The use of evidence for improving the delivery of post-rape care in South Africa

A thesis completed by published work, Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy JOHANNESBURG, SOUTH AFRICA 19 November 2015Rape is a human rights violation and has significant health and social impact. South Africa, with its historical background seeped in violence has high levels of crime including a high prevalence of rape. As such, the South African government has made some efforts to improve the health and criminal justice response to rape, but in general these have been slow, disrupted or reversed. A review of the literature on post-rape health care has indicated that there are areas in the delivery of service where sufficient evidence is lacking, and where research is available, high quality work has predominantly been undertaken in high-income countries. The aim of this thesis was to strengthen the evidence base for post-rape care service in South Africa by addressing some of the gaps in the literature. Methodology For the thesis, data from three studies are presented in three published and one unpublished article. The first study consists of a systematic review of articles published between 1990 and 2014 that evaluated the effect of health system models of care on survivors of rape or IPV in terms of health outcomes, rape or IPV recurrence, provision of related services, and referrals. The second study was related to a national post-rape care training programme. Baseline knowledge and confidence were assessed and multivariable analyses were done to test for factors associated with higher knowledge and confidence levels. The change in knowledge and confidence was also calculated from baseline to post-training, and factors associated with these changes were tested through two logistic models. The final study comprised of a review of a random sample of rape cases that were reported in Gauteng province in 2003. In the second publication, descriptive analyses were done to present the pattern of genito-anal injuries. In addition, logistic regression was done to test for survivor, rape and examination characteristics that were associated with the absence of genito-anal injuries in all survivors and those who had no previous sexual experience. Findings In the first study, no model of post-rape or IPV care could be recommended in relation to the tested outcomes due to the lack of studies on that evaluated the effect of a post-rape model of care on the specific outcomes, and due to the lack of high quality studies on IPV models of care. In the second study, it was found that the knowledge of health care providers was low although confidence was high. Higher baseline knowledge was associated with rank, having an appropriate attitude towards rape, and having served less time at the current facility, while higher confidence levels were associated with having a crisis centre in the facility and being involved in care of survivors. Significant improvements in knowledge and confidence levels were noted after the training, and providers with lower levels of empathy were found to have greater changes in knowledge. The facility level and baseline knowledge and confidence levels were associated with change in confidence. An earlier publication from the final study, for which I was a co-author, showed a strong association between the documentation of injuries and case progression in the justice system, so it was considered important to test for the factors associated with the absence of injuries in this study population. Here it was noted that there was a significantly greater odds of having injuries in survivors who were virgins, if multiple perpetrators had raped survivors, and if doctors with additional qualifications had examined survivors. Conclusion The findings of this thesis have implications for post-rape health care services in three broad focus areas: the organisation of services, the selection and capacitation of providers, and the interpretation of medico-legal evidence in term of genito-anal injuries. Proposals are suggested regarding potential improvements that could be made to post-rape care services in South Africa. The findings provide evidence for some of the principles in the South African National Sexual Assault Policy and raises important questions for future research work such as the need to critically evaluate the Thuthuzela one stop model that is being implemented in South Africa

Improving the recording of clinical medicolegal findings in South Africa

Background. The accurate recording of findings in clinical medicolegal cases is important, yet the current J88 form used for this purpose in South Africa has been reported to have many flaws. In addition, there are reports of poor completion of the form, which could in part be due to its poor design and clarity. Objective. To describe the process that was undertaken to revise the current J88 form.Methods. A repetitive consultative process was used to revise the current J88 form and to obtain inputs from relevant government institutions. Results. A brief outline of the changes that have been made to the current J88 form and the reasons why these changes were proposed by national experts is provided. Conclusion. The revised J88 form will provide clearer guidance to healthcare providers on the completion of necessary information in an expedited fashion. It is hoped that the form will soon be approved by the necessary government institution

