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Improving Health-seeking Behavior and Care among Sexual Violence Survivors in Rural Tanzania
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Muhimbili University of Health and Allied Sciences, Tanzania.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this thesis was to assess the effects of providing community education and training to healthcare workers to improve community response, healthcare and support for rape survivors in the Kilombero district of Tanzania. The overall design of the project was to begin with an exploratory study (Paper I) to establish the community’s perceptions towards sexual violence and their perceived recommendations to address this issue. Using a structured questionnaire, the community’s knowledge and attitudes towards sexual violence were determined along with their associations with demographic factors (Paper II). Papers III and IV assessed the effect of healthcare workers’ training and a community information package, respectively, using a controlled quasi-experimental design. The findings highlighted the social norms and variety of barriers that impacted negatively on the survivors’ care-seeking from support services and health outcomes. Increasing age and higher education were associated with better knowledge and less accepting attitudes towards sexual violence. Training on the management of sexual violence was effective in improving healthcare workers’ knowledge and practice but not attitude. Knowledge on sexual violence among the communities in the intervention and comparison areas increased significantly over the study period; from 57.3% to 80.6% in the intervention area and from 55.5% to 71.9% in the comparison area. In the intervention area, women had significantly less knowledge than men at baseline (53% Vs 64%, p<.001).There was a reduction, though not significantly, in acceptance attitudes from 28.1% to 21.8% in favor of women. In conclusion, the current intervention provides evidence that healthcare workers’ training and community education is effective in improving knowledge but not attitudes towards sexual violence. The findings have potential implications for interventions aimed at preventing and responding to violence. The broader societal norms that hinder rape disclosure need to be re-addressed.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 74 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1133
Keyword [en]
healthcare worker, community, sexual violence, rape, intervention, quasi-experimental, qualitative, rural, Tanzania
National Category
Medical and Health Sciences
Research subject
Obstetrics and Gynaecology
Identifiers
URN: urn:nbn:se:uu:diva-261902ISBN: 978-91-554-9329-5 (print)OAI: oai:DiVA.org:uu-261902DiVA: diva2:852056
Public defence
2015-10-26, Rosensalen, Akademiska Sjukhuset, Entrance 95/96, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2015-09-30 Created: 2015-09-05 Last updated: 2015-10-01
List of papers
1. Community perceptions of rape and child sexual abuse: a qualitative study in rural Tanzania
Open this publication in new window or tab >>Community perceptions of rape and child sexual abuse: a qualitative study in rural Tanzania
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2014 (English)In: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 14, 23- p.Article in journal (Refereed) Published
Abstract [en]

Background: Rape of women and children is recognized as a health and human rights issue in Tanzania and internationally. Exploration of the prevailing perceptions in rural areas is needed in order to expand the understanding of sexual violence in the diversity of Tanzania's contexts. The aim of this study therefore was to explore and understand perceptions of rape of women and children at the community level in a rural district in Tanzania with the added objective of exploring those perceptions that may contribute to perpetuating and/or hindering the disclosure of rape incidences. Methods: A qualitative design was employed using focus group discussions with male and female community members including religious leaders, professionals, and other community members. The discussions centered on causes of rape, survivors of rape, help-seeking and reporting, and gathered suggestions on measures for improvement. Six focus group discussions (four of single gender and two of mixed gender) were conducted. The focus group discussions were recorded, transcribed verbatim, and analyzed using manifest qualitative content analysis. Results: The participants perceived rape of women and children to be a frequent and hidden phenomenon. A number of factors were singled out as contributing to rape, such as erosion of social norms, globalization, poverty, vulnerability of children, alcohol/drug abuse and poor parental care. Participants perceived the need for educating the community to raise their knowledge of sexual violence and its consequences, and their roles as preventive agents. Conclusions: In this rural context, social norms reinforce sexual violence against women and children, and hinder them from seeking help from support services. Addressing the identified challenges may promote help-seeking behavior and improve care of survivors of sexual violence, while changes in social and cultural norms are needed for the prevention of sexual violence.

Keyword
Child sexual abuse, Community perceptions, Focus group discussions, Rape, Rural, Sexual violence, Tanzania
National Category
Environmental Health and Occupational Health
Identifiers
urn:nbn:se:uu:diva-232600 (URN)10.1186/1472-698X-14-23 (DOI)000340801600001 ()
Available from: 2014-09-23 Created: 2014-09-22 Last updated: 2017-12-05Bibliographically approved
2. Knowledge and attitude towards rape and child sexual abuse - a community-based cross-sectional study in Rural Tanzania
Open this publication in new window or tab >>Knowledge and attitude towards rape and child sexual abuse - a community-based cross-sectional study in Rural Tanzania
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2015 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, no 1, 428Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Violence against women and children is globally recognized as a social and human rights concern. In Tanzania, sexual violence towards women and children is a public health problem. The aim of this study was to determine community knowledge of and attitudes towards rape and child sexual abuse, and assess associations between knowledge and attitudes and socio-demographic characteristics.

METHODS: A cross-sectional study was undertaken between May and June 2012. The study was conducted in the Kilombero and Ulanga rural districts in the Morogoro Region of Tanzania. Men and women aged 18-49 years were eligible for the study. Through a three-stage cluster sampling strategy, a household survey was conducted using a structured questionnaire. The questionnaire included socio-demographic characteristics, attitudes about gender roles and violence, and knowledge on health consequences of rape. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 21. Main outcome measures were knowledge of and attitudes towards sexual violence. Multivariate analyses were used to assess associations between socio-demographic characteristics and knowledge of and attitudes towards sexual violence.

