Abstract
This survey-based study gathered information on health professionals’ attitudes and behaviors regarding victims of sexual assault, focusing on the applicability and utility of best practices put forth by the World Health Organization and the United Nations. This cross-sectional study involved a self-administered, 84-question survey to health care professionals affiliated with Mulago National Referral and Kayunga Hospitals in Uganda. The survey included demographic questions as well as questions about participants’ attitudes toward sexual violence and the role of HPs in addressing sexual violence. The remainder of the survey transformed two sets of international guidelines into a series of statements with which participants could agree or disagree using a Likert-type scale. In total, 75 partially or fully completed surveys were collected, 45 from Mulago, and 30 from Kayunga. A minority of participants indicated that the guidelines were unrealistic (4.1%) or culturally inappropriate (14.1%). Most HPs agreed (91.8%) with the key components of recommended care. However, many respondents highlighted the need for additional training (68%). Nearly half of participants were uncertain or disagreed that there was a clear protocol for care of survivors of sexual violence (48%). Targets for improvement identified by participants included enhanced support of staff, access to resources, and relationships with community partners. Ugandan HPs have been receptive to the World Health Organization and United Nations guidelines. The majority of participants felt that the guidelines were realistic and culturally appropriate. Furthermore, many of these guidelines have been implemented. However, additional steps identified by Ugandan health workers could be undertaken to further improve the care received by survivors of sexual violence.
Introduction
Sexual violence can have devastating consequences for the physical and psychological health of survivors, and optimal care of survivors is a stated goal of the World Health Organization (WHO) and the United Nations Inter-Agency Standing Committee (IASC, 2005) Task Force on Gender and Humanitarian Assistance. Despite this focus, accurate estimates of its prevalence and even consensus on its definition remain elusive.
An international crime victim survey found that between 0.3% (Philippines) and 8% (Brazil) of women more than 16 years of age reported sexual assault in the past 5 years (Krug et al., 2002). In a systematic review of published population-based data, an estimated 11.4% of women in eastern sub-Saharan Africa are affected by nonpartner sexual violence based on 43 prevalence estimates (Abrahams et al., 2014). Variations in reported prevalence and incidence may reflect local practice of disclosure, and these figures are likely an underestimate. Therefore, a much larger percentage of the global population is affected by, but does not report, sexual violence.
A survey conducted domestically revealed that 28% of women and 11% of men in Kampala report experiencing sexual violence (Nayiga, 2009). Notably, Uganda’s annual crime report found a 14.5% increase in reported rape from 2009 to 2010, despite an overall 4% reduction in crimes on a national level (Kayihura, 2011). This trend remained in the 2014 report, which found a 49% increase in investigated rapes in the background of a 0.5% decrease in overall crime (Kayihura, 2013). These data not only show the persistence of sexual violence as a significant public health issues, as it is elsewhere, but also reflect the impact of sexual violence as a tool of conflict. Northern Uganda has been affected by warfare over the past several decades with research indicating that nearly 30% of women in affected areas report war-related violence by both members of the Lord’s Resistance Army and government soldiers (Kinyanda et al., 2010).
Some data have been reported on sexual violence survivors’ experience in Uganda. At a large referral hospital in Uganda, most sexual violence survivors presented for care more than 24 hr after assault, few returned for 3 month follow-up testing, and no one received HIV prophylaxis (Ononge, Wandabwa, Kiondo, & Busingye, 2005). Furthermore, in a survey evaluating predictors of intimate partner violence, there was a significant association between Ugandan men who reported violence and high-risk sexual behaviors (Francisco et al., 2013). The authors concluded that stereotypical gender roles connect these behaviors and support ongoing violence against women (Francisco et al., 2013), attitudes and norms that are modifiable as shown in a community mobilization intervention by the same study group (Abramsky et al., 2014). No doubt, these complex intersections between gender and violence shape the environment in which survivors seek and health care professionals provide care. Already, a significant portion (estimated 42%) of Ugandans ultimately do seek help following sexual crimes, supporting a high likelihood that health care professionals have cared and will care for sexual violence survivors (UDHS, 2012). Health care systems should optimally provide comprehensive care following a sexual assault, including pregnancy prevention, STI testing and prophylaxis, treatment of injuries and provision of psychosocial counseling (WHO, 2003). Therefore, data on health care professionals’ behaviors and attitudes regarding sexual assault are critical. Uganda is not unique in its effort to respond to the epidemic yet preventable problem of gender-based violence; however, the means of combatting this problem will have unique features, which published international guidelines may not acknowledge.
