The implementation and effectiveness of the one stop centre model for intimate partner and sexual violence in low- and middle-income countries: a ...
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Original research
The implementation and effectiveness
of the one stop centre model for
intimate partner and sexual violence in
low- and middle-income countries: a
systematic review of barriers
and enablers
Rose McKeon Olson ,1 Claudia García-Moreno,2 Manuela Colombini3
To cite: Olson RMcK, Abstract
García-Moreno C, Colombini M. Key questions
Introduction Many low- and middle-income countries
The implementation and have implemented health-system based one stop centres
effectiveness of the one stop What is already known?
to respond to intimate partner violence (IPV) and sexual
centre model for intimate ►► Several process evaluations of the one stop centre
violence. Despite its growing popularity in low- and
partner and sexual violence (OSC) model in low- and middle-income country
in low- and middle-income middle-income countries and among donors, no studies
(LMIC) settings have documented various challeng-
countries: a systematic have systematically reviewed the one stop centre. Using a
es, enablers and lessons learnt.
review of barriers and thematic synthesis approach, this systematic review aims
►► Important evaluation findings of OSCs are scattered
enablers. BMJ Global Health to identify enablers and barriers to implementation of the
across the published literature and in unpublished
2020;5:e001883. doi:10.1136/ one stop centre (OSC) model and to achieving its intended
bmjgh-2019-001883 technical reports.
results for women survivors of violence in low- and
►► Only one outcome evaluation has been published
middle-income countries.
Handling editor Seye Abimbola
which reported that the OSC model led to increased
Methods We searched PubMed, CINAHL and Embase
short-term utilisation of primary health services.
►► Additional material is
databases and grey literature using a predetermined
►► Despite increasing popularity of the OSC model in
published online only. To view search strategy to identify all relevant qualitative,
LMICs and among funders, no studies have evalu-
please visit the journal online quantitative and mixed methods studies. Overall, 42
ated the effectiveness of the OSC model in meeting
(http://dx.doi.org/10.1136/ studies were included from 24 low- and middle-income
survivor needs.
bmjgh-2019-001883). countries. We used a three-stage thematic synthesis
►► No systematic review or evidence-based synthesis
methodology to synthesise the qualitative evidence, and
on the OSC model has been performed prior to the
we used the CERQual (Confidence in the Evidence from
Received 31 July 2019 present study.
Reviews of Qualitative Research) approach to assess
Revised 7 February 2020
confidence in the qualitative research. Meta-analysis What are the new findings?
Accepted 15 February 2020
could not be performed due heterogeneity in results and ►► The review found 15 high-confidence evidence bar-
outcome measures. Quantitative data are presented by riers to implementation of the OSC model and to
individual study characteristics and outcomes, and key achieving its intended results. These included barri-
findings are incorporated into the qualitative thematic ers to implementation such as staff time constraints
framework. and lack of basic medical supplies, which lead to
Results The review found 15 barriers with high- barriers to achieving intended results like accessible
confidence evidence and identified seven enablers with care due to long wait times and out-of-pocket fees.
moderate-confidence evidence. These include barriers ►► The review also identified seven enablers with
to implementation such as lack of multisectoral staff moderate-confidence evidence. These included en-
© Author(s) (or their and private consultation space as well as barriers to ablers to implementation such as standardised pol-
employer(s)) 2020. Re-use achieving the intended result of multisectoral coordination icies and procedures. They also included enablers
permitted under CC BY-NC. No due to fragmented services and unclear responsibilities to achieving intended results, such as regular inter-
commercial re-use. See rights of implementing partners. There were also differences agency meetings that facilitated increased multisec-
and permissions. Published by
between enablers and barriers of various OSC models such toral coordination.
BMJ.
as the hospital-based OSC, the stand-alone OSC and the
For numbered affiliations see
NGO-run OSC.
end of article.
Conclusion This review demonstrates that there are acceptable, multisectoral care. Existing OSCs will likely
Correspondence to several barriers that have often prevented the OSC model require strategic investment to address these specific
Dr Rose McKeon Olson; from being implemented as designed and achieving barriers before they can achieve their ultimate goal of
rose.mckeon.olson@gmail.com the intended result of providing high quality, accessible, reducing survivor retraumatisation when seeking care.
