Effects of bystander programs on the prevention of sexual assault among adolescents and college students: A systematic review

Bystander sexual assault prevention programs have beneficial effects on bystander intervention but there is no evidence of effects on sexual assault perpetration. Effects on knowledge and attitudes are inconsistent across outcomes. Sexual assault is a significant problem among adolescents and college students across the world. One promising strategy for preventing these assaults is the implementation of bystander sexual assault prevention programs, which encourage young people to intervene when witnessing incidents or warning signs of sexual assault. This review examines the effects bystander programs have on knowledge and attitudes concerning sexual assault and bystander behavior, bystander intervention when witnessing sexual assault or its warning signs, and participants' rates of perpetration of sexual assault. What is the aim of this review? This Campbell systematic review examines the effects of bystander programs on knowledge and attitudes concerning sexual assault and bystander intervention, bystander intervention when witnessing sexual assault or its warning signs, and the perpetration of sexual assault. The review summarizes evidence from 27 high-quality studies, including 21 randomized controlled trials. This review includes studies that evaluate the effects of bystander programs for young people on (a) knowledge and attitudes concerning sexual assault and bystander intervention, (b) bystander intervention behavior when witnessing sexual assault or its warning signs, and (c) perpetration of sexual assault. Twenty-seven studies met the inclusion criteria. These included studies span the period from 1997 to 2017 and were primarily conducted in the USA (one study was conducted in Canada and one in India). Twenty-one studies were randomized controlled trials and six were high quality quasi-experimental studies. Bystander programs have an effect on knowledge and attitudes for some outcomes. The most pronounced beneficial effects are on rape myth acceptance and bystander efficacy outcomes. There are also delayed effects (i.e., 1 to 4 months after the intervention) on taking responsibility for intervening/acting, knowing strategies for intervening, and intentions to intervene outcomes. There is little or no evidence of effects on gender attitudes, victim empathy, date rape attitudes, and on noticing sexual assault outcomes. Bystander programs have a beneficial effect on bystander intervention. There is no evidence that bystander programs have an effect on participants' rates of sexual assault perpetration. The United States 2013 Campus Sexual Violence Elimination (SaVE) Act requires postsecondary educational institutions participating in Title IX financial aid programs to provide incoming college students with sexual violence prevention programming that includes a component on bystander intervention. Bystander programs have a significant effect on bystander intervention. But there is no evidence that these programs have an effect on rates of sexual assault perpetration. This suggests that bystander programs may be appropriate for targeting the behavior of potential bystanders but may not be appropriate for targeting the behavior of potential perpetrators. Beneficial effects of bystander programs on bystander intervention were diminished by 6 months post-intervention. Thus, booster sessions may be needed to yield any sustained effects. There are still important questions worth further exploration. Namely, more research is needed to investigate the underlying causal mechanisms of program effects on bystander behavior (e.g., to model relationships between specific knowledge/attitude effects and bystander intervention effects), and to identify the most effective types of bystander programs (e.g., using randomized controlled trials to compare the effects of two alternate program models). Additionally, more research is needed in contexts outside of the USA so that researchers can better understand the role of bystander programs across the world. The review authors searched for studies up to June 2017. This Campbell systematic review was submitted in October 2017, revised in October 2018, and published January 2019. Sexual assault is a significant problem among adolescents and college students in the United States and globally. Findings from the Campus Sexual Assault study estimated that 15.9% of college women had experienced attempted or completed sexual assault (i.e., unwanted sexual contact that could include sexual touching, oral sex, intercourse, anal sex, or penetration with a finger or object) prior to entering college and 19% had experienced attempted or completed sexual assault since entering college (Krebs, Lindquist, Warner, Fisher, & Martin, 2009). Similar rates have been reported in Australia (Australian Human Rights Commission, 2017), Chile (Lehrer, Lehrer, & Koss, 2013), China (Su, Hao, Huang, Xiao, & Tao, 2011), Finland (Bjorklund, Hakkanen-Nyholm, Huttunen, & Kunttu, 2010), Poland (Tomaszewska & Krahe, 2018), Rwanda (Van Decraen, Michielsen, Herbots, Van Rossem, & Temmerman, 2012), Spain (Vázquez, Torres, & Otero, 2012), and in a global survey of countries in Africa, Asia, and the Americas (Pengpid & Peltzer, 2016). One