HEALTH CARE SERVICES FOR VICTIMS/SURVIVORS OF SEXUAL VIOLENCE: THE STATE OF SERVICES IN NICARAGUA, GUATEMALA, HONDURAS AND EL SALVADOR
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1 HEALTH CARE SERVICES FOR VICTIMS/SURVIVORS OF SEXUAL VIOLENCE: THE STATE OF SERVICES IN NICARAGUA, GUATEMALA, HONDURAS AND EL SALVADOR Yolanda Paredes- Gaitan Ipas, Nicaragua Deborah L. Billings Karen Padilla Ipas, USA 1
2 Antecedents and Context This research is part of an UNFPA project to improve services available to victims/survivors and increase public awareness of sexual violence as a serious public health issue in Central America Since 2000, Ipas and UNFPA have been implementing a strategy to improve the quality of care offered to female victims and survivors of sexual violence (VSSV) at health facilities 2
3 Model of health care provided to women victims/survivors Early Detection Referral and Counter-Referral Legal support Promotion and Prevention Counseling Clinical support Follow-up Information systems Medical care Emotional and psychological support 3 Source : Adapted by the author from (Getting it Right! )Ver y atender! Guía práctica para conocer cómo funcionan los servicios de salud para mujeres víctimas y sobrevivientes de violencia sexual. Pag.6 IPAS 2007.
4 Objectives: To observe the quality of public and private sector health care services offered to female adolescent and adult victims/survivors of sexual violence. To document the legal and normative frameworks that guide health care practices. 4 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR 2009
5 Methods & Activities 1-Legal and normative review (sexual violence and health service responsibilities) 2- Analysis of documentation of health providers 3-Observation of and interviews with health care providers LAWS ACTS RESOLUTIONS PROTOCOLS MANUALS PROTOCOLS GUIDES FORMS MEDICAL RECORDS OB & GYN SERVICES EMERGENCY ROOM PRIMARY HEALTH SERVICES LABORATORY DISINFECTION AND STERILIZATION AREA SUPPORT SERVICES (ENVIRONMENTAL ) 5
6 Infection Control & Patient Safety Sterilization Waste management Equipment Management (maintenance) Additional check list Methods & Activities Information Management Forms Analysis Custody Medication Management Physical Environment Showers Restrooms Ventilation 6
7 Methods & Activities CENTRAL AMERICA Guatemala Belize El Salvador Honduras Nicaragua Costa Rica 4 countries visited Nicaragua Guatemala Honduras El Salvador 54 health care facilities were selected 49 were visited Panama 7 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
8 Strengths Violence against women recognized as a significant public health and human rights issue Greater knowledge of legislation in women s NGOs Guatemala : Implementation of integral model & Sexual Assault Medication Kits (UNFPA) The four Central American countries have regulations that recognize sexual violence as an important issue There are national guidelines regarding the care of VSSV in 3 countries. 8 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
9 RESULTS: HUMAN RESOURCES (TEAMS) HEALTH PROVIDERS WITH COMPLETE AND INCOMPLETE TEAMS 1 2 COMPLETE INCOMPLETE COMPLETE TEAM: Physician and /or Nurse Psychologist and /or Social Worker Lawyer and/or others (social worker if psychologist present) 27% 73% 22% N=49 Only one person attending (Physician or Psychologist) 91b OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
10 RESULTS:REFERRAL AND COUNTER-REFERRAL FLOW OF ATTENTION VSSV COUNTRY C FEBRUARY 2009 HEALTH CARE PROVIDER LEVEL I AND II Interview and physical exam Interview and physical exam FORENSIC SERVICES LABORATORY Sometimes interview to fill out HIV test forms Interview and physical exam HOSPITAL LEVEL II or III INFECTIOUS DISEASES PROGRAM HIV PROGRAM 10 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
11 RESULTS: CARE # of health care facilities Biological Samples for Diagnosis Health Porpuses Presence of Laboratory 35% 65% 1 2 yes no 0 VDRL VAGINAL SMEAR VAGINAL SMEAR CULTURE RAPID HIV TESTING ELISA RAPID CHLAMYDIA TESTING Nicaragua N= Guatemala n= Honduras n= El Salvador n= VDRL=venereal disease research laboratory 11 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
12 RESULTS: CARE The medical forensic examination is to collect medical-legal evidence. 59% had rapid HIV test. Test quality is in question ELISA was found in 20% of the institutions No follow-up (for ELISA or other test referred) Vaginal smear culture quality in some institutions is in question. 12 Paredes-Gaitan Y. LABORATORY SERVICES Horizontal Laminar Flow Workstation?? OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