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883 1
BMJ Global Health
Rationale for development of the OSC
Key questions
The development of the OSC model was a response
What do the new findings imply? to numerous issues identified by survivors and their
►► The results of this review provide essential evidence to guide OSC advocates when seeking services in traditional (non-
leadership, funders, policymakers and government officials on spe- integrated) healthcare, police and legal systems. Survi-
cific factors that should be optimised in order for OSCs to be imple- vors often need several multidisciplinary services that are
mented as intended, achieve their intended results and reach their scattered in different locations. They frequently need
ultimate goal—namely, to reduce victim retraumatisation when to retell their stories of trauma each time they engage
seeking care. with a different service/sector which can contribute to
►► These data should be used to prioritise and guide investment, as secondary victimisation. The intended results of the OSC
well as inform more rigorous evaluation of existing OSCs prior to model are to increase accessibility, acceptability, quality
further promotion and scale-up of this model in LMICs.
and multisectoral coordination of care in order to reach
the ultimate goal of reducing survivor retraumatisation
when seeking care.15–17
More rigorous and systematic evaluation of the OSC model is needed to
better understand whether the OSC model of care is improving support for Current evidence of the OSC model
survivors of IPV and sexual violence.
While multiple process evaluations of the OSC model
The systematic review protocol was registered and is available online
have been performed, no studies have examined the
(PROSPERO: CRD42018083988).
effectiveness of the OSC model.18–51 Only one outcome
evaluation has been published, which found that the
OSC model led to short- term increased utilisation of
primary health services.13 No systematic reviews on the
Introduction OSC model have been published.
Violence against women (VAW) is associated with harmful
health consequences1 2 and is a major public health
Theory of change of the OSC model
concern.3 VAW is also a barrier to achieving Sustainable
The authors have provided a theory of change for the
Development Goal 5 on gender equality and women’s
OSC model to serve as an analytical framework for the
empowerment, and Sustainable Development Goal 3 on
study findings (figure 1). The OSC model requires
health.4 The health sector is well situated to respond,
specific inputs such as multidisciplinary staff and private
as women facing violence are more likely to view health
consultation rooms, which contribute to OSC outputs
workers as trustworthy for disclosure of abuse and to
such as more services provided at one location and at all
use a variety of health services, including mental health,
hours, and reduced survivor interviews. These contribute
emergency department and primary care services when
to OSC outcomes such as improved multisectoral coor-
compared with non-abused women.5–8 A variety of one
dination and improved quality of survivor-centred care.
stop centre (OSC) models have emerged over the years
These outcomes contribute to the ultimate goal of the
that vary in structure and services provided, resulting
OSC to reduce survivor revictimisation when seeking
in discussion as to how the OSC should be defined. For
care.
the purpose of this review, the authors defined an OSC
model as an interprofessional, health-system based centre
that provides survivor-centred health services alongside Practical rationale of this review
some combination of social, legal, police and/or shelter There has been increasing global implementation, scal-
services to survivors of intimate partner violence (IPV) ing-up and donor investment in OSCs, despite a lack
and/or sexual violence (SV). of rigorous evaluation of their implementation or their
The original OSC was developed in a tertiary hospital effectiveness. A meeting on this was organised by the
and aimed to provide acute services to survivors of WHO in June 2018 where experts discussed current
violence.9 Soon after OSCs were established in Malaysia evidence of the OSC model, contextual variations, as
in 1994, the model was replicated throughout South East well as its strengths and limitations. It was recommended
Asia and Western Pacific regions.9 10 It has now been that a systematic review be performed to better assess
widely implemented with donor support in several African the barriers and enablers to OSC implementation and
countries,11 12 and similar models are emerging in Latin achieving its intended results, and to inform a framework
America.13 The majority of OSCs are hospital-based, typi- for more systematic evaluations of OSCs.
cally within tertiary care facilities, while others are stand-
alone centres that provide basic health services on-site Review objective
and refer for specialised and emergency services.14 Some Using a thematic synthesis approach, this systematic
OSCs are more strongly linked to the judicial system as in review aims to identify enablers and barriers to imple-
the case of the Thuthutzela centres in South Africa. They mentation of the OSC model and to achieving its
may be managed by the government, private sector, non- intended results for women survivors of violence in low-
governmental organisations (NGOs) or a combination.14 and middle-income countries (LMICs).
2 Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883BMJ Global Health
Figure 1 Theory of change of the OSC model.OSC, one stop centre; VAW, violence against women.
