violence prevention educators, its expansion to include illicit substance use and intersecting forms of violence, and its adaptation to community settings outside of schools. It supports a model of care that is feasible to deliver in substance use treatment settings, where PSS are already integrated and serving as trusted advocates. Given the high risk for violence exposure among women with substance use disorders and the lack of broad implementation of trauma‐focused care in substance use treatment, the THRIVE program addresses a critical need for an accessible and scalable violence prevention program specifically adapted for these settings. If successful, this program could reduce the incidence of sexual and IPV, substance use, and violence‐related mental health outcomes among women in substance use treatment.

AUTHOR CONTRIBUTIONS

Heidi M. Zinzow: conceptualization, investigation, funding acquisition, writing—original draft, methodology, validation, software, formal analysis, project administration, data curation, supervision, resources, writing—review and editing, visualization. Lauren Smalls: investigation, writing—original draft, writing—review and editing, software, formal analysis, project administration, data curation, supervision, visualization. Irene Pericot‐Valverde: conceptualization, investigation, writing—original draft, methodology, writing—review and editing, supervision. Meghan Shank: investigation, writing—review and editing, writing—original draft. Madelyn Brancato: writing—review and editing, investigation. Greyson Chapman: investigation, writing—review and editing. Allison Smith: investigation, writing—review and editing. Caroline Greco: investigation, writing—review and editing. Kacey Eichelberger: investigation, writing—review and editing, resources. Kimbley Smith: investigation, writing—review and editing, resources. Alain H. Litwin: resources, investigation, writing—review and editing.

AUTHOR NOTE

Funding for this project was provided by grants from the South Carolina Opioid Recovery Funds and Prisma Health Sciences Center.

Artificial intelligence was used to format the reference section of this paper.

We would like to acknowledge Leigh Huckins, Abby Blackwell, and Jessica Owens for their support in recruitment, enrollment, and data collection for this study. We also kindly acknowledge Takka McCord and Jamie Hendricks, the peer support specialists who delivered the program and provided their feedback.

OPEN PRACTICES STATEMENT

This article was preregistered (ClinicalTrials.gov Identifier: NCT06608979). The data that support the findings of this study are available on request from the corresponding author, pending ethical board review. The data are not publicly available due to privacy or ethical restrictions.

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