Evaluation of sexual and gender-based violence program in Harare City, Zimbabwe, 2016: a descriptive cross-sectional study

Introduction In Zimbabwe, there is a gap between sexual violence (SV) survivors' health care needs versus the existing facilities. Harare city started Sexual Gender Based Violence (SGBV) project in 2011, with the aim to reduce SV morbidity.Only 592 (42%) of 1425 SV survivors reported for medical services within 72 hours in 2015. HIV post-exposure prophylaxis (PEP) is effective within 72hours of post exposure. We evaluated the program performance in Harare city. Methods We conducted a process-outcome evaluation using a logic model. We purposively recruited all eight SGBV sites and key informants. We randomly selected 27nurses into the study. Interviewer-administered questionnaires and checklists were used to collect data. To generate frequencies, means and proportions we used Epi info 7. Results The program adequately received inputs except for counselling rooms (1/8). About 4285 survivors were recorded from 2013-2016. Of these, 97% were counselled, 93% received HIV test, 41% reported to the clinic within 72hrs of post-rape, and 12% received PEP. About 16% of the total survivors were followed up. The programme failed to meet its targets on decentralised sites (8/10), awareness campaigns(16/32) and sensitisation activities(16/32). About 500(12.5%) IEC materials were distributed. All 96-targeted supervisory visits were achieved. Two ofeight district supervisors were trained. Majority of health workers (25/35) citedlack of awareness as major reasons for underperformance. Conclusion Availability of resources did not translate to program performance. Most survivors were not reporting to the clinic timeously due to the low level of awareness of the programme to the community, hence were not protected from getting HIV through PEP. The programme was not well disseminated, as most supervisors were not trained. Following this evaluation, we distributed150 IEC materials to each of the eight facilities. A follow-up study on outcomes of clients referred for services and training of district officers were recommended.


Introduction
Sexual violence (SV) refers to any act attempt or threat of a sexual nature that results or is likely to result, in physical, psychosocial and emotional harm [1]. Sexual violence is a gross violation of human rights and an issue of public health concern [2]. Survivors of sexual violence are more vulnerable to depression, substance abuse, repeat sexual abuse, Post Traumatic Stress Disorder (PTSD), suicide and sexual dysfunction later in life than their non-abused counterparts [3]. Globally, about 7% of women have been sexually assaulted by someone other than a partner [4]. Many UN organisations including the World Health Organization (WHO) argue that the deep-rooted and pervasive gender inequalities and sexual violence are responsible for the high and accelerated prevalence of HIV among women [5]. Women are at up to six times at greater risk of HIV infection compared to their male counterparts [6]. The gender ratio of infections reflects the greater vulnerability of women [7]. Sexual violence is a widespread problem in sub-Saharan Africa [8], and Sub-Saharan African countries are increasingly responding to sexual violence with a range of legislative and healthcare interventions [9]. Zimbabwe is not spared from the crimes of sexual violence. According to the 2015 Zimbabwe Demographic and Health Survey (ZDHS), 35% of all women, aged 15-49 reported having experienced physical violence [10]. In Zimbabwe, there is a gap between the healthcare needs of survivors of sexual violence and the existing level of health care provided, since most doctors and nurses have not received adequate training in the management of sexual violence. Specialist clinics were in central hospitals but were not easily accessible to the majority of sexual violence survivors who needed prompt and appropriate management close to their homes [11]. In light of the health, human rights, social and economic consequences of violence against women, Harare City in collaboration with Medicines San Frontiers (MSF) started a separate Sexual Gender Based Violence (SGBV) project in 2011 with the aim to reduce the morbidity and mortality of survivors of sexual violence in Harare city [12]. In Harare city, the SGBV program follows the Ministry of Health and Child Care (MOHCC) national protocol on care for survivors of SGBV. It offers free medical care, HIV testing and counselling, screening and referrals for psychological, psychosocial and legal support. According to the Harare city data, sexual violence increased from 1162 in 2014 to 1356 survivors in 2015. Of concern is that only 42% of the survivors attended to in 2015 reported for medical services within 72 hours. It is a cause for concern considering that HIV post-exposure prophylaxis (PEP) is effective within 72hours of post exposure. In the light of these issues, we here consider the question "why is the 58% of the SV survivors not accessing quality post-rape services promptly?" We therefore broadly evaluated the performance of the programme and specifically assessed the inputs, processes, outputs and outcomes of the program.

Study design:
We conducted a process-outcome evaluation using the logic model. This was used to assess the inputs, which were injected into the program, the processes carried out, the outputs realised and the outcomes of the SGBV program (Table 1).

Permission and ethical considerations:
We sought permission to carry out the study from Harare city ethical review board, and the Health Studies Office. We also sought written informed consent from the health workers. Participants were given the freedom of choiceto either participate, decline or withdraw from the study at any given time. Confidentiality was assured and maintained throughout the study by; interviewing each participant privately and ensuring that no information obtained was disclosed to any persons other than those relevant to the study. Also, names of participants were not includedinthe questionnaires. All questionnaires were kept confidential.

Demographic characteristics of study participants:
We  (Table 2).

Processes involved in running the sexual gender based
violence programme: Two targeted staff training courses per yearwere met. About 16% (700/4285) of clients were followed up.

Discussion
The study findings demonstrate that lack of awareness of the program and its services was a major factor that enhances thelate presentation of SV survivors to the clinic. Closely related to the late reporting was fear of being harmed further by the perpetrator manifested especially in thecontext of late disclosure of the survivor to the guardian or partner. This study sought to answer "why the SV survivors were not accessing quality post-rape services promptly?" Therefore, we evaluated the performance of the SGBV programme. It is evident from the study that the program was not well disseminated as no district officers were trained on SGBV. This Africa,unwanted pregnancies could be prevented by ensuring adolescents have access to information on sexuality and are supported to build good social and decision-making skills in a supportive environment [9]. In this study, SGBV information and support were not fully offered. However, some reasons were extracted from the survivors' records.

Conclusion
We concluded that even though this programme was adequately What is known about this topic  Sexual violence against women is a massive cause of morbidity and mortality but remains overlooked. While rape will always be a traumatic experience and a violation of human rights, the effects of this trauma for an individual may be different in different contexts. Hence quality care should be rendered to these survivors.

What this study adds
 Availability of resources does not translate to program performance. Therefore, inputs need to be converted to outputs through activities.Programs need to be well disseminated for them to be sustainable. Knowledgeable workers are key to the implementation of the programme.
Hence there is need to train HCW before the program starts.

Competing interests
The authors declare no competing interests.