Abstract
INTRODUCTION
An estimated one in three women globally experience sexual violence (SV) and intimate partner violence. MSF has provided comprehensive medical and psychosocial care for SV and IPV survivors in Port-au-Prince, Haiti, and Delhi, India, since 2015. We aimed to understand the knowledge, attitudes, and practices (KAP) surrounding SV and care-seeking pathways, to improve access to and uptake of services.
METHODS
We conducted two sequential mixed-methods studies between March and October 2018. Quantitative data were collected using a KAP survey in randomly selected households. Qualitative data were collected using in-depth interviews (IDI’s) with key stakeholders and focus group discussions (FGD’s) with community members; in Haiti FGD’s with young people and IDI’s with survivors of SV were also done.
ETHICS
These studies were approved by the ethics committee of the Dr. B.R. Ambedkar Medical College in India (for Delhi), the Comité National de Bioéthique in Haiti (for Port-au-Prince), and the MSF Ethics Review Board (for both).
RESULTS
2340 people participated in household surveys: 1083 in Haiti and 1257 in India. Qualitative data were collated for 382 individuals: 289 in Haiti (24 adult FGD’s, eight youth FGD’s, 15 IDI’s with key stakeholders and eight IDI’s with SV survivors during their follow-up visit) and 93 in India (14 adult FGD’s and 12 IDI’s with health workers). We found an almost universal perceived need for medical care for SV survivors, mostly for injury treatment. However, in both contexts, participants described numerous issues perceived to hinder or prevent survivors seeking and accessing care. Shame, fear of stigma, and social consequences were the most significant barriers reported, compounded by major service-level barriers. There were also context-specific factors. In India, lower knowledge of health consequences and available treatment, combined with media-influenced perceptions of rape as a physically violent event and a 'police issue' were major barriers, compounded by mandatory police reporting and a lack of confidentiality in health facilities. In Haiti, knowledge of medical consequences and care needs was higher than in India, but perceived lack of services, their inaccessibility, and high costs impeded access to care. Participants in both studies explained that most survivors were likely to stay silent. Those who would seek medical help would do so only should physical consequences (eg injuries) arise. A key factor facilitating access to care was support from trusted confidants; improving access would require enhancing social support and facilitating community referral networks, combined with ensuring provision and awareness of quality, comprehensive, confidential care.
CONCLUSION
Sociocultural conceptualisations and structural responses to SV influence perceived and lived consequences for survivors, shaping engagement with support and available services. These findings inform MSF's SV response, supporting adaptation of modalities of care provision and augmenting local knowledge and networks to improve access. We propose a model for understanding context-specific factors affecting access to survivor-centred care in different settings, to better inform development of strategies and activities to improve access and service utilisation.
CONFLICTS OF INTEREST
None declared.
