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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.

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.

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.

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.

Grounded theory guided the analysis of 30 in-depth interviews with raped women and community members who had supported raped women in their contact with the police and health care services in Tanzania. The aim of this study was to understand and conceptualize the experiences of the informants by creating a theoretical model focusing on barriers, strategies, and responses during the help seeking process. The results illustrate a process of managing in the contemporary world characterized as walking a path of anger and humiliation. The barriers are illustrated by painful experiences of realizing it's all about money, meeting unprofessionalism and irresponsibility, subjected to unreliable services, and by being caught in a messed-up system. Negotiating truths and knowing what to do capture the informants' coping strategies. The study indicates an urgent need for improvement in the formal procedures of handling rape cases, improved collaboration between the police and the health care system, as well as specific training for professionals to improve their communication and caring skills.

To understand the barriers rape victims and their supporters face from their informal networks while disclosing rape events in Tanzania, 30 in-depth interviews with victims and supporters were conducted. We found, that decisions to disclose rape events were influenced at the individual, family, and community levels. The overall theme, ‘normative justification of rape’ indicated wider societal beliefs and attitudes through all levels. The categories ‘internalizing shame and fearing the consequences’, ‘defending family integrity’, ‘reconciling role of the elders’, and ‘marginalizing victims and supporters’ captured the impact the identified normative justification of rape had on specific levels. The possible consequences and implications for interventions are discussed.

Using a community representative sample of 1,505 adults we examined interpretations of rape situations in order to establish attitudes toward rape. We assessed their intentions to express negative social reactions (NSRs) toward rape survivors. We then determined effects of attitudinal and sociodemographic characteristics in logistic regression models assessing the odds of expressing NSRs. Being old, male, and Muslim, and failing to interpret the legal circumstances of rape increased their risks of expressing NSRs. The degree of interpretation of lack of consent as rape affected their intentions to express NSRs, but not how they responded to survivors of different social status.

This thesis assessed responses toward rape against women as experienced by the victims and victim supporters in the context of the interaction between victims, supporters, and formal agencies in Tanzania. The overall research design was based on triangulation with a combination of qualitative and quantitative methods. A semi-qualitative study, in which free listings and semi-structured questionnaires were used, explored social reactions from 44 community nurses and 50 rape victims (Paper I). A tool developed from this first study was utilized for collecting data on people’s attitudes and their behavior toward rape and rape victims from a representative community sample of 1505 men and women aged 18-65 years (Paper II). Both studies helped to access suitable rape victims and supporters who participated in the third study to share experiences on the process of rape disclosure to formal and informal social networks (Papers III and IV). The results highlighted the salient social reactions and how rape victims perceived the impact of these reactions. Half of the participants interpreted rape situations based on social relationships, circumstances, and social status of the woman, rather than the legal definition. Two-thirds of the adults explained they would express negative social reactions toward a victim in some rape scenarios, and this correlated with their attitudes towards rape and rape victims. A variety of barriers in the informal and formal networks with potentially negative impacts on rape reporting, service utilization and, health outcomes were identified. In conclusion, successful interventions aimed at improving people’s response to rape, rape disclosure and, health outcomes in Tanzania should assume a holistic approach to address the negative factors identified at the individual, family and, community levels without forgetting the normative context that appears to underlie most decisions and practice.