Gender-based violence (GBV)—defined as harmful acts, policies, and programs directed at a person or community based on their gender [1,2]—disproportionately impacts women, girls, and gender-diverse people [2]. GBV is a global health concern, contributing to severe health inequities among those impacted, including a disproportionate burden of chronic illnesses, suicidal ideation, posttraumatic stress disorder, traumatic brain injury, cardiovascular and degenerative neuromuscular diseases, depression, and addictions [3-5]. Despite these pressing health inequities, substantial barriers to appropriate and timely care persist, resulting in worsening health, ongoing violence, high rates of emergency department use, and premature and preventable death [6,7]. Structural features of the organization and delivery of care, including inadequate and/or inappropriate services; siloed care delivery models that overlook the complexity of women’s interrelated health and social concerns (eg, traumatic brain injury, poverty, or precarious housing); and previous negative clinical encounters that exacerbate mistrust in care providers (eg, discrimination, incomplete care) are well substantiated barriers [6,8-11]. Additionally, the structural disadvantages of poverty, precarious housing, and the multiple and competing demands women juggle to address basic health and safety needs for themselves and their families (eg, securing food, shelter, and income generation) intersect with other facets of health service delivery to exacerbate barriers to care [12-15].

Outreach, as a service delivery model, is an important strategy to help improve women’s engagement with the health care system [16-20]. While a universal consensus on outreach is lacking, it is generally described as a relational practice to locate and build connections with people chronically underserved in health care with the aim of linking them to essential health services (V Bungay et al, unpublished data, 2025) [16]. Outreach tends to occur in community settings where people spend their time, such as parks, drop-in centers, on the street [16,21], in their homes, and in emergency shelters [22-25]. Within health services programs, outreach has been used effectively to foster health care engagement among people experiencing homelessness, chronic mental health issues, and/or substance use-related challenges. Harm reduction supply distribution, health promotion education, crisis intervention, infectious disease testing, and linkages to emergency shelter and health care are common outreach services [16,19,20,26], with notable benefits of sustaining engagement with mainstream health services, improving access to housing, and reducing drug-related harms [26,27]. Outreach has also increasingly been undertaken with women experiencing intimate partner violence (IPV), which is markedly reported as the most predominant form of GBV [2]. IPV-related outreach services frequently include advocacy, emotional support, linkages to health and social services, and safety planning [25,28], and evidence indicates positive outcomes of reduced violence and improved physical and psychological functioning [24,28,29].

While extant evidence indicates promising results for outreach as a health promotion strategy, much research tends to be highly compartmentalized, focusing on women’s behaviors (eg, substance use), “choices,” and motivations as barriers to care, thereby overlooking the aforementioned structural and marginalizing conditions shaping women’s experiences of GBV, health, and care engagement [9,16]. Attention to structural features of society that create and sustain conditions of GBV and poor health is critical, particularly given the documented interrelationships between systemic inequities such as racism, ableism, sexism, and classism and women’s health and health care. Indigenous women, newcomers, and women living in poverty and/or with a disability, for instance, are substantially more likely than other women to experience GBV and barriers to appropriate and timely health care [30-34]. Such health service barriers are often a direct result of stigma and discrimination within clinical encounters, which increases the likelihood of insufficient or inappropriate care, women’s reluctance to engage with care, and leaving without care being completed [34-36].

In response to some of the gaps in outreach as a health service intervention specific to women experiencing GBV, we have witnessed increasing awareness of the relevance of trauma-informed—and trauma- and violence-informed—approaches to care engagement (Table 1). Such approaches recognize the need to create working relationships with women that build from women’s strengths and resilience and the obligations of service providers to foster safe, nonretraumatizing environments in which care occurs [28]. To date, many of these interventions have remained focused on IPV and women’s health care needs after leaving an abusive partner. While these studies are important, further intervention research is needed to advance outreach with diverse groups of women experiencing multiple and intersecting forms of GBV, particularly those experiencing the greatest violence severity, duration, and type. Moreover, as most research has focused on behavioral outcomes decontextualized from the marginalizing conditions of women’s lives, research designs that integrate data concerning structural facets of women’s experiences and their engagement with programming are urgently needed. Therefore, we are undertaking a multisite exploratory mixed methods study of implementing a strengths-based, trauma- and violence-informed outreach model with diverse groups of women experiencing GBV. The study participants comprise women experiencing varying forms of GBV and structural disadvantage who are simultaneously not well connected to health care or social services that can address their priority needs. We hypothesize that by centering women’s strengths and rights to self-determination and offering outreach through a harm reduction and trauma- and violence-informed care way, women will build working relationships with outreach workers over time, and we will explore how these relationships may influence changes in trust with outreach teams, women’s care engagement, and capacity for safety planning over time. These study findings may contribute to further development of outreach models that avoid siloed approaches to service delivery while supporting women’s rights to self-determination.

