The use of evidence for improving the delivery of post-rape care in South Africa

Abstract

Rape is a human rights violation and has significant health and social impact. South Africa, with its historical background seeped in violence has high levels of crime including a high prevalence of rape. As such, the South African government has made some efforts to improve the health and criminal justice response to rape, but in general these have been slow, disrupted or reversed. A review of the literature on post-rape health care has indicated that there are areas in the delivery of service where sufficient evidence is lacking, and where research is available, high quality work has predominantly been undertaken in high-income countries. The aim of this thesis was to strengthen the evidence base for post-rape care service in South Africa by addressing some of the gaps in the literature. Methodology For the thesis, data from three studies are presented in three published and one unpublished article. The first study consists of a systematic review of articles published between 1990 and 2014 that evaluated the effect of health system models of care on survivors of rape or IPV in terms of health outcomes, rape or IPV recurrence, provision of related services, and referrals. The second study was related to a national post-rape care training programme. Baseline knowledge and confidence were assessed and multivariable analyses were done to test for factors associated with higher knowledge and confidence levels. The change in knowledge and confidence was also calculated from baseline to post-training, and factors associated with these changes were tested through two logistic models. The final study comprised of a review of a random sample of rape cases that were reported in Gauteng province in 2003. In the second publication, descriptive analyses were done to present the pattern of genito-anal injuries. In addition, logistic regression was done to test for survivor, rape and examination characteristics that were associated with the absence of genito-anal injuries in all survivors and those who had no previous sexual experience. Findings In the first study, no model of post-rape or IPV care could be recommended in relation to the tested outcomes due to the lack of studies on that evaluated the effect of a post-rape model of care on the specific outcomes, and due to the lack of high quality studies on IPV models of care. In the second study, it was found that the knowledge of health care providers was low although confidence was high. Higher baseline knowledge was associated with rank, having an appropriate attitude towards rape, and having served less time at the current facility, while higher confidence levels were associated with having a crisis centre in the facility and being involved in care of survivors. Significant improvements in knowledge and confidence levels were noted after the training, and providers with lower levels of empathy were found to have greater changes in knowledge. The facility level and baseline knowledge and confidence levels were associated with change in confidence. An earlier publication from the final study, for which I was a co-author, showed a strong association between the documentation of injuries and case progression in the justice system, so it was considered important to test for the factors associated with the absence of injuries in this study population. Here it was noted that there was a significantly greater odds of having injuries in survivors who were virgins, if multiple perpetrators had raped survivors, and if doctors with additional qualifications had examined survivors. Conclusion The findings of this thesis have implications for post-rape health care services in three broad focus areas: the organisation of services, the selection and capacitation of providers, and the interpretation of medico-legal evidence in term of genito-anal injuries. Proposals are suggested regarding potential improvements that could be made to post-rape care services in South Africa. The findings provide evidence for some of the principles in the South African National Sexual Assault Policy and raises important questions for future research work such as the need to critically evaluate the Thuthuzela one stop model that is being implemented in South Africa.