International guidelines for the response to sexual violence in health care settings exist, but actual practices vary. Global standardization of response may fail to appreciate the unique strategy of individual communities and the reality of implementing a complex response system presents challenges. There are scant data on the role of health care professionals in responding to sexual violence survivors in resource-limited settings. Previous systematic review has found a wide range of health care professionals’ knowledge and attitudes, including discomfort with examination of this patient population, concerns regarding confidentiality and lack of clarity of role (Gatuguta et al., 2017). In one assessment of care provision to sexual violence survivors in South Africa, investigators documented a lack of treatment protocols, fragmented service delivery, limited training, and negative attitudes of service providers (Kim et al., 2007). In a study based in Kenya, limited forensic services were provided to those affected by sexual violence because of “flawed evidence collection, difficulties in collecting samples and bottlenecks caused by shortages of doctors”(Ajema, Mukoma, Kilonzo, Bwire, & Otwombe, 2011).
In the current study, our aim was to gather information on Ugandan health professionals’ (HP) behaviors and attitudes regarding sexual assault, focusing on the applicability and utility of best practices put forth by the WHO and IASC task force. Specific study objectives included an assessment of the integration of these guidelines into current practice, identification of barriers to guideline integration, and exploration of the changes recommended, if any, by local HPs.
Method
The study was conducted in the Republic of Uganda, a landlocked country in East Africa with an estimated total population of 35 million (Central Intelligence Agency [CIA], 2017). The country is divided into 112 political and administrative districts. Kampala district is the country’s major urban center with approximately two million inhabitants and home to the country’s largest hospital, Mulago National Referral Hospital. The capital city of Kampala is a multiethnic city with diverse socioeconomic groups. In contrast, Kayunga district is a rural area with approximately 300,000 inhabitants predominately from one ethnic group, the Baganda (UDHS, 2012). At both of these hospitals, a protocol for response to sexual violence survivors was not available; this was confirmed via personal communication with leadership at Raising Voices and the Center for Domestic Violence Prevention, organizations that provide leadership domestically on matters concerning violence against women and have a close relationship with study sites and the Ministry of Health. (Y. Alal, personal communication, September 28, 2016).
Data
The study was administered at two sites: Mulago Hospital in Kampala and Kayunga District Hospital in Kayunga. Mulago Hospital is a 1500-bed hospital with emergency wards, chronic care inpatient wards, and outpatient clinics. Because of the large number of hospital staff, the study was carried out within the Department of Obstetrics and Gynecology whose staff manage approximately 39,000 deliveries a year (Ministry of Health, 2018). Staff of the Obstetrics and Gynecology department were among the most likely to care for survivors of sexual violence, particularly during service in the Gynecology Emergency Ward, and therefore, were deemed to be relevant stakeholders during study planning with faculty of the Makerere University College of Health Sciences. The second study location was Kayunga District Hospital. It is the only hospital in the district and has 100 beds distributed among male, female, pediatric, and maternity wards. Kayunga Hospital also has general outpatient services and specialist clinics. Both hospitals are affiliated with Makerere University.
This cross-sectional study involved a self-administered, 84-question survey. A survey was chosen as the preferred method of data collection over in-person interviews because of the sensitive nature of the topic. The survey collected basic demographic information: age, gender, profession, years in the profession, and site. The survey then asked about participants’ attitudes toward sexual violence and the role of HPs using a Likert-type scale. This included participants’ agreement with the WHO definition of sexual violence, exposure to sexual violence survivors, screening practices, perception of sexual violence as both a crime and public health issue, and identification of barrier to care. The remainder of the survey transformed the two sets of international guidelines into a series of statements with which participants could agree or disagree, also using a Likert-type scale. The content of the survey was derived from the criteria set forth by the WHO for service provision (Chapter 3; WHO, 2003) and the United Nations IASC minimum prevention and response guidelines for sexual violence-related health services (Action Sheet 8; IASC, 2005). The IASC produces global recommendations for improved multisectoral humanitarian assistance. The gender-based violence guidelines provide an international standard to meet the needs of sexual violence survivors, particularly, in emergencies or conflict areas. The WHO guidelines are a tool to guide specifically health workers in their daily practice as well as provide a framework to policy makers in shaping local services for comprehensive and sensitive care of this patient population.
Survey prompts included questions regarding access, training and staffing, forensic services, supplies and resources, and future improvements. Each section concluded with an open-ended question and participants were free to write additional comments. The question stems are included in the tables.