Guided by central principles associated with rights to self-determination, trauma- and violence-informed engagement, and harm reduction, and our aims to address the impacts of GBV for women’s engagement with health care, this study’s objectives are as follows:

The current study builds from an existing program of research aimed at improving health service delivery for women impacted by GBV and structural disadvantage, inclusive of stigma and discrimination in health care encounters [14,16,50,51]. Critical perspectives concerning marginalization, equity, inclusion, and social justice inform all aspects of this work. For our purposes, marginalization refers to the structural disadvantage associated with intersecting inequities, such as poverty, racism, ableism, sexism, stigma, and discrimination [1,14]. This structural disadvantage operates as socially and historically situated exclusion of individuals and communities from political, material, and economic resources that influence their opportunities for optimal health. Marginalization is often implicitly sanctioned, justified by beliefs and perspectives that create and sustain privilege of some in ways that subordinate and discriminate against those who are marginalized. Consequently, marginalization is deeply entwined with GBV and its negative effects for women [1,8,14,52]. For example, social norms that create and sustain the “feminine” as subordinate to “masculine” contribute to victim blaming of female survivors, which negatively impacts women’s likelihood to seek health care and/or other forms of support when victimized by violence [1]. Moreover, gendered pay-equity gaps sustain women’s poverty, thereby reducing options and opportunities for health. Such understandings of marginalization do not negate the agency of individuals. Given the socially constructed facets of marginalization, however, agency is understood as a series of social processes embedded in historical and social contexts in which people’s opportunities are activated in different ways depending on circumstances and context [37]. In keeping with our goals to tackle structural disadvantage and the related barriers to care (eg, stigma and discrimination in care encounters; siloed service delivery models) and our commitment to inclusive and equity-oriented approaches to service delivery, we codeveloped a holistic outreach model known as the community-led outreach and engagement (CLOE) intervention detailed below.

Health interventions, particularly those that aim to ameliorate health inequities among groups experiencing marginalization, are noticeably more effective when designed and implemented through fulsome community engagement [53]. Thus, our study draws on central tenets of community-based and participatory research approaches, including tackling core issues contextualized to the local communities in which the research is situated, integrating inclusive research teams comprised of community service leaders and staff, women with lived experience of GBV and academic researchers, and commitments to equity and justice. Together, these teams have undertaken a series of studies to inform the study protocol. Earlier exploratory research and systematic reviews identified 5 core principles underpinning outreach practice that were necessary to build and sustain working relationships between outreach service providers and women experiencing GBV [14]. These principles are detailed in Table 1. Research has also identified the core strategies to translate these principles into practice, the net results of which enabled women’s trust in the outreach teams as competent, respectful, and safe clinicians who could facilitate women’s engagement with essential health and social care services. These studies show promising exploratory results for improved health care engagement, including increased ease of accessing health care, obtaining a consistent primary care provider, enhanced sense of self-worth, and increased capacity of women to more autonomously navigate health and social care services (V Bungay et al, unpublished data, 2025) [54].

This exploratory study includes a 1-year outreach intervention across 2 study settings with women with lived or living experience of GBV. Given the exploratory nature of the study concerned with trends and context, a convergent mixed methods design [55] will be used to address the 5 objectives outlined above. Convergent designs enable researchers to collect and analyze quantitative and qualitative data separately and in parallel, merging and comparing results for a comprehensive understanding of trends observed during the intervention period and contextual features of participants’ experiences influencing trends observed [56]. Surveys and interviews with women who enroll in the project and participant case notes concerning their engagement with outreach workers comprise the data sources collected throughout the intervention period, which is expected to last from November 2023 to January 2026. Specifically, for our exploratory intervention study, surveys will provide the quantitative breadth by systematically gathering structured data with the entire sample, while the interviews will offer qualitative depth by allowing participants to articulate their experiences in their own words and through their own interpretations. This protocol was developed in accordance with American Psychological Association Style Journal Article Reporting Standards: Mixed Methods Article Reporting Standards.

The design and implementation of the study adhere to core principles of community-based participatory research [14,57,58]. As such, the research team represents a coleadership model inclusive of community service managers and staff, women with lived and living experience of GBV, and researchers with quantitative and qualitative expertise in women’s health and health care. Specifically, the need for a novel women-led, strengths-based, and trauma- and violence-informed outreach intervention was identified by community service leaders, staff, and women with lived or living experience [14]. A community advisory committee comprised of women with lived or living experience provided guidance and expertise on outreach strategies and training for interventionists. Community service managers contributed to protocol development, tailoring the intervention to their local context, and integration of the study into their existing programming. Named research partners will support delivery of the intervention, data collection and analysis, and be active in the dissemination of the results to appropriate stakeholders inclusive of peer-reviewed publications.

The study intervention settings, hereafter referred to as study hubs, include 2 nonprofit organizations in 2 Canadian provinces, detailed in Table 2. Each organization serves diverse groups of women with lived or living experience of GBV through central feminist principles of gender equity. The study hubs were purposely selected to maximize existing partnerships within the research team and the diversity of settings with established credibility for serving women impacted by GBV in their communities. Intervention activities have been tailored to the local contexts of the 2 community-service organizations, which are focused on providing various supports ranging from emergency and short-term shelter, outreach and education, harm reduction programming, and legal and victim-specific services. Intervention tailoring also considers the unique services and contexts of 2 different urban centers: 1 mid-sized city in East-central Canada, with an economy largely driven by manufacturing and its strategic location as a major US-Canada border crossing and hub for the auto industry; and 1 smaller city and outlying rural area in Western Canada, with economic ties to agriculture, tourism, and manufacturing.

