Postrape care services to minors in Kenya: are the services healing or hurting survivors?

A Systematic Review of Criminal Justice Initiatives to Strengthen the Criminal Investigation and Prosecution of Sexual Violence in East Africa

Sexual violence (SV) is a widespread public health and human rights problem, with countries in East Africa having higher rates than the global average. Prosecutions of SV in East Africa are rare, and survivors face many challenges accessing medico-legal justice and services. Developing initiatives that support survivors in navigating the criminal justice system is vital, yet there is limited research on efforts to improve the criminal justice system's management and treatment of survivors. We conducted a scoping review of research on initiatives to strengthen responses toward investigating and prosecuting cases. We identified 25 academic articles and reports through a search of electronic databases and gray literature that address these initiatives in East Africa. The results reveal that seven types of initiatives have been studied: one-stop centers (OSCs), multisectoral referral networks, gender desks, community interventions, mobile applications, and specialized police and prosecution units. Upon review, we found that barriers to success include a lack of resources and facilities, a lack of trained health care, police, and judicial personnel to perform services, weak medico-legal partnerships, and stigma and impunity restricting the uptake and fair distribution of services. Overall, limited systematic evidence on the effectiveness and adaptability of initiatives exists, showing that SV interventions in East Africa remain an under-researched and under-resourced area, and need greater scientific rigor to inform practice and coordinated advocacy. This review is a call to action for policy makers and service providers working in East Africa-and for international bodies working toward achieving Sustainable Development Goals 5-to improve criminal justice initiatives.

Conceptual Framework for Rape Survivors Diagnosed with PTSD in the North West Province of South Africa

The lack of a conceptual framework that can be utilized to manage rape survivors diagnosed with Post-Traumatic Stress Disorders presents a challenge in the North-West province. The study aims to provide a conceptual framework for managing rape survivors with PTSD in the province of the North-West using Practice-Oriented Theory and Donabedian's Structure Process Outcome Model Features. The research was conducted using an explanatory, sequential and mixed-methods approach. Additionally, used was the descriptive and explorative programme evaluation design. The results of the study demonstrated the significance of PTSD assessment before management interventions for rape survivors. The study findings outlined and designed a framework to assess and manage PTSD among rape survivors consulting at Thuthuzela Care Centre and those referred to hospitals for further management. The Practice-Oriented theory by Dickoff, James and Wiedenbach, and the Structure Process Outcome model by Donabedian served as points of reference for the development of the conceptual framework. The study is limited to North-West provincial healthcare facilities and Thuthuzela care centres (TCCs), however, it highlights the lack of a conceptual framework pertaining to the psychological management of PTSD rape survivors in the province and South Africa.

Evaluating the effectiveness of a mobile application to improve the quality, collection, and usability of forensic documentation of sexual violence

BACKGROUND

Survivors of sexual violence deserve timely and high-quality forensic examination, evidence collection, and documentation as part of comprehensive care. However, in many countries, the quality of medical-legal documentation is severely limited. MediCapt is an innovative digital application that enables clinicians to document forensic medical evidence as well as capture and securely store forensic photographs of injuries. This study evaluated the effectiveness and usability of MediCapt to document forensic medical evidence of sexual violence.

METHODS

This mixed-methods evaluation involved key-informant interviews, usability questionnaires, and forensic record reviews. Participants included clinicians, medical records personnel, information technology personnel, and health facility administrators, as well as law enforcement and legal professionals in Kenya.

RESULTS

The Physicians for Human Rights (PHR) data quality checklist found that using MediCapt led to significantly higher data-quality scores compared to paper-based forms. MediCapt forms scored higher on 23 of 26 checklist items. While a wide difference in quality was seen among paper-based forms, MediCapt appeared to both standardize and improve quality of documentation across sites. MediCapt strengths included data security and confidentiality, accuracy and efficiency, and supplemental documentation with photography. Weaknesses included infrastructure challenges, required technological proficiencies, and time to learn the new system. Although it is early to assess the impact of MediCapt on prosecutions, providers and law and justice sector professionals were optimistic about its usefulness. They identified MediCapt as appropriate for use with survivors of sexual violence and reported MediCapt's legibility and photography features had already been commended by the court.