Participant recruitment occurred for 2 weeks at Mulago Hospital and 1 week at Kayunga Hospital. More time was allotted to Mulago because it is a significantly larger institution. The principal investigator (K.F.) met with hospital leadership, at both Mulago and Kayunga hospitals, to ensure that the staff were aware of ongoing research and understood the research goals. In addition, announcements about the study were made 3 times at Department of Obstetrics and Gynecology of Mulago Hospital staff meetings. In Kayunga, there were no formal staff meetings during recruitment such that most study awareness was spread through outreach to individual staff members. When staff members were on break from clinical duties, the study investigator approached them and introduced the study. Most health care professionals were already familiar with the study because of prior announcements and information from hospital leadership. Staff were invited to complete the study in private and return it to a secure drop box, completed or empty. The first page of the survey included a consent form. Completion of all or part of the survey and return to the drop box implied consent.
Inclusion criteria were any health care professional, including but not limited to physicians, nurses, midwives, and community health advocates, who would potentially provide service at Mulago Hospital’s Department of Obstetrics and Gynecology or at Kayunga District Hospital. Survey participants were not expected to have prior knowledge of international guidelines. Participants were required to know how to read and write. All staff approached were fluent and comfortable communicating in English.
Analysis
Quantitative data analysis was conducted using the software program SPSS22 (Corporation, 2013). Qualitative responses were analyzed to inform the quantitative results and direct quotations have been included to illustrate specific points.
Ethical Approval
Informed written consent was obtained from all participants. Participants could complete the survey on their own time and return it anonymously. This study received Northwestern University Institutional Review Board approval (STU00063825) and Makerere University School of Biomedical Sciences Research and Ethics Committee approval (SBSREC-048).
Results
Ninety-two surveys were given out at Mulago Hospital and 43 surveys were given out at Kayunga District Hospital. In total, 75 partially or fully completed surveys were collected: 45 of 92 (49%) surveys were returned from Mulago and 30 of 43 (70%) surveys from Kayunga.
Demographic characteristics of participants are shown in Table 1. The study population was 57.3% female and 40% male (2.7% unknown). The vast majority (85.3%) of participants were below 45 years of age. A wide variety of professions were recruited from both sites. For employer, nearly three quarters of participants listed Mulago Hospital or Kayunga District Hospital as their home institution. Others were employed through international organizations, government organizations, or were visiting from another university.
Demographic Characteristics of Survey Participants.
Other included Makerere University Walter Reed Project (3), Ministry of Health, Nakaseke Hospital, Mbarara University, Kamwenge District Local Government.
Overall, participants’ responses showed that they were receptive to the WHO and IASC guidelines (Table 2, Future Improvements). After reviewing the elements of the guidelines, a minority of participants indicated that the guidelines were unrealistic (4.1%) or culturally inappropriate (14.1%). Most participants agreed or strongly agreed that they (71.6%) and their colleagues (72.6%) were committed to providing sexual violence survivors quality care. In terms of attitudes toward sexual violence, 96% of participants agreed that sexual violence is a crime and 89% reported that it is a significant problem in their district. A majority (93.2%) of participants agreed with the presented definition of sexual violence, however, 6.8% “strongly disagreed.” No comments were written in the questionnaire to expound on these opinions. One hundred percent of participants believed that sexual violence affects survivors’ health. Despite these opinions, over half of participants reported that they did not regularly screen patients for sexual violence (Figure 1).
Beliefs About Sexual Violence.
Note. HPs = health professionals.
All of the values were calculated from valid responses. Missing data were not included.
The values under “Strongly Disagree” to “Strongly Agree” are given in the format of “% (n)”
The World Health Organization definition was placed above the question: “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including, but not limited to home and work.”
These questions were preceded with “Based on the questions above about specific guidelines regarding access, staffing/training, forensic exams, and supplies,”
Response to statement regarding regular screening for sexual violence by percentage.
Participants’ opinions on the delivery of care varied widely (Table 3). Most HPs (91.8%) agreed or strongly agreed with the statement that the key components of health care for sexual violence survivors include an account of the assault, a thorough physical exam, attendance to a survivor’s emotions, access to prophylactic (contraceptive, sexually transmitted infection) care, and forensic management. The majority of respondents knew the elements of forensic evidence collection, but the resources needed to perform services were not available at all times. Knowledge of the need for emergency contraception (85%) and screening and treatment for sexually transmitted infections (95.9%) was high.