promising strategy for preventing sexual assault among adolescents and young adults is the implementation of bystander programs, which encourage young people to intervene when witnessing incidents or warning signs of sexual assault. Bystander programs seek to sensitize young people to warning signs of sexual assault, create attitudinal changes that foster bystander responsibility for intervening (e.g., creating empathy for victims), and build requisite skills and knowledge of tactics for taking action (Banyard, 2011; Banyard, Plante, & Moynihan, 2004; Burn, 2009; McMahon & Banyard, 2012). Many of these programs are implemented with large groups of adolescents or college students in the format of a single training/education session (e.g., as part of college orientation). However, some programs use broader implementation strategies, such as advertising campaigns that post signs across college campuses to encourage students to act when witnessing signs of violence. By treating young people as potential allies in preventing sexual assault, bystander programs have the capacity to be less threatening than traditional sexual assault prevention programs, which tend to address young people as either potential perpetrators or victims of sexual violence (Burn, 2009; Messner, 2015; [Jackson] Katz, 1995). Instead of placing emphasis on how young people may modify their individual behavior to either respect the sexual boundaries of others or reduce their personal risk for being sexually assaulted, bystander programs aim to foster prerequisite knowledge and skills for intervening on behalf of potential victims. Thus, by treating young people as part of the solution to sexual assault, rather than part of the problem, bystander programs may limit the risk of defensiveness or backlash among participants (e.g., decreased empathy for victims, increased rape myth acceptance; Banyard et al., 2004; Katz, 1995). The first objective was to assess the overall effects (including adverse effects), and the variability of the effects, of bystander programs on adolescents' and college students' attitudes and behaviors regarding sexual assault. The second objective was to explore the comparative effectiveness of bystander programs for different profiles of participants (e.g., mean age of the sample, education level of the sample, proportion of males/females in the sample, proportion of fraternity/sorority members in the sample, proportion of athletic team members in the sample). The third objective was to explore the comparative effectiveness of different bystander programs in terms of gendered content and approach (e.g., conceptualizing sexual assault as a gendered or gender-neutral problem, mixed- or single-sex group implementation). Candidate studies were identified through searches of electronic databases, relevant academic journals, and gray literature sources. Gray literature searches included contacting leading authors and experts on bystander programs to identify any current/ongoing research that might be eligible for the review, screening bibliographies of eligible studies and relevant reviews to identify additional candidate studies, and conducting forward citation searches (searches for reports citing eligible studies) using the website Google Scholar. To be included in the review studies had to meet eligibility criteria in the following domains: types of study, types of participants, types of interventions, types of outcome measures, duration of follow-up, and types of settings. To be eligible for inclusion in the review, studies must have used an experimental or controlled quasi-experimental research design to compare an intervention group (i.e., students assigned to a bystander program) with a comparison group (i.e., students not assigned to a bystander program). The review focused on studies that examined outcomes of bystander programs that targeted sexual assault and were implemented with adolescents and/or college students in educational settings. Eligible participants included adolescents enrolled in grades 7 through 12 and college students enrolled in any type of undergraduate postsecondary educational institution. The mean age of samples could be no less than age 12 and no greater than age 25. Eligible intervention programs were those that approached participants as allies in preventing and/or alleviating sexual assault among adolescents and/or college students. Some part of the program had to focus on ways that cultivate willingness for a person to respond to others who are at risk for sexual assault. All delivery formats were eligible for inclusion (e.g., in-person training sessions, video programs, web-based training, and advertising/poster campaigns). There were no intervention duration criteria for inclusion. Eligible comparison groups must have received no intervention services targeting bystander attitudes/behavior or sexual assault. General attitudes toward sexual assault and victims (e.g., victim empathy, rape myth acceptance). Prerequisite skills and knowledge for bystander intervention as defined by Burn (2009) (e.g., noticing sexual assault or its warning signs, identifying a situation as appropriate for intervention, taking responsibility for acting/intervening, and knowing strategies for helping/intervening). Self-efficacy with regard to bystander intervention (e.g., respondents' confidence in their ability to intervene). Intentions to intervene when witnessing instances or warning signs of sexual assault. Actual intervention behavior when witnessing instances or warning signs of sexual assault. Perpetration of sexual assault (i.e., participants' rates of perpetration). Studies reporting follow-ups of any duration were eligible for inclusion. When studies reported outcomes at more than one follow-up wave, each wave was coded and identified by its reported duration. Follow-ups of similar durations were analyzed together. The review focused on studies that examined outcomes of bystander programs that targeted sexual assault and were implemented with adolescents and/or college students in educational settings. Eligible educational settings included secondary schools (i.e., grades 7–12) and colleges or universities. There were no geographic limitations on inclusion criteria. Research conducted in any country was eligible. Once candidate studies were identified, two reviewers independently screened each study title and abstract for eligibility; disagreements between reviewers were resolved by discussion and consensus. Potentially eligible studies were then retrieved in full text, and these full texts were reviewed for eligibility, again using two independent reviewers. Two reviewers independently double-coded all included studies, using a piloted codebook. Coding disagreements were resolved via discussion and consensus. The primary categories for coding were as follows: participant demographics and characteristics (e.g., age, gender, education level, race/ethnicity, athletic team membership, fraternity/sorority membership); intervention setting (e.g., state, country, secondary or postsecondary institution, mixed- or single-sex group); study characteristics (e.g., attrition, duration of follow-up, study design, participant dose, sample N); outcome construct (e.g., type, description of measure); and outcome results (e.g., timing at measurement, baseline, and follow-up means and standard deviations or proportions). During the coding process, relevant summary statistics (e.g., means and standard deviations, proportions, observed sample sizes) were extracted from research reports to calculate effect sizes. Effect sizes were reported as standardized mean differences (SMD), adjusted for small sample size (Hedges' g). Positive effect size values (i.e., greater than 0) indicate a beneficial outcome for the bystander intervention group. Intervention effects for each outcome construct were synthesized via meta-analyses using random-effects inverse variance weights. All statistical analyses were conducted with the metafor package in R. Synthesis results are displayed using forest plots. Mean effect sizes are reported with their 95% confidence intervals. Effects for knowledge and attitude outcomes varied widely across constructs. The most pronounced beneficial effect in this domain was on rape myth acceptance. The effect for this outcome was immediate and sustained across all reported follow-up waves (i.e., from immediate posttest to 6- to 7-month post-intervention). Intervention effects on bystander efficacy were also fairly pronounced, with an effect observed at both immediate posttest and 1- to 4-month post-intervention. A significant effect was not observed for this outcome 6 months post-intervention; however, this should be interpreted with caution, as only one study reported bystander efficacy effects at this follow-up period. Effects on other knowledge and attitude outcomes were either delayed or unobserved. Intervention effects on taking responsibility for intervening or acting, knowing strategies for intervening, and intentions to intervene were nonsignificant at immediate posttest, but significant and beneficial by 1- to 4-month post-intervention. We found limited or no evidence of significant intervention effects on gender attitudes, victim empathy, date rape attitudes, and noticing sexual assault. The results indicated that bystander programs have a beneficial effect on bystander intervention behavior. However, this effect, which was observed at 1- to 4-month post-intervention, was not statistically significant at 6 months post-intervention. Bystander programs did not have a significant effect on sexual assault perpetration. We had planned to conduct moderator analyses to assess a wide range of participant characteristics as potential effect size moderators. However, our review only yielded a sufficient number of studies (n ≥ 10) to conduct moderator analyses for the bystander intervention outcome domain. The results indicated that mean age, education level, and proportion of males/female were not statistically significant predictors of the magnitude of intervention effects. We conducted moderator analyses to assess any differential effects of bystander programs on measured outcomes based on (a) the gender of perpetrators and victims in specific bystander programs and (b) whether programs were implemented in mixed- or single-sex settings. Our review only produced a sufficient number of studies (n ≥ 10) to conduct such moderator analyses for the bystander intervention outcome domain. We found that neither of these measures was a significant predictor of the effectiveness of bystander programs on bystander intervention. The