In accordance with convergent mixed methods research, quantitative and qualitative data sources will initially be analyzed independently (ie, in parallel) prior to data integration [55,56].

The study protocol was approved by the Behavioral Ethics Review Boards at the University of British Columbia (H23-02810; H23-03111; H24-01477), the University of Windsor (23‐202; 23‐203; 24-177), and Dalhousie University (2023‐6999; 2023‐7000). Prior to data collection, all participants will provide written informed consent to participate in the research. Financial honoraria will be provided to all participants for surveys ($30 CAD [US $21.53]) and qualitative interviews ($50 CAD [US $35.88]). Only researchers involved directly with this study will have access to encoded data. Findings will be presented to stakeholders through community reports, policy briefs, and at national and international conferences, as well as published in peer-reviewed scientific journals.

This study examines the implementation of a strengths-based, trauma- and violence-informed outreach intervention for women experiencing GBV who are not well-connected to health and social services. We anticipate that relational outreach, grounded in harm reduction and respect for self-determination, will support the development of trust between participants and outreach teams and may be associated with increased engagement with health and social services and strengthened safety planning over time. The mixed methods design is expected to generate insight into contextual and structural factors shaping these trends, contributing evidence that extends beyond behavioral explanations of care engagement.

Existing research suggests that outreach-based service delivery models can improve engagement among populations experiencing structural marginalization, including individuals affected by homelessness, mental health challenges, and substance use-related harms [16-20]. Outreach interventions addressing IPV have similarly reported improvements in psychosocial functioning and safety-related outcomes [24,28,29]. However, much of this literature conceptualizes engagement primarily through behavioral or individual-level determinants and gives limited attention to the structural conditions shaping service access and use. As a result, the roles of intersecting inequities—such as racism, sexism, poverty, and disability—in shaping engagement processes remain underexamined.

This study extends prior work by embedding outreach within a trauma- and violence-informed care framework and explicitly situating engagement within interpersonal and structural contexts. In contrast to approaches focused narrowly on IPV or postseparation support, the protocol encompasses diverse manifestations of GBV among women experiencing intersecting social and economic disadvantages. By integrating quantitative indicators of engagement with qualitative exploration of lived experiences, the study seeks to advance conceptualization of outreach beyond an individual-level intervention toward understanding it as a relational and structurally mediated health service strategy.

Furthermore, the study incorporates outcome domains that are less frequently operationalized in outreach research, including trust in providers, navigation of fragmented service systems, and safety planning processes. Examining these dimensions alongside contextual accounts may generate insight into mechanisms through which outreach contributes to engagement and well-being. This multidimensional approach positions the research to contribute to methodological and conceptual gaps in the literature by foregrounding the relational dynamics, system-level barriers, and structural determinants that shape outreach effectiveness, thereby informing the design of more equitable service delivery models.

The study’s convergent mixed methods design enables integration of quantitative survey data with qualitative interviews and case-note documentation, supporting a nuanced examination of observable trends, participant experiences, and factors impacting trends [55]. Multisite implementation enhances contextual depth and allows exploration of variation across service settings [56]. Grounding the intervention in trauma- and violence-informed and harm reduction principles aligns with current best practices for engagement with populations affected by GBV [41-43].

As an exploratory protocol without a comparison group, the study will not support causal inference regarding intervention effectiveness, which, as noted earlier, is beyond the scope of an exploratory study. Sample size and potential attrition may limit statistical power and longitudinal interpretation. Findings may not be generalizable beyond similar programmatic or geographic contexts. Additionally, reliance on self-reported and program-generated data introduces the possibility of recall and reporting bias [56]. However, the inclusion of multiple data sources and time points can help alleviate potential bias.

Findings from this study will inform subsequent research examining outreach interventions for women experiencing GBV. Future work may include larger-scale or controlled evaluations to assess effectiveness and implementation outcomes, as well as adaptations across additional settings or populations facing intersecting structural inequities. Further development of measurement approaches capturing trust, relational engagement, and structural determinants of care access may also be warranted. Beyond research implications, study insights may inform program and policy development by supporting integrated, nonsiloed service delivery models that prioritize relational engagement and trauma- and violence-informed principles [14].

Study findings will be disseminated through academic, practice, and community-focused channels. Academic dissemination will include peer-reviewed publications and conference presentations. Practice-oriented outputs will be developed for service providers and community organizations, including brief reports, presentations, or webinars to support knowledge translation into program contexts. Community-engaged dissemination strategies will include plain-language summaries and stakeholder discussions to enhance accessibility and relevance for participating organizations and communities. Policy-relevant outputs may also be prepared to inform decision-makers regarding service integration and outreach approaches addressing GBV and structural barriers to care.