Missed treatment opportunities and barriers to comprehensive treatment for sexual violence survivors in Kenya: a mixed methods study

Abstract

BackgroundIn Kenya, most sexual violence survivors either do not access healthcare, access healthcare late or do not complete treatment. To design interventions that ensure optimal healthcare for survivors, it is important to understand the characteristics of those who do and do not access healthcare. In this paper, we aim to: compare the characteristics of survivors who present for healthcare to those of survivors reporting violence on national surveys; understand the healthcare services provided to survivors; and, identify barriers to treatment.MethodsA mixed methods approach was used. Hospital records for survivors from two referral hospitals were compared with national-level data from the Kenya Demographic and Health Survey 2014, and the Violence Against Children Survey 2010. Descriptive summaries were calculated and differences in characteristics of the survivors assessed using chi-square tests. Qualitative data from six in-depth interviews with healthcare providers were analysed thematically.ResultsAmong the 543 hospital respondents, 93.2% were female; 69.5% single; 71.9% knew the perpetrator; and 69.2% were children below 18 years. Compared to respondents disclosing sexual violence in nationally representative datasets, those who presented at hospital were less likely to be partnered, male, or assaulted by an intimate partner. Data suggest missed opportunities for treatment among those who did present to hospital: HIV PEP and other STI prophylaxis was not given to 30 and 16% of survivors respectively; 43% of eligible women did not receive emergency contraceptive; and, laboratory results were missing in more than 40% of the records. Those aged 18 years or below and those assaulted by known perpetrators were more likely to miss being put on HIV PEP. Qualitative data highlighted challenges in accessing and providing healthcare that included stigma, lack of staff training, missing equipment and poor coordination of services.ConclusionsNationally, survivors at higher risk of not accessing healthcare include older survivors; partnered or ever partnered survivors; survivors experiencing sexual violence from intimate partners; children experiencing violence in schools; and men. Interventions at the community level should target survivors who are unlikely to access healthcare and address barriers to early access to care. Staff training and specific clinical guidelines/protocols for treating children are urgently needed.

Clinical Care of Victims of Interpersonal Violence and Rape in Tanzania: A Qualitative Investigation

“…Most providers, and especially the students, were unclear about their ethical and legal responsibilities to these victims. This lack of training may be a regional problem as evidenced in studies from other parts of sub-Saharan Africa, 11,12,33,43 and elsewhere. 15,36,44,45 Across Africa, providers need training in how to treat both rape and IPV victims, when and how to refer, and the procedures in the collection and handling of forensic evidence.…”

“…21 In our case study, some experienced providers appeared unaware about the availability of rape kits, collection procedures including sample contamination, and its transportation. Studies in other parts of Africa have also reported poor healthcare provider knowledge of forensic evidence protocols including evidence collection 11,12,15,33,43 and a shortage of specialized units for rape victims with reference to studies done in Kenya, Ghana and South Africa. 11,46,47 These units act as "one stop centers" in managing assault survivors in a holistic approach, catering for victims' physical and mental health as well as judicial and welfare needs.…”

“…Other studies from Kenya and outside Africa report similar results. 12,44 This law increases the chances of victim safety and it allows earlier detection of victims, providing necessary intervention and referral to other required services. 18 However, such laws may also present some challenges for survivors, including a fear of seeking medical help if the information might be used by legal authorities to prosecute the perpetrator.…”

“…In such training, students need to be taught both their legal duties and clinical protocols for management of violence-related cases. 12,20,21 Such policies and guidelines should also be part of continuing education to experienced health professionals in order to reduce uncertainties when providing care to victims.…”

“…7,8,10 Across Africa, victims of GBV including rape victims face enormous challenges when receiving health services. 11,12 Providers' misconceptions, judgements, unaccepting attitudes, and stereotypes around various forms of violence acts may increase the risk of patients not disclosing about their health status and violence experiences. 13,14 Given the lack of training, the health providers' responses towards victims may reflect their own personal experiences, values and sociocultural beliefs.…”