CONCLUSION

MediCapt was well-received across all sectors, its use was perceived as feasible and sustainable, and it significantly improved the quality of collected forensic data. It is anticipated this improvement in forensic documentation will increase successful prosecutions, strengthen accountability for perpetrators, and improve justice for survivors.

Health care providers' responses to sexually abused children and adolescents: a systematic review

Background

Sexual abuse of children and adolescents is a significant health concern worldwide. Appropriate and timely health services for victims can prevent severe and long-term consequences. This study identified and categorized diagnostic and treatment services needed for sexually abused children and adolescents.

Methods

Several databases, including MEDLINE, Web of Science, Scopus, Science Direct, ProQuest, and Google Scholar, were searched to retrieve studies on the topic and clinical guidelines in English covering the literature from 2010 to 2020 using search terms. Primary studies and guidelines were reviewed to identify treatment strategies and medical interventions related to sexually abused children and adolescents.

Results

Twenty-one studies and guidelines were selected and analyzed narratively. The quality of evidence was relatively good. We identified that effective health care systems for sexually abused children include the following: interview and obtain medical history, physical and anogenital examination, collecting forensic and DNA evidence, documenting all the findings, prevention and termination of pregnancy, diagnostic tests, prophylaxis for HIV and other STIs, vaccinations, and psychological intervention.

Conclusions

This review provides up-to-date evidence about adequate health care services for children and adolescent victims of sexual abuse. We conclude that recent studies have focused more on prophylaxis against HIV and other STIs, studies on vaccinating against HPV for victims are still limited, and future research in this area is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07814-9.

Development and validation of a data quality index for forensic documentation of sexual and gender-based violence in Kenya

Introduction

High-quality forensic documentation can improve justice outcomes for survivors of sexual and gender-based violence, but there are limited tools to assess documentation data quality. This study aimed to develop and validate a data quality assessment index to objectively assess clinician documentation across the 26 key elements of the standardized forensic evidence forms used in Kenya.

Methods

Informed by prior quality assessment tools, an initial draft of the index was developed. Feedback from Kenya- and U.S.-based clinicians and human rights experts was solicited and incorporated into the draft index in an iterative fashion. Two raters independently employed the finalized Physicians for Human Rights Data Quality Index to assess and score the quality of documentation across 31 clinician-completed forms. Inter-rater reliability was determined using Cohen kappa (к) coefficients.

Results

The Index was found to have substantial overall reliability. Of the 26 documentation items, the Index had a perfect (к = 1.0) and almost perfect (к = 0.81–0.99) level of inter-rater agreement across 17 (65.4%) and 5 (19.2%) items, respectively. On a low-to-high documentation quality scale of 0 to 2, the majority of items (n = 19, 73.1%) had a mean documentation quality score >1.5–2.

Conclusion

Quality assurance of forensic documentation is an essential component of post-sexual assault care. To our knowledge, this is the first validated quality-assessment tool in the peer-reviewed literature for sexual assault documentation and may be a promising strategy to enhance the quality of sexual assault documentation in other settings, locally, regionally, and internationally.

Challenges in Supporting Survivors of Child Sexual Abuse in Kenya: A Qualitative Study of Government and Non-governmental Organizations

Child sexual abuse (CSA) is a global, social, and health challenge. Existing literature on post-sexual assault care has focused largely on health providers' skills and capacity to offer quality clinical, medicolegal, and psychosocial care. Services other than medical and psychosocial care provided to survivors of CSA remain poorly studied, particularly in the global south. The study aimed to explore challenges facing service providers supporting children who have experienced sexual abuse and make suitable recommendations. We triangulated different qualitative methods: in-depth interviews with 61 key informants, three focus group discussions with community leaders, and unstructured observations for data collection. Findings indicate that service providers supporting children who had experienced sexual abuse play a vital role in ensuring that survivors receive clinical and medicolegal care, psychosocial support, have access to justice, and are protected from further victimization. However, these service providers face several challenges, including poor infrastructure, the lack of effective coordination and linkage among the service providers in the continuum of care, corruption among officials, and harmful patriarchal norms that hinder reporting of abuse. To effectively support and care for survivors, we recommend government commitment to, and investments in, safe spaces, supervision, and professional development of providers. Working with community leaders and gatekeepers of all genders is critical to address harmful practices that perpetuate CSA and make it difficult to care for and obtain justice for CSA survivors.