13 TEMPERATURE Paredes-Gaitan Y or 15 o C Paredes-Gaitan Y. OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR 2009
14 TEMPERATURE 2 or 8 o C 2-30 o C KIT STORAGE 2-8 o C SPECIMEN STORAGE 14
15 TRANSPORTATION TRANSPORTATION REQUIREMENTS FOR INFECTIOUS SUBSTANCES 15
16 PREVENTIVE AND PREDICTIVE MAINTENANCE 16 Paredes-Gaitan Y. Paredes-Gaitan Y.
17 RESULTS: CARE % of health facilities Medications Found at the Facility (Country B ) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Analgesics Emergency contracepti on Prophylaxis STI Prophylaxis VIH Treatment STI Treatment HIV & AIDS % of health providers with 80% 80% 60% 30% 60% 20% One facility did not offer clinical service, only emotional support 17 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
18 RESULTS: CARE 18 # of health facilities 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Services Offered to Women Pregnant as a Result of Sexual Violence NICARAGUA GUATEMALA HONDURAS EL SALVADOR Legal abortion 0% 0% 0% 0% Adoption 16% 30% 78% 0% Prenatal care 74% 50% 33% 36% OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
19 RESULTS: CLINICAL EQUIPMENT Type of Sterilization Used 2% STEAM STERILIZATION 98% DRY HEAT STERILIZERS (OVEN) n = 43 reported sterilization Paredes-Gaitan Y. Paredes-Gaitan Y. 19 parameters of steam sterilization: steam, pressure, temperature, and time. STEAM STERILIZATION (Autoclave)
20 RESULTS: CLINICAL EQUIPMENT % of health facilities X 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% The steam cycle should be monitored by mechanical, chemical, and biological monitors Monitoring Sterilization Use of Biological Monitors NICARAGUA GUATEMALA HONDURAS EL SALVADOR USE 6% 22% 12% 11% DO NOT USE 94% 78% 88% 89% 20 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
21 RESULTS: CLINICAL EQUIPMENT Chemical Disinfectants Hypochlorite (chlorine disinfectant) was the most widely used. Unknown concentrations Inadequate storage Paredes-Gaitan Y. No existence of guidelines 21 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
22 RESULTS: INFORMATION SYSTEM Documentation SV SPECIFIC RECORD Country "A" SV SPECIFIC RECORD Country "B" MEDICAL RECORD MEDICAL RECORD + SV SPECIFIC RECORD OTHERS NONE 16% 5% 21% MEDICAL RECORD MEDICAL RECORD + SV SPECIFIC RECORD OTHERS 40% 20% 10% 26% 32% NONE 20% 10% 22 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
23 GENERAL INFORMATION TYPE OF VIOLENCE CHIEF COMPLAINT & ACTIONS 23 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
24 RESULTS: SERVICE DELIVERY AREA CHALLENGES Access to gowns to cover up Private bathroom Equipment for physcial exam Auditory privacy Visual privacy Door, screen, or curtain Chair(s) yes no yes no no yes yes Few restrooms Showers (only one) Privacy Vs. Ventilation No privacy in emergency rooms 24 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
25 RESULTS: SERVICE DELIVERY AREA Equipment for physical exam Mobile Light source Otoscope 25 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
26 26 Constraints Deficient trained mental health & social workers Incomplete medication kits and lab tests Lack of coordination between care levels Deficient delivery of protocols on SV to health care settings Lack of prevention & promotion materials Inadequate communication between systems, multiple local systems creates confusion Weaknesses in the justice system prevent health workers from reporting SV cases Political polarization. OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
27 RECOMMENDATIONS Human resources Diagnostic tests Equipment Integral service Information System Delivery service area Education and prevention Manuals & protocols Health provider training 27 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
28 RECOMMENDATIONS Training health care providers in detection, treatment, transport and confidentiality of forensic evidence Strengthen the integral health sector response Activate the screening (on suspicion, sentinel services) Enhance capacity for collecting evidence and data on SV Promote primary prevention responses Ethnic diversity requires diverse approaches Increase the women s support groups Evaluate quality of prophylaxis and lab management 28 OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR
29 29 THANKS GRACIAS
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