Support of Health Professional in Responding to Sexual Violence.
All of the values were calculated from valid responses. Missing data were not included.
The values under “I Do Not Know” to “Strongly Agree” are given in the format of “% (n)”
This question was placed in “The Health Professional’s Role in Sexual Violence Response” survey section, which did not include the option “I Do Not Know.”
Just over half of participants (58.9%) believed that providers were well prepared to care for survivors of sexual violence and that providers were competent to perform sexual assault assessments (61.4%). However, many respondents (68%) highlighted the need for additional training. One HP noted: Sexual violence is still a rather new concept. Many of us who trained more than 10 years ago did not have it incorporated into our curricula. There is [a] need for sexual violence to become part of pre-service training and for orientation of all those already working.
Others mentioned that most of the available training occurs at workshops and conferences when trainees are working and, therefore, unable to attend.
Participants were less positive about the availability of support and supervision for staff providing care to survivors. Only 52% agreed that a protocol existed for the care of survivors of sexual violence. Importantly, 61.6% felt that staff did not have adequate time to give survivors necessary attention, and only 41.9% reported that services were available 24 hr a day. One HP stated: There is no clear protocol to respond to sexual violence, no support for staff who serve and no appropriate supervision. Health workers should be given enough training on how to handle sexual violence care. Enough staff should be employed to handle the cases and give enough time to survivors.
Over 25% of participants either did not know or did not agree that Police Form 3, the official medical form required to pursue cases in the criminal justice system, was used at their facility.
Many of the WHO and IASC guidelines had been implemented, although ongoing challenges identified included access to supplies, distance to care, and ability of patients to return for follow up visits. Forty participants (62.7%) reported that there were barriers to change, and 96.2% of these agreed that the barriers to change were mostly based on supplies or structural problems. Many of the recommended supplies were not consistently available to health workers. Supplies that were regularly unavailable included pads/tampons, towels, tweezers/combs, plastic specimen bags, paper bags, drop sheets, pregnancy testing kits, and anal speculums (Table 4). Furthermore, services were difficult to access for some survivors as only 36% of participants stated that care was walking distance or easily accessible and only 33.8% agreed that all necessary services were available in one location. A minority of participants (37.9%) believed that community members were aware of the services available for survivors. One participant did note that at times the “health worker [travels] to where the victim is due to lack of transportation.”
Sexual Violence Supplies Accessible to Health Professionals.
Note. STI = sexually transmitted infection.
All of the values were calculated from valid responses. Missing data were not included.
The values under “Never” to “Always” are given in the format “ (n).”
The full question stem is “Drop sheet (to collect hairs, fibers, etc.).”
Many participants identified gaps in successful collaboration with community partners. One participant noted, “the staff fear anything concerning the law” this participant also described the low opinion of HPs within the criminal justice system and poor sensitization to sexual assault by the community at large. Another participant confided that there is no funding for transportation when HPs are called to testify. Unfortunately, forensic services are limited not only by supplies and training, but also, per multiple HPs, jeopardized by broken chain of custody and reliance on police for forensic forms. One participant stated: “Forensic exams should not be an option, but rather a part of management. Not only police forms [should be used. There are also] standard forms for the hospitals.” In addition, HPs expressed concern over their security and the security of survivors. Nearly, one third (31.2%) of HPs noted that private rooms are not ensured and 25.8% HPs did not think confidentiality is ensured. Neither Mulago nor Kayunga Hospitals have video surveillance, a guideline recommendation.
Twenty five percent of HPs wrote in their surveys about the stigma concerning sexual violence, with one person noting that some communities may “conceal the offender” should police come looking for him or her. Others stated survivors refrain from reporting because of stigma and cultural beliefs, highlighting the need to have “a high index of suspicion to detect the silent victims or survivors.”
Discussion
This study assessed the opinions of Ugandan HPs regarding their care for sexual violence survivors, through the lens of established international guidelines. Ugandan HPs are invested in being advocates for and providing quality care to sexual violence survivors. This is in line with the sentiments expressed at the WHO workshop in June 2014 in Entebbe, Uganda, where representatives from surrounding countries reviewed guidelines and reflected that while the framework for such response is endorsed, the actualization has been limited (Institute of Medicine and National Research Council, 2015). Provision of care is challenging, however, due to issues of accessibility of services, coordination with police, appropriate staffing and training, and sufficient resources.
