South African Program Promotes "Resilience" and Improves Post-Rape Care
The prevalence of rape in South Africa presents a daunting public health challenge. According to a June 2009 study by the South African Medical Research Council, as many as a quarter of all men surveyed admitted to raping a woman or girl. In many cases the attacks happen to children under age 13. The health consequences are significant: in addition to the immediate physical injury and psychological trauma, rape survivors often suffer long-term consequences such as depression, post-traumatic stress disorders, and gynecological disorders, and are at risk of unwanted pregnancy and sexually transmitted infections (STIs), including HIV.
A Population Council-supported program known as Refentse--meaning resilience in the face of adversity--demonstrates how a rural hospital can improve post-rape care by training nurses to provide integrated medical-care management for rape survivors. The improvements, which cost little to implement, strengthen and link established services and decentralize care from doctors to nurses. Results of the study were described in a recent issue of the British Medical Journal.
Good care requires quick response
In part because of the violent and invasive nature of sexual assault, health care professionals in both industrialized and developing countries face many challenges in providing timely and comprehensive post-rape services. In addition to immediate medical attention for physical injuries, rape survivors require various therapeutic, social, and legal services, including post-exposure prophylaxis (PEP) for HIV and other STIs, emergency contraception, and trauma counseling. Administration of HIV PEP, which provides the only option for protecting against HIV infection following an assault, is especially challenging: to be most effective, PEP must be started within 72 hours of exposure. Many practitioners lack an adequate understanding of how to administer PEP in the context of sexual assault, and even fewer have well-developed strategies for ensuring adherence to the full 28-day course of treatment. Other important procedures such as emergency contraception to prevent pregnancy and the collection of forensic evidence for legal prosecution are also time-dependent.
Ian Askew, the Population Council's director of reproductive health services and research, and his colleagues from the Rural AIDS and Development Action Research Programme (RADAR), School of Public Health, University of the Witwatersrand in South Africa, initiated the Refentse program in 2003 at a 450-bed district hospital in a rural region in the country's northeast corner. The hospital functions as a referral center for surrounding clinics.
New approach improves services, raises awareness
The team set out to improve the quality of post-rape care with a five-part intervention:
1. A sexual violence advisory committee, comprising hospital staff members, social workers, and local police, contributed to the study's design.