overwhelming majority of eligible studies assessing the effects of bystander programs were conducted in the United States. This is not necessarily surprising considering that the United States has implemented public policy that encourages the implementation of such programs on college campuses. The United States 2013 Campus SaVE Act requires postsecondary educational institutions participating in Title IX financial aid programs to provide incoming college students with primary prevention and awareness programs addressing sexual violence. The Campus SaVE Act mandates that these programs include a component on bystander intervention. Currently, there is no comparable legislation regarding sexual assault among adolescents (e.g., mandating bystander programs in secondary schools). Findings from this review indicate that bystander programs have beneficial effects on bystander intervention behavior. This review therefore provides important evidence of the effectiveness of mandated programs on college campuses. Additionally, results from the moderator analyses indicated that the effects on bystander intervention are similar for adolescents and college students, which suggests that early implementation of bystander programs (i.e., in secondary schools with adolescents) may be warranted. Importantly, although we found that bystander programs had a significant effect on bystander intervention behavior, there was no evidence that these programs had an effect on participants' sexual assault perpetration. Although most bystander sexual assault prevention programs aim to shift attitudes in the hopes of preventing sexual assault perpetration, this review provided no evidence that these programs decrease participants' perpetration rates. This suggests that bystander programs may be appropriate for targeting bystander behavior but may not be appropriate for targeting the behavior of potential perpetrators. Additionally, effects of bystander programs on bystander intervention diminished 6-month post-intervention. Thus, booster sessions may be needed to yield any sustained intervention effects. Findings from this review suggest there is a fairly strong body of research assessing the effects of bystander programs on attitudes and behaviors. However, there are important questions worth further exploration. First, according to one prominent logic model, bystander programs promote bystander intervention by fostering prerequisite knowledge and attitudes (Burn, 2009). Our meta-analysis provides inconsistent evidence of the effects of bystander programs on knowledge and attitudes, but promising evidence of short-term effects on bystander intervention behavior. These results cast uncertainty on the proposed relationship between knowledge/attitudes and bystander behavior. However, our methods do not permit any formal evaluation of this relationship. The field's understanding of the causal mechanisms of program effects on bystander behavior would benefit from further analysis (e.g., path analysis mapping relationships between specific knowledge/attitude effects and bystander intervention). Second, bystander programs exhibit a great deal of content variability, most notably in framing sexual assault as a gendered or gender-neutral problem. That is, bystander programs tend to adopt one of two main approaches to addressing sexual assault: (a) they present sexual assault as a gendered problem (overwhelmingly affecting women) or (b) they present sexual assault as a gender-neutral problem (affecting women and men alike). Differential effects of these two types of programs remain largely unexamined. Our analysis indicated that (a) the sex of victims/perpetrators presented in interventions (i.e., portrayed in programs as gender neutral or male perpetrator and female victim) and (b) whether programs were implemented in mixed- or single-sex settings were not significant predictors of program effects on bystander intervention. However, these findings are limited to a single outcome and they should be considered preliminary, as they are based on a small sample (n = 11). The field's understanding of the differential effects of gendered versus gender neutral programs would benefit from the design and implementation of high-quality primary studies that make direct comparisons between these two types of programs (e.g., randomized controlled trials [RCTs] comparing the effects of two active treatment arms that differ in their gendered approach). Finally, as previously noted, all but two eligible studies were conducted in the United States. Thus, high-quality studies conducted outside of the United States are needed to provide a global perspective on the efficacy of bystander programs. Sexual assault is a significant problem among adolescents and college students in the United States and globally. Findings from the Campus Sexual Assault study estimated that 15.9% of American college women had experienced attempted or completed sexual assault (i.e., unwanted sexual contact that could include sexual touching, oral sex, intercourse, anal sex, or penetration with a finger or object) prior to entering college and 19% had experienced attempted or completed sexual assault since entering college (Krebs et al., 2009). Similar rates have been reported in Australia (Australian Human Rights Commission, 2017), Chile (Lehrer et