Methods and unpublished reports: WHO Global Health Library,
Patient and public involvement Cochrane Library, Database of Abstracts of Reviews of
Patient/survivor experiences, preferences and priorities Effects, Google Scholar, Centre for Reviews and Dissem-
were sought in every step of the systematic review process. ination Database, OpenGrey and EThOS. Searches were
While perspectives of all stakeholders of the OSC model conducted from 31 June 2018 to 31 December 2018. The
were included in the review, survivor experiences were search strategies were reviewed by two expert librarians.
specially desired and sought after during study selection Numerous researchers in relevant fields were contacted
and data extraction, as it was felt survivors could best to identify additional published and unpublished studies.
inform how implementation of the OSC was affecting its
beneficiaries (the survivors) and how the barriers and Study selection
enablers were perceived to be meeting survivor needs. All titles and abstracts identified were independently
Patients/survivors themselves were not involved in the screened using a standardised form (RMO, CG-M). Each
design or conduct of this systematic review. full-text article was reviewed by RMO, and in consulta-
tion with CG- M, pre-
determined inclusion and exclu-
Search strategy sion criteria were applied (see table 1). The Preferred
Published literature was searched in PubMed, CINAHL Reporting Items for Systematic Reviews and Meta-Analyses
and Embase using controlled vocabulary and free-text
terms combining three main search elements: (a) partner
violence and/or sexual violence, (b) one stop centre Table 1 Criteria for inclusion and exclusion
and (c) LMIC. Examples of IPV and/or sexual violence Inclusion criteria Exclusion criteria
search terms include, ‘Rape’(Mesh) OR ‘Intimate Partner
Violence’(Mesh) OR ‘Domestic Violence’(Mesh). Exam- Uses quantitative, qualitative or Does not present primary
ples of one-stop centre search terms include centre(tiab) mixed method study designs research
OR centre(tiab) OR one stop(tiab) OR stand alone(- Discusses the OSC model Not published in English,
tiab) OR protection unit(tiab). Full search strategies are Spanish or French
language
available in online supplementary tables S1–3. The third
search element was the LMIC context, which was used via Reports barriers and/or enablers Full text is not available
the Cochrane Effective Practice and Organisation of Care of the OSC model
(EPOC) Group LMIC filter (http://epoc.-cochrane.org/ Conducted in LMIC context Women were not
lmic-
filters). Numerous combinations of these search beneficiaries of the OSC
(eg, the OSC was only
elements were identified through thesaurus and Medical
for child survivors)
Subject Headings terms. The following databases were
searched for additional studies, including grey literature LMIC, low- and middle-income country; OSC, one stop centre.
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883 3BMJ Global Health
(PRISMA) diagram of search and study inclusion process Quality assessment and confidence assessment
is provided in online supplementary figure 1. For the The CERQual (Confidence in the Evidence from Reviews of
purposes of this review, the OSC was defined as any Qualitative Research) approach was applied to each review
centre that provided integrated, multidisciplinary care finding to assess confidence in each review finding.54 The
to survivors of intimate partner and/or sexual violence CERQual approach assesses how much confidence to place
with healthcare as a necessary component, as well as two in review findings of qualitative systematic reviews based
or more additional on-site services, which could include on: (1) methodological limitations, (2) relevance of the
any combination of social, legal and police services. For review question, (3) coherence and (4) adequacy of data.
example, an integrated model that provided legal and Methodological limitations were assessed using two tools:
police services was not considered an OSC, while a model an adaptation of the Critical Appraisal Skills Programme
that provided healthcare, shelter and legal services was (CASP) tool was used to assess the quality of the qualita-
considered an OSC. Any discrepancies in the screening tive studies,55 and an adaptation of the Strengthening
were resolved through discussion and consultation with a the Reporting of Observational Studies in Epidemiology
third author (MC). (STROBE) statement was used to assess the quality of the
quantitative studies.56 Examples of methodological limi-
Data extraction tations include unclear statement of aims, inappropriate
Data were extracted using a standardised form (online recruitment strategy or lack of rigour in data analysis. No
supplementary file S1). Themes, participant quotations studies were excluded based on quality assessment, instead,
and findings were extracted from qualitative studies, methodological quality is reflected in the CERQual assess-
and where relevant, results and discussion sections of ments. Each author independently assessed study quality
quantitative studies. Results and outcome measures using the CASP tool and STROBE checklist to qualitative
and quantitative studies, respectively (online supplemen-
were extracted from quantitative studies. Both types
tary files S4 and S5). Using a pre- determined scoring
of data were extracted in the case of mixed methods
template, each author applied each of the four CERQual
studies.
criteria to each review finding (online supplementary
file S6). After each of the quality assessments and four
Synthesis CERQual elements were evaluated, the CERQual level of
A thematic synthesis methodology was used to analyse the confidence for each review finding was assigned as high,
qualitative data.52 The lead author (RMO) developed a moderate or low (RMO, MC, CG-M). Discrepancies were
spreadsheet of all qualitative data from the studies’ find- resolved by discussion until consensus was reached among
ings sections, and where relevant, discussion sections. authors.