Recovering of DNA evidence after rape

Objective. Sexual assault evidence collection kits (SAECKs) are used to collect evidence for DNA recovery after rape. The aim of this study was to assess the extent of completion of the kits by health care workers in 6 provinces of South Africa. Methods. A cross-sectional study was conducted to code SAECKs that were analysed at one forensic science laboratory in South Africa. Results. The findings from 204 SAECKs that were analysed are presented. The study found that none of the SAECKs complied fully with administrative quality requirements. Almost all of the specimens that were collected were analysed, except for pubic and head hair specimens that were rarely collected and analysed. A quarter of SAECKs did not have one of the three genital specimens collected. The presence and availability of all three genital swabs for forensic DNA analysis were found to be significant as this increased the chance of evidence recovery and obtaining a foreign forensic DNA profile. In 80% of cases, the DNA matched the suspect. Conclusions. The study showed that there was a need to improve the identification of priority cases involving children. The importance of administrative quality and the significance of collecting all three genital specimens should be emphasised in training programmes for health care workers. The SAECKs must also be adapted to local settings to minimise wastage. The study raises questions related to other aspects of sexual assault services and has implications regarding the overall quality of care that survivors receive

Recommendations to improve the National Development Plan for Health

In November 2011, a draft National Development Plan (NDP) was released that addresses two of South Africa’s major challenges: poverty and inequity. Health and economic development are interdependent, presenting an important opportunity through the NDP to integrate health within goals of broader socio-economic development. Reviewing the NDP identified gaps based on evidence and the epidemiological risk profile of South Africa. Recommendations to improve the NDP and to deal with poverty and inequity should focus on prevention and addressing the social determinants of health, including: (i) a multisectoral approach to establish a comprehensive early childhood development programme; (ii) fiscal and legislative policies to bolster efforts to reduce the burden of non-communicable diseases; (iii) promoting and maintaining a healthy workforce; (iv) and promoting a culture of evidence-based priority setting. Achieving the goal of ‘a long and healthy life for all South Africans’ will require healthy public policies, well functioning institutional and physical infrastructure, social solidarity, and an active and conscientious civil society

Medico-Legal Findings, Legal Case Progression, and Outcomes in South African Rape Cases: Retrospective Review

Rachel Jewkes and colleagues examine the processing of rape cases by South African police and courts and show an association between documentation of ano-genital injuries, trials commencing, and convictions in rape cases

Circumstances, policing, and attrition of multiple compared to single perpetrator rape cases within the South African criminal justice system

Abstract Background Research into the circumstances of rape, and criminal justice system responses, is pivotal to informing prevention and improving the likelihood of justice for victims. In this paper, we explore the differences in the circumstances of multiple-perpetrator rapes (MPRs) and single-perpetrator rapes (SPRs), their case management, and attrition, and describe areas for improvemensuplt around rape response within the South African criminal justice system. Methods The sample comprised 3952 rape cases reported to the South African Police Services (SAPS) in 2012, selected through a multi-stage random sampling of 172 police stations from a total of 1164 police stations in the nine provinces, followed by the random selection of cases from each station’s case list. Data were abstracted from police dockets, medico-legal examination forms, charge sheets, and trial transcripts. MPRs were defined as cases in which more than one perpetrator had sexual contact with the victim during a single incident, i.e., sexually assaulted or raped. Descriptive statistics and Chi-square tests for associations were used to compare MPRs and SPRs in circumstances of the rape, case management, and attrition. Results Seventeen percent of cases were MPRs. MPRs were comparably more violent crimes with a higher frequency of aggressive tactics employed by perpetrators, for example, abductions, firearms use, and threats to kill. Overall, cases were often poorly handled by police, and there were deviations from standard policing and investigation procedures; we found more evidence of this with MPRs compared to SPRs. MPR cases were most likely to have been closed by police due to undetected perpetrators in combination with other victim reasons. The weaker investigations of MPRs were associated with higher attrition rates compared to SPRs, firstly at the police investigation and subsequent stages. Conclusions The findings confirm differences in case management, patterns of attrition and trajectories of MPRs compared to SPRs. In an overall context of high rape case attrition and impunity for perpetrators, MPR victims are even less likely to see justice served than SPR victims. There needs to be much more effective supervision of rape case investigations by SAPS, particularly in MPR cases. Continual investigator training strengthened supervision and better resourcing are necessary to improve MPRs detection and convictions in adherence to the Directives for rape policing

Logistic regression models showing associations between whether a trial started and the accused was found guilty and the medico-legal findings.

<p>Models 1 and 2 were adjusted for victim's age and whether a first witness statement was taken. Models 3 and 4 were adjusted for victim's age.</p><p>OR, odds ratio.</p

Characteristics of the rapes of children under 18 y by case outcome.

a<p>Only available if there was an arrest.</p