al., 2013), China (Su et al., 2011), Finland (Bjorklund et al., 2010), Poland (Tomaszewska & Krahe, 2018), Rwanda (Van Decraen et al., 2012), Spain (Vázquez et al., 2012), and in a global survey of countries in Africa, Asia, and the Americas (Pengpid & Peltzer, 2016). These rates are problematic, as sexual assault in adolescence and/or young adulthood is associated with numerous adverse outcomes, including risk of repeated victimization, depressive symptomology, heavy drinking, and suicidal ideation (Exner- Cortens, Eckenrode, & Rothman, 2013; Cui, Ueno, Gordon, & Fincham, 2013; Halpern, Spriggs, Martin, & Kupper, 2009). Importantly, there is evidence that indicates that experiences of sexual assault during these two life phases are related as victimization and perpetration during adolescence, respectively, associated with increased risk of victimization and perpetration during young adulthood (Cui et al., 2013). Thus, early prevention efforts are of paramount importance. Reviews of research on the effectiveness of programs designed to prevent sexual assault among adolescents and college students have noted both a dearth of high-quality studies, such as RCTs and minimal evidence that these prevention programs have meaningful effects on young people's behavior (De Koker, Mathews, Zuch, Bastien, & Mason-Jones, 2014; DeGue et al., 2014). Concerning the latter point, evaluations of such programs tend to measure attitudinal outcomes (e.g., rape supportive attitudes, rape myth acceptance) more frequently than behavioral outcomes (e.g., perpetration or victimization; Anderson & Whiston, 2005; Cornelius & Resseguie, 2007; DeGue et al., 2014). Additionally, findings from a meta-analysis of studies assessing outcomes of college sexual assault prevention programs suggested that effects are larger for attitudinal outcomes than for the actual incidence of sexual assault (Anderson & Whiston, 2005). Given this paucity of evidence regarding behavior change, it is imperative to identify effective strategies for preventing sexual assault among adolescents and young adults. One promising strategy is the implementation of bystander programs, which encourage young people to intervene when witnessing incidents or warning signs of sexual assault (e.g., controlling behavior, such as intervening with a would-be perpetrator leading an intoxicated person into an isolated area). The strength of the bystander model lies in its emphasis on the role of peers in the prevention of violence. Peers are a salient influence on young people's intimate relationships (Adelman & Kil, 2007; Giordano, 2003). In some respects, this influence can be detrimental, as having friends involved in violent intimate relationships (i.e., characterized by sexual or physical violence) is a risk factor for becoming both a perpetrator and victim of violence (Arriaga & Foshee, 2004; Foshee, Benefield, Ennett, Bauman, & Suchindran, 2004; Foshee, Linder, MacDougall, & Bangdiwala, 2001; Foshee, Reyes, & Ennett, 2010; McCauley et al., 2013). However, peers can also have a positive impact on intimate relationships. 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However, the potential for intervention can be by a that responsibility for action in group settings & To intervene as a to sexual assault, must the its warning the as responsibility for (i.e., a of personal and a sufficient level of (i.e., to & Studies have indicated as to sexual assault, young people often to meet these criteria (Banyard, Banyard, & 2014; Burn, 2009; & & 2011; McCauley et al., 2013; 2010; & with being less than to intervene (Banyard, Burn, 2009; & 2015; & 2011; Thus, bystander programs seek to sensitize young people to warning signs of sexual assault, create attitudinal that bystander responsibility for intervening (e.g., creating empathy for victims), and build requisite for taking action et al., 2004; Banyard, 2011; Burn, 2009; McMahon & Banyard, 2012). Many of these programs are implemented with large groups of adolescents or college students in the format of a single training/education session (e.g., as part of college orientation). However, some programs use broader implementation strategies, such as advertising campaigns signs are across college campuses to encourage students to act when witnessing signs of violence. The bystander model was and in the but has been for use in global By treating young people as potential allies in preventing sexual assault, bystander programs have the potential to be less threatening than traditional sexual assault prevention programs, which tend to approach young people as either potential perpetrators or victims of sexual violence (Burn, 2009; [Jackson] Katz, Messner, Instead of placing emphasis on how young people may modify their individual behavior to either respect the sexual boundaries of others or reduce their personal risk for being sexually assaulted, bystander programs aim to foster prerequisite knowledge and skills for intervening on behalf of victims. Thus, by treating young people as part of the solution to sexual assault, rather than part of the problem, bystander programs limit the risk of defensiveness or backlash among participants (e.g., decreased empathy for victims, increased rape myth acceptance; Banyard et al., 2004; Katz, 1995). 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