Using the three stage method outlined by Thomas and
Harden, 2008, each relevant line of text was openly Reporting
coded (RMO) through an inductive, line-by-line process This systematic review follows the Enhancing Transpar-
to develop first-order themes, which were descriptive and ency in Reporting the Synthesis of Qualitative Research
similar in meaning to the primary studies.52 Based on (ENTREQ) statement guidelines (online supplementary
the initial coding, 16 broad themes were developed, and file S2).57 It also follows the 2009 PRISMA guidelines
through in iterative process, all text units were classified (online supplementary file S3).58 59
into one of the broad themes. Each theme was analysed
further to develop the axial coding scheme and to disag- Results
gregate core themes. The text units were hand-sorted Database searches identified 3529 potentially relevant arti-
into first-order, second-order and third- order themes cles. Thirty-eight published and unpublished reports were
whereby axial codes were then systematically applied. retrieved by contacting relevant researchers, for a total of
Second-order themes were developed by grouping first- 3567 potentially eligible studies. Of the 191 studies selected
level themes together based on similarities and differ- for full-text review, 42 studies met inclusion criteria (see
ences. Third-order themes were developed by grouping figure 1). This systematic review presents primary research
first-order and second-order themes together based on findings from 42 studies from 24 LMICs, including 15
higher analytical themes.53 Enablers and barriers that countries in Asia and 9 countries in Africa (see table 2).
emerged from quantitative studies were compared with Nineteen studies used qualitative methods, 8 studies used
qualitative themes and when appropriate, incorporated quantitative methods and 16 studies used mixed methods.
into the thematic analysis. For example, some quanti- In 17 studies, the respondents were OSC stakeholders, in
tative studies found that provision of the full course of 11 studies the respondents were survivors of IPV and/or
HIV pre-exposure prophylaxis (PEP) at first encounter SV, in 12 studies the respondents were both OSC stake-
improved PEP adherence rates. This result was felt holders and survivors and in 1 study the respondents
to support the theme, ‘minimisation of points of care were community members.46 OSC stakeholders included
facilitates medication adherence’ and thus was refer- government officials in 14 studies, healthcare workers in
enced under this theme in the mixed method thematic 15 studies, OSC staff (other than healthcare workers) in 25
synthesis. studies and police members in 6 studies.
4 Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883Table 2 Summary of study characteristics
Citation Sample characteristics, data
number Country/ collection method and recruitment Quality
(year) countries Study design Setting characteristics strategy* Data analysis assessment
41 (2005) Bangladesh Qualitative, Two sites; hospital-based; In depth interviews (n=28) of OSC Thematic analysis Medium
descriptive NGO and government run stakeholders (government, NGO,
employees and women survivors)
Purposive, snowball sampling
26 (2006) Bangladesh Mixed methods, One site; hospital-based; Survey (n=310) of women treated at Descriptive analysis Low
cross-sectional NGO and government run OSC, as identified by medical chart
survey review
Purposive sampling
43 (2013) Malaysia Qualitative, Seven sites; hospital-based; In depth interviews (n=54) of OSC Thematic analysis High
descriptive NGO and government run healthcare workers (including nurses,
medical officers, gynaecologists, medical
social workers and hospital managers)
Snowball sampling
48 (2016) Nepal Qualitative, One site; hospital-based FGDs (n=117) of community members, Qualitative content High
descriptive including men (n=41) and women (n=76) analysis
Purposive sampling
12 (2012) Kenya, Zambia Mixed methods, Five sites; In-depth interviews (n=25) of female and Qualitative: thematic Medium-high
comparative one NGO-owned stand- male survivors of gender-based violence, analysis, Quantitative:
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
case study alone, caregivers of child survivors, hospital EpiData and SPSS,
one NGO-owned hospital- managers and key informant interviews; accounting approach
based, three hospital- medical chart review, facility inventory cost-analysis
owned hospital based review
Purposive sampling
11 (2010) 27 countries in Asia-Pacific; Qualitative, Variety of government-led, Desk review, field visits, phone and Content analysis, Low-medium
relevant countries include: descriptive NGO-led and combined email interviews with relevant OSC thematic analysis
Bangladesh, India, Indonesia, responses, both hospital- stakeholders at country and regional
Malaysia, Maldives, Nepal, based and stand-alone offices
Papau New Guinea, Philippines, facilities. Purposive sampling
Sri Lanka, Thailand and Timor-
Leste
46 (2016) Sylet and Cox's Bazar, Qualitative, Five sites; stand-alone and Key informant semi-structured interviews Content analysis, Low-medium