Perceptions and Professional Role
Participants were overwhelmingly positive regarding the importance, relevance, and commitment to sexual violence care. There was largely agreement among participants on the definition and criminality of sexual violence, two areas where data have shown conflicting reports from surveyed health care professional populations. In general, this field of research has been plagued by inconsistent definition of the acts that constitute sexual violence, undermining the generalizability, or even understanding of, research findings. Lack of consensus definitions also affects survivor justice. For example, a study with regional data from Kenya demonstrated that legal outcomes from sexual assault cases were jeopardized by medical providers’ “lack of clarity and uniformity in practitioners’ definition of sexual violence,” (e.g., failing to appropriately report or define the violent acts survivors endured or having conflicting terminology in describing a survivor’s experience; Ajema et al., 2011). In terms of statue, Uganda is notable for the progressive nature of its constitution, including specific laws regarding domestic violence, female genital mutilation, and trafficking; further, Uganda is a signatory to UN’s Convention on Elimination of All Forms of Discrimination against Women, Declaration of Elimination of Violence Against Women, and Protocol to the African Charter on human and People’s Rights on the Rights of Women in Africa. However, illustrated through testimony from David Batema, a judge in the High Court of Uganda, there is a pervasive “culture of silence,” which prevents enforcement (Institute of Medicine and National Research Council, 2015). Thus, while there are statues that criminalized violence against women, historically, these acts have not been reported to authorities nor prosecuted like other crimes. The agreement on the criminality in this study suggests a paradigm shift in the perception of sexual violence.
Participants indicated that guidelines were realistic and culturally appropriate. One of the critical findings in this study is that the IASC and WHO guidelines are acceptable resources for Ugandan health care providers. Hospitals and policy makers should promote structural change to foster adherence to the guidelines, particularly in the interim while national guidelines are developed and implemented.
Access
Services are often not within walking distance of survivors or available in a single location, especially in rural areas. The current system in which survivors travel to centralized areas for medical care, while practical, may limit care and justice for survivors due to structural (transportation), psychosocial (fear of reporting), and informational (lack of awareness) barriers. Although it is unlikely that home visits could regularly be provided, a future area of focus could be to examine the possibility of expanding a service of forensically trained HPs traveling to more rural areas, which is already occurring on occasion per participant report. Other HPs suggested that sexual violence services be announced over the radio and local councils should facilitate access to services. Finally, one of the best ways to improve access for survivors may be improved identification of survivors. One simple, but powerful way to do so would be increasing routine screening rates. In resource constrained areas, the ethics and efficacy of screening and referral programs have been debated (Jewkes, 2013). Screening obligates treatment, and some areas may be unable to provide appropriate intervention and prevention programs (Institute of Medicine, the National Research Council, 2015). However, there is evidence to support the feasibility of screening in East Africa, including programs in Uganda (Undie, Maternowska, Mak’anyengo, & Askew, 2016). The East Central and Southern African Health Community, which holds an annual best practices forum among health ministers, passed a resolution to integrate screening to care (Odiyo, Undie, & Mak’anyengo, 2016). A prior study of the management of sexual violence survivors also at Mulago hospital found that all participants were referred to a community support program (Ononge et al., 2005).
Community Collaboration
Many respondents identified lack of police coordination as an area for improvement. Substantiated in other Ugandan literature, some survivors do not go to the hospital first following an assault (UDHS, 2012). In the summary of Institute of Medicine, National Research Council, and Uganda National Academy of Sciences Joint Workshop, speakers provided further context to sexual violence in Uganda, highlighting the pervasive belief that sexual violence is a private matter and that should additional support be needed, most survivors seek help in local government first, over the health sector or other legal entities (Institute of Medicine, the National Research Council, 2015). Unfortunately, if survivors arrive at the hospital more than 72 hr after assault, the efficacy of emergency contraception and HIV prophylaxis is significantly reduced. Referral of survivors elsewhere, including police, may delay their medical care, increase their health care burden (e.g., increased risk of infection transmission), and jeopardize the quality of evidence collected. Uganda’s Police Form 3 was modified in 2011 to allow midwives, clinical officers, and medical officers to “examine a survivor, document evidence, and testify in court,” expanded from the prior four police surgeons qualified to complete the form (Rubimbwa & Komurembe, 2012). Of concern is the large number of respondents who were unaware of current documentation procedures and thus may refer survivors away from the hospital to police for evaluation or may fail to consider forensic evidence collection entirely. Expanded forensic training of HPs would provide improved collaboration with police and would disseminate up-to-date information about sexual violence to HPs.