RESULTS: A total of 1,568 participants were interviewed. The majority (58.4%) of participants were women. Most (58.3%) of the women respondents had poor knowledge on sexual violence and 63.8% had accepting attitudes towards sexual violence. Those who were married were significantly more likely to have good knowledge on sexual violence compared to the divorced/separated group (AOR = 1.6 (95% CI: 1.1-2.2)) but less likely to have non-accepting attitudes towards sexual violence compared to the single group (AOR = 1.8 (95%CI: 1.4-2.3)). Sex of respondents, age, marital status and level of education were associated with knowledge and attitudes towards sexual violence.

CONCLUSIONS: Our study showed that these rural communities have poor knowledge on sexual violence and have accepting attitudes towards sexual violence. Increasing age and higher education were associated with better knowledge and less accepting attitudes towards sexual violence. The findings have potentially important implications for interventions aimed at preventing violence. The results highlight the challenges associated with changing attitudes towards sexual violence, particularly as the highest levels of support for such violence were found among women.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-253212 (URN)10.1186/s12889-015-1757-7 (DOI)000353941200001 ()25927715 (PubMedID)
Available from: 2015-05-25 Created: 2015-05-25 Last updated: 2017-12-04Bibliographically approved
3. Evaluation of a training program for health care workers to improve the quality of care for rape survivors: a quasi-experimental design study in Morogoro, Tanzania
Open this publication in new window or tab >>Evaluation of a training program for health care workers to improve the quality of care for rape survivors: a quasi-experimental design study in Morogoro, Tanzania
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2016 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, 31735Article, review/survey (Refereed) Published
Abstract [en]

BACKGROUND:

Sexual violence against women and children in Tanzania and globally is a human rights violation and a developmental challenge.

OBJECTIVE:

The aim of this study was to assess the impact of training health professionals on rape management. The specific objectives were to evaluate the changes of knowledge and attitudes toward sexual violence among a selected population of health professionals at primary health care level.

DESIGN:

A quasi-experimental design using cross-sectional surveys was conducted to evaluate health care workers' knowledge, attitude, and clinical practice toward sexual violence before and after the training program. The study involved the Kilombero (intervention) and Ulanga (comparison) districts in Morogoro region. A total of 151 health professionals at baseline (2012) and 169 in the final assessment (2014) participated in the survey. Data were collected using the same structured questionnaire. The amount of change in key indicators from baseline to final assessment in the two areas was compared using composite scores in the pre- and post-interventions, and the net intervention effect was calculated by the difference in difference method.

RESULTS:

Overall, there was improved knowledge in the intervention district from 55% at baseline to 86% and a decreased knowledge from 58.5 to 36.2% in the comparison area with a net effect of 53.7% and a p-value less than 0.0001. The proportion of participants who exhibited an accepting attitude toward violence declined from 15.3 to 11.2% in the intervention area but increased from 13.2 to 20.0% in the comparison area.

CONCLUSIONS:

Training on the management of sexual violence is feasible and the results indicate improvement in healthcare workers' knowledge and practice but not attitudes. Lessons learned from this study for successful replication of such an intervention in similar settings require commitment from those at strategic level within the health service to ensure that adequate resources are made available.

Keyword
healthcare worker, training, quasi-experimental, rape, sexual violence, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-261889 (URN)10.3402/gha.v9.31735 (DOI)000381095700001 ()27435570 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2015-09-05 Created: 2015-09-04 Last updated: 2017-12-04Bibliographically approved
4. A community-based intervention for improving health-seeking behavior among sexual violence survivors: A controlled before and after design study in rural Tanzania
Open this publication in new window or tab >>A community-based intervention for improving health-seeking behavior among sexual violence survivors: A controlled before and after design study in rural Tanzania
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2015 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, 28608Article in journal (Refereed) Published
Abstract [en]

Background: Despite global recognition that sexual violence is a violation of human rights, evidence still shows it is a pervasive problem across all societies. Promising community intervention studies in the low- and middle-income countries are limited.

Objective: This study assessed the impact of a community-based intervention, focusing on improving the community’s knowledge and reducing social acceptability of violence against women norms with the goal to prevent and respond to sexual violence.

Design: The strategies used to create awareness included radio programs, information, education communication materials and advocacy meetings with local leaders. The intervention took place in Morogoro region in Tanzania. The evaluation used a quasi-experimental design including cross-sectional surveys at baseline (2012) and endline (2014) with men and women aged 18-49. Main outcome measures were number of reported rape cases at health facilities and the community’s knowledge and attitudes towards sexual violence.

Results: The number of reported rape events increased by more than 50% at health facilities during the intervention. Knowledge on sexual violence increased significantly in both areas over the study period (from 57.3% to 80.6% in the intervention area and from 55.5% to 71.9% in the comparison area; p<.001), and the net effect of the intervention between the two areas was statistically significant (6.9, 95% CI 0.2–13.5, p= 0.03). There was significant improvement in most of attitude indicators in the intervention area, but not in the comparison area. However, the intervention had no significant effect in the overall scores of acceptance attitudes in the final assessment when comparing the two areas (-2.4, 95%CI: -8.4 – 3.6, p= 0.42).

Conclusions: The intervention had an effect on some indicators on knowledge and attitudes towards sexual violence even after a short period of intervention. This finding informs the public health practitioners of the importance of combined strategies in achieving changes.

Keyword
sexual violence, evaluation, community intervention, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-261900 (URN)10.3402/gha.v8.28608 (DOI)000361749600001 ()
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2015-09-05 Created: 2015-09-05 Last updated: 2017-12-04Bibliographically approved

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