Bangladesh descriptive hospital based; mostly (n=124) of United Nations Population thematic analysis
government run with some Fund (UNFPA) staff, government
NGO involvement ministries, implementing partners
and donors); mixed FGDs (n=12) of
government and implementing partner
staff, and community beneficiaries; site
visits, desk review
Purposive sampling
Continued
BMJ Global Health
56
Table 2 Continued
Citation Sample characteristics, data
number Country/ collection method and recruitment Quality
(year) countries Study design Setting characteristics strategy* Data analysis assessment
44 (2013) Rwanda Qualitative, one site; Semi-structured interviews and FGDs Thematic analysis High
descriptive hospital-based; government (n=93, breakdown not given) of survivors,
and NGO run OSC staff, and UN and government
stakeholders; facility observation
BMJ Global Health
Convenience and purposive sampling
33 (2013) Zambia Qualitative, Eight sites; two stand-alone Survey (n=197) of female and male Descriptive analysis Low
cross-sectional centres and six hospital- survivors of IPV or SV who accessed
survey based; all international NGO centre
funded Convenience sampling
30 (2013) Nepal Mixed methods Four sites; hospital-based; In-depth interviews of female and Content and thematic Medium
government-run male survivors of IPV or SV (n=20) and analysis, SWOT
central stakeholders (n=137) including analysis
government employees and donors
(n=13), health workers (n=58), members
of coordination committees (n=42) and
other (n=24).
Purposive and convenience sampling
13 (2016) South Africa Qualitative, 55 sites (Thuthuzela Semi-structured interviews and surveys Qualitative: thematic High
descriptive centres); hospital-based and (number not provided) of National analysis
stand-alone; government Prosecuting Authority staff, NGO staff,
and NGO run OSC managers and national experts in
GBV in South Africa; facility observation
Non-random sampling not otherwise
specified
51 (2003) Kenya Qualitative, 10 voluntary counselling In-depth and semi-structured interviews Thematic analysis, High
descriptive and testing (VCT) sites, of male and female key informants (n=34) content analysis
11 hospitals, 6 legal and FGDs (n=18) including hospital staff,
and advocacy support police officers, government and NGO
programme; one hospital- workers and VCT counsellors; facility
based, private OSC (gender observations
violence recovery centres) Stratified and purposive sampling
45 (2010) Zambia Mixed methods 10 sites; stand-alone and Semi-structured interviews (n=240) of Descriptive analysis Low
hospital-based, NGO and key informants including beneficiaries,
government- run stakeholders and ministry officials;
facility observations
Sampling strategy not stated
37 (2014) Nepal Qualitative, 16 sites; hospital-based, Interviews of survivors of IPV and SV, Descriptive analysis Low
descriptive government-run (Ministry of government officials, OSC staff and
Health and Population) community members
Sampling strategy not stated
Continued
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883Table 2 Continued
Citation Sample characteristics, data
number Country/ collection method and recruitment Quality
(year) countries Study design Setting characteristics strategy* Data analysis assessment
39 (2016) Pakistan Mixed methods; 12 sites; stand-alone, Semi-structured telephone interviews Quantitative: standard Medium-high
cross-sectional, or within government (n=136), including female survivors of IPV statistical techniques,
qualitative (non-medical) facilities, and SV (n=123), and male and female that is, descriptive
descriptive government-run OSC managers (n=13); field visits and analysis using SPSS
surveys and MS office;
Simple random sampling qualitative: thematic
analysis of the open
ended survey and
interview questions
38 (2017) India Qualitative, Four sites; In-depth interviews (n=80) including Thematic analysis Medium-high
descriptive hospital-based and police- survivors of sexual assault (n=15),
station-based, government- family members of survivors (n=25)
run. and lawyers, civil society activists and
advocates (n=15), doctors and forensic
experts (n=6), government officials (n=12)
and police officers (n=7)
Purposive sampling
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
18 (2002) Philippines Mixed methods; One site (women and Medical chart review of non-pregnant Basic descriptive Medium
retrospective children protection unit); women and children who were survivors statistical analysis
cohort, hospital-based, of IPV and/or SV (n=1354)
qualitative government-run Convenience sampling
descriptive
19 (2013) Kenya Mixed methods; One site; Medical chart review of female and Basic descriptive Medium-high
retrospective Clinic-based, NGO-run male, child and adult survivors of sexual statistical analysis
cohort, (Médecins Sans Frontières) violence (n=866) using Microsoft Excel
qualitative Purposive sampling and EpiData Analysis
descriptive 2.1, qualitative
descriptive analysis
20 (2015) Malaysia Quantitative one site; Self-reporting survey of male and female Basic statistical High
cross-sectional hospital-based, survivors of IPV (n=159) analyses conducted
observational government-run Purposive sampling using SPSS V.20.