Staffing and Training
Training and staffing were repeatedly identified as ways to empower HPs. Similarly, in a qualitative study examining services available to survivors in Northern Uganda, compared with IASC guidelines, local stakeholders highlighted limitations and delays in care due to lack of protocolized response and appropriate training (Henttonen, Watts, Roberts, Kaducu, & Borchert, 2008). In a study of physicians and nurses in South Africa, one third of participants felt that rape was not a serious medical condition, often because other patients had more life-threatening presentations (Christofides et al., 2005). Despite participants reporting on average 27 sexual violence survivors in the past 6 months, fewer than 15% had sent clothing for forensics, more than half reported no protocol to guide care of this patient population (a national protocol did exist at the time of study), and fewer than half referred survivors to counseling (Christofides et al., 2005).
Service provision to sexual violence survivors is a relatively recent addition to global academic discourse in the medical community. Thus, both novice and seasoned HPs stand to benefit from further training in a field that may only grow larger as survivors increasingly identify HPs as sources of care and support following an assault. Furthermore, training within the health care community may increase screening rates to improve identification of those who need services and support. Ongoing education may also address the international challenge of stigma, cited by one fourth of all participants. Participants in this study are not immune to the cultural forces that perpetuate stigma, but responses suggest that many have insight into this barrier and recognize screening as an important tool.
Infrastructure
Lack of funding dictated the resources at the disposal of HPs, particularly, those with high patient volumes. Items that are used in a number of services (e.g., saline, syringes, swabs, analgesics) were reported as “always” available and more specialty items (e.g., plastic specimen bags, anal speculums, tweezers) were more often reported as “never” available. The impact of stocking hospitals based on items with the broadest applicability is utilitarian, but may be influenced by a lack of awareness of the items necessary to carry out the full complement of sexual violence services.
These findings had some similarities to those reported by Kaye, Mirembe, and Bantebya (2005) regarding HPs perception of domestic violence. In this study, also conducted within the Obstetrics and Gynecology Department at Mulago hospital, few providers reported regularly screening patients for violence and participants reported no education on domestic violence during preservice or in-service training. Although sexual violence can occur with or distinct from domestic violence, this study, published in 2005, reported staff at Mulago as having limited knowledge regarding domestic violence and negative attitudes toward survivors, in contrast to the characteristics of the population in this study. This suggests that significant strides have been made in the decade since that study. In another study on HPs’ delivery of comprehensive sexual violence services in Rwanda and Uganda, Ugandan participants reported limited staff, training, and resources, but demonstrated a knowledge of major health risks associated with sexual violence as well as the critical components of care (Keesbury & Elson, 2010). This cohort also conveyed a commitment to treating sexual violence as an emergency. The conclusion that there is a national unmet need for improved sexual violence services with a provider base willing to rise to the demand are similar to the findings in this study.
Limitations
This study has several limitations. The survey completion rate, particularly at Mulago hospital, was low and data were not collected on those who did not return surveys. The possibility that the answers we obtained are not representative of those who did not respond cannot be excluded. The sample size of 75 is small and may not accurately represent the HPs at these two institutions. Some HPs did not list Mulago or Kayunga hospital as their home institution during the time of study administration such that all participants were currently but perhaps not permanently practicing at the study sites. In addition, while the sample did include different types of HPs at an urban and rural center, it may not be generalizable to Ugandan HPs as a whole, particularly given that the population at Mulago hospital may reflect providers with more specialized experience and knowledge as women’s health providers in the Department of Obstetrics and Gynecology. Finally, sexual violence is a sensitive topic. Even though these surveys were filled out anonymously, participants may have felt compelled to respond to questions in a particular manner, whether or not it represented their true opinions.
Conclusion
These data reflect the excellent work currently being done by Ugandan HPs, including care beyond the scope of international guidelines. Participants had significant existing knowledge regarding the care of survivors and demonstrated an interest in providing compassionate health and forensic care. Systems collaboration and resource supply are particularly challenging areas to establish a globally determined, protocolized response. International guidelines for sexual violence response can successfully and broadly serve as a foundation, but these data also highlight the need for sensitivity and contextualization on a local level. Ongoing efforts to improve infrastructure and training are still urgently needed to improve the care of this vulnerable group of patients.
Footnotes
Acknowledgements
The authors would like to acknowledge Makerere and Northwestern Universities for funding and all the staff who generously donated their time for the completion of this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: International Health Fellowship, Northwestern University Center for Global Health, Chicago, IL, The United States.