The use of case advocates to manage child survivors of sexual violence in public health facilities in Kenya: A qualitative study exploring the perceptions of child survivors, care givers and health care providers

BACKGROUND

The uptake of and retention in health services by child survivors of violence (CSV) is a growing challenge, especially in sub-Saharan Africa. While lay health workers have been used in several settings to improve access to health services, there is limited literature on the use of such workers to support services for CSV.

OBJECTIVE

To explore the acceptability of using trained lay health workers (case advocates) to provide basic information and escort CSV to various referral points within two public health facilities in Kenya.

PARTICIPANTS

The following participants were enrolled after giving their consent: CSV 14-18 years of age presenting for services along with their caregivers during the study; caregivers above age 18; and healthcare providers (HCPs) providing services for sexual violence at the two study sites.

METHODS

In-depth interviews (14 with CSV and 27 with caregivers) and four focus group discussions (with 30 HCPs) were conducted. Data were transcribed in MSWord and analysed using a grounded theory analytical approach.

RESULTS

Caregivers and CSV reported that the case advocates were useful in fast-tracking access to services, easing CSV movement through health facilities and helping CSV communicate their issues. HCPs reported improved timeliness and completeness of services due to the involvement of the case advocates.

CONCLUSION

The use of case advocates to support CSV is acceptable to children, caregivers and HCPs. Task-sharing between case advocates and HCPs has the potential to improve the uptake of the various services offered to CSV, especially in resource-limited settings.

A review of the literature on good practice considerations for initial health system response to child and adolescent sexual abuse

BACKGROUND

Healthcare workers play an important role in responding to the needs of the millions of children and adolescents who experience sexual abuse around the globe. A supportive child and adolescent-centered initial response is crucial for the physical and emotional wellbeing of survivors.

OBJECTIVE

In 2017, the World Health Organization (WHO) published clinical guidelines for responding to child and adolescent sexual abuse. The review described in this paper informed the development of good practice statements on how best to deliver health care to survivors.

PARTICIPANTS AND SETTING

This review examined the values and preferences of children and adolescents who were sexually abused, and of their caregivers and healthcare workers, regarding: 1) initial response to children and adolescents who have been sexually abused; and 2) obtaining medical history, conducting physical examination, and documenting examination findings.

METHODS

Searches were conducted in Scopus, Pubmed, and the WHO's Global Index Medicus (1 January, 1995-15 July 2016). All articles in English that indicated preferences of survivors, caregivers and/or healthcare workers in ensuring empathetic and trauma-informed care were included.

RESULTS

Sixty-two articles were included and analyzed thematically. Key findings included the importance of providing care to survivors in a manner that respects the child or adolescent's autonomy and wishes, ensures privacy and confidentiality, and makes services and facilities appropriate and welcoming.

CONCLUSIONS

Findings indicate how evidence-based recommendations can be delivered in a child or adolescent-centred and trauma-informed manner.

Sexualised violence against children: a review of laws and policies in Kenya

Child sexual abuse (CSA) is a major global health challenge. Extant literature shows that CSA is prevalent in Kenya. As a signatory of the United Nations Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child, the Kenyan government is mandated to ensure that children are protected from sexual abuse through sound laws and policies. This paper reviews existing laws and policies on CSA and highlights their strengths and weaknesses. Our findings indicate that laws on child protection exist and are protective to a large extent, as harsh penalties are outlined for sexual offences. Survivors of CSA are entitled to free legal and medical services. However, there are no reparations offered to survivors in criminal proceedings. Moreover, there is no legislation on age-appropriate comprehensive sexuality education which plays an important role in cultivating positive gender norms and describing what constitutes CSA and reporting procedures. The national standard operating procedures for the management of sexual violence against children lack CSA screening procedures. There is urgent need for review of these laws and policies and development of multisectoral protocols at the national and county level, that outline roles and responsibilities for various service providers, supervisory and accountability measures and referral networks.

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

Background

In 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.

Methods

A 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.

Results

Among 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.

Conclusions

Nationally, 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.