15 (2011) Malaysia Qualitative, Two sites; In-depth interviews (n=20), including Content analysis High
descriptive Hospital-based, combined policymakers (n=8), NGO representatives
NGO and government run (n=7), healthcare workers (n=1) and
police and social welfare representatives
(n=4)
Purposive and snowball sampling
Continued
BMJ Global Health
78
Table 2 Continued
Citation Sample characteristics, data
number Country/ collection method and recruitment Quality
(year) countries Study design Setting characteristics strategy* Data analysis assessment
16 (2012) Malaysia Qualitative Seven sites; In-depth and semi-structured Content and High
descriptive hospital-based, combined interviews (n=74) including accidents framework analysis
NGO and government run and emergency doctors (n=23),
gynaecologists (n=6), nurses (n=14),
BMJ Global Health
medical social workers (n=5), counsellors
(n=2), psychiatrists (n=4), policymakers
(n=8) and key informants (n=12)
Purposive and snowball sampling
49 (2009) India Mixed methods; One centre (Centre for Self-reported reflections and interviews Descriptive narrative Low
cross-sectional Vulnerable Women and with healthcare workers, female survivors analysis
observational, Children); stand-alone, of IPV/SV who utilised the centre
qualitative combined NGO and (number not provided)
descriptive government-run Convenience sampling
10 (2002) Thailand Retrospective Two centres; hospital- Structured and in-depth interviews Descriptive analysis Low
cohort, quasi- based, government-run (n=249) of female and male hospital
experimental, staff including physicians, nurses, social
cross-over workers, psychologists and intake
personnel, community women’s leader
groups, staff attorneys and police
officers
Sampling strategy not stated
21 (2017) Zimbabwe Retrospective One site (Sexual and Medical chart review (n=3617) of female Descriptive statistics High
cohort Gender-Based Violence and male survivors of sexual violence, using Stata V.11. X2
Clinic); including survivors ages over 16 tests, Fisher’s exact
clinic-based, combined (n=1071), ages 12–15 (n==615) and ages tests, logic regression,
NGO (MSF) and under 12 (n=93). and model building
government-run Census
40 (2009) Kenya Qualitative, Three sites; Client exit interviews (n=734) of female Situational analysis Low
descriptive hospital-based (emergency and male, child and adult survivors of
department), combined rape
NGO and government-run Sampling strategy not stated
32 (2009) South Africa Before and after One site; Semi-structured interviews with female Quantitative Moderate
intervention; hospital-based, and male survivors of rape (n=109) and descriptive analysis
retrospective government-run service providers (n=16) (doctors, nurses, using Stata. Risk
cohort social workers, a pharmacist and police ratios estimated using
officers); medical chart review Poisson regression to
Convenience sampling estimate intervention
effect.
Qualitative analysis
methods not clearly
stated
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
ContinuedTable 2 Continued
Citation Sample characteristics, data
number Country/ collection method and recruitment Quality
(year) countries Study design Setting characteristics strategy* Data analysis assessment
17 (2016) Democratic Republic of Congo Qualitative, Two sites; Descriptive personal narrative of medical Thematic analysis Low
descriptive Hospital based, privately- director/obstetrics-gynaecologist and
run midwife (n=2)
22 (2011) Kenya Retrospective One site; Medical chart review of female and Summary descriptive High
cohort hospital-based, male survivors of sexual abuse (n=321), statistics using Stata
government-run including children and adults, (median SE 10.0. Estimates of
age 15.9 years; range 8 months to 100 association calculated
years) using Student’s t-test,
Purposive sampling X2 tests and Fisher’s
exact tests
23 (2006) South Africa Observational, One site (victim support Self-reported survey of female and male Descriptive analysis Low
descriptive centre); survivors of rape (n=105)
hospital-based, (median age 23.5 years; range 16–68)
government-run treated at the centre
Purposive sampling
14 (2010) Ethiopia, Kenya, Malawi, Retrospective Seven sites; Interviews, surveys and medical chart Data analysis methods Low
Senegal, South Africa, Zambia, cohort, includes variety of review of survivors of sexual violence, not clearly stated
Zimbabwe qualitative, comprehensive care models healthcare workers, policymakers,
descriptive including Thohoyandou government officials
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
Victim Empowerment Sampling strategy not stated
Programme, South Africa,
and the
Kamuzu Central Hospital,
Malawi;
hospital-based, NGO-run
24 (2017) Taiwan Cross-sectional Five centres; Survey (n=140), using Index of Statistical analysis via High
hospital-based, Interdisciplinary Collaboration tool of SPSS 18. Multivariate
government-run social workers, doctors, nurses, police analysis of variance
officers and prosecutor conducted for
Purposive sampling association analyses,
eta-square for
power of effect, and
multilinear regression
for influencers on
collaboration
25 (2016) China Retrospective Two sites (RainLily); Medical chart review (n=154) of female Descriptive statistical Low
cohort Hospital-based, survivors of sexual assault (median age analysis via PASW
NGO-run 22 years; range 13–64) Statistics 18, and
Purposive sampling Mann-Whitney test
for highly skewed
distributions
BMJ Global Health
9
Continued10
Table 2 Continued
Citation Sample characteristics, data
number Country/ collection method and recruitment Quality
(year) countries Study design Setting characteristics strategy* Data analysis assessment
31 (2008) Papua New Guinea Mixed methods; ten sites (only Family Survey (n=39) of stakeholders Descriptive and Moderate
cross-sectional, Support Centres (FSCs) (government officials, NGO thematic analysis
BMJ Global Health
qualitative relevant to this review); representatives, and donors;
descriptive Hospital-based, government In-depth interviews (n=17) of key
and NGO run informants (donors, service providers,
governments officials, local women’s
rights activists and faith-based groups)
Purposive and snowball sampling
50 (2016) Papua New Guinea Retrospective One site (FSC); hospital- Medical chart review (n=5212) of male Statistical analysis Moderate-high
cohort based, government and and female presentations for SV and/or via χ2-squared or
NGO (MSF) run IPV Fisher’s exact tests,
Purposive sampling multiple variable
adjusted analyses,
and modified Poisson
regression
36 (2013) South Africa Qualitative, Two sites; Telephone and in-person interviews Descriptive and Moderate
descriptive Stand-alone (near health (n=20) of staff, representatives from thematic analysis
facility), run by NGO (United government, civil society organisations,
Nations Office on Drugs and UNODC and advisory committees
Crime), later transferred to Convenience sampling
SA government
29 (2011) Malawi Mixed methods; Three sites; hospital- In-depth interviews (n=15) of healthcare Qualitative: thematic High
retrospective based, combined NGO and workers (including doctors, clinical analysis
cohort, government-run officers, nurses, midwives, social Quantitative:
qualitative workers, health surveillance assistants descriptive statistical
descriptive and village health committee members). analysis and summary
Key informant interviews (n=12) with statistics via Epi Info,
policymakers, donors and other Pearson’s X2 and
stakeholders and FGDs (n=10) with Fisher’s exact test
healthcare workers; chart review
Purposive stratified sampling
47 (2012) Kenya Qualitative, Four sites (only the Semi-structural interviews of female Thematic analysis High
descriptive Gender-Based Violence adult survivors of IPV/SV (n=8), and staff
Recovery Centre members (n=5) (head of department,
(GBVRC) relevant to this psychologist, social worker, nurse
review); hospital-based, counsellor and receptionist); client flow
government-run observations
Purposive sampling
Continued
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883Table 2 Continued
Citation Sample characteristics, data
number Country/ collection method and recruitment Quality
(year) countries Study design Setting characteristics strategy* Data analysis assessment
27 (2010) Sierra Leone Qualitative, Three centres (Rainbow In-depth interviews and FGDs of (n=101) Descriptive analysis Moderate
descriptive Centres); male and female survivors of sexual
stand-alone, NGO-run assault and
(n=22) OSC and NGO staff, including
community leaders, judicial investigators,
court magistrates and police; facility
observations
Convenience sampling
35 (2015) South Africa Qualitative, 29 sites (Thuthuzela In-depth interviews (n=40) of OSC Descriptive analysis Moderate
descriptive centres); variety of hospital- directors and programme managers;
based, stand-alone, police participant observation
and court-based centres; Non-random sampling not otherwise
combined NGO and specified
government run, or only
government-run
42 (2004) India Qualitative, One centre (Dilaasa); Semi-structured interviews Content analysis High
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
descriptive hospital-based, (n=27) of adult female survivors of
Combined NGO and IPV/SV, including current and former
government run programme participants
Purposive sampling
34 (2010) India Qualitative, Two centres (Dilaasa); Semi-structured interviews with Thematic analysis Moderate
descriptive hospital- based, combined survivors of violence, project personnel,
NGO and government run coordinator, mentors and hospital
staff (number not specified); facility
observation
Sampling strategy not stated
28 (2018) Mongolia Qualitative, Four sites; variety of In-depth interviews (n=36) and FGDs Thematic analysis Low-moderate
descriptive centres–some health facility (n=6) of key informants
based, stand-alone, and Sampling strategy not stated
police-station based, variety
of government and NGO-
run, funded by UNFPA
*Some details of sample characteristics such as participant sex, age, professional role, specific sampling strategy and data collection and analysis methods were not provided in the
primary studies, and thus do not appear in table 2.
FGD, focus group discussion; FSC, family support centre; IPV, intimate partner violence; MOU, memorandum of understanding; MSF, Médecins Sans Frontières; OSC, one stop centre;
SOP, standard operating procedures; SPSS, Statistical Package for the Social Sciences; SV, sexual violence; VAW, violence against women.
BMJ Global Health
11BMJ Global Health
Table 3 Summary of quantitative study findings
Citation number Quality Themes incorporated into qualitative
(year) Key findings of enablers and barriers assessment synthesis (E=enabler, B=barrier)
18 (2002) There was a delay from time of the abuse to presentation at the Medium ►► B: Lack of access to rural populations
OSC, which was attributed to the geographic inaccessibility of the ►► B: Lack of community awareness of OSC
centre, especially for rural populations, as well as lack of community services
awareness. Higher reporting of sexual abuse cases was attributed ►► F: Sensitive staff knowledge, attitudes and
to preference among women and children community members to behaviours
seek care from doctors who specialise in this care and can meet
survivor needs.
19 (2013) There was poor follow-up for medical interventions that required Medium-high ►► B: Lack of long-term support and
repeat visits. Standardised procedures and protocols assisted in follow-up
providing quality care to survivors. ►► F: Standardised policies and procedures
20 (2015) There were weaknesses in OSC staff documentation and concerns High ►► B: Poor documentation and data
over survivor confidentiality. OSC staff had unclear roles and management systems
responsibilities. Some of the OSC staff were found to have victim- ►► B: Compromised confidentiality and
blaming attitudes, and many failed to provide necessary health privacy
information to patients. Some staff did not provide rape survivors ►► B: Unclear staff responsibilities and roles
with sensitive care and failed to spend time to console patients ►► B: Harmful staff attitudes
after report of sexual assault. There was a lack of OSC staff training, ►► B: Harmful behaviours of health workers
with more than half of the staff having never attended any training ►► B: Failure to provide health information
sessions in OSC management even after some had worked for ►► B: Inadequate training on trauma informed
years in the OSC. care and OSC operations
21 (2017) Follow-up was a common issue, and 42% or 938 survivors had no High ►► B: Lack of long-term support and
follow-up follow-up
22 (2011) 44% of survivors were reported to receive counselling at the centre. High ►► B: Lack of adequate psychosocial
There was a lack of available psychosocial support, and only one services and staff
counsellor was available during standard business hours throughout ►► B: Lack of services on nights and
the duration of this study. There was a lack of support for survivors weekends
who presented at night or on weekends. Another barrier was lack of ►► B: Lack of community awareness of OSC
awareness of OSC services and support for women rape survivors services
in the community. Clear protocols were noted to assist in improved ►► F: Standardised policies and procedures
documentation at the centre.
23 (2006) There was a lack of survivor-centred care, with privacy concerns. Low ►► B: Compromised confidentiality and
Survivors had to wait in their blood stained, dirty clothes until the privacy
healthcare worker could examine them. There was also a lack of ►► B: Failure to provide health information
provision of health information, such as STI, HIV and pregnancy risk ►► B: Long wait times
after sexual assault. Long waiting times were also a concern at the
hospital.
24 (2017) The perceived degree of interdisciplinary collaboration was lowest High ►► B: Weak multi-sectoral collaboration
among social workers, who felt less trust, respect, informal ►► F: Regular interagency meetings
communication and understanding between collaborators. ►► F: Support from executive leadership
Healthcare workers perceived the least support from their ►► F: Increased interprofessional interaction
organisation. Support from higher management and regular opportunities
interagency meetings were viewed as helpful to improve
collaboration.
25 (2016) Follow-up attendance after the incident was 57.8%, 63.6%, Low ►► B: Lack of long-term support and
59.1% and 46.8% at 2 weeks, 6 weeks, 3 months and 6 months, follow-up
respectively. Overall, less than half of survivors returned for follow-
up visits.
OSC, one stop centre; STI, sexually transmitted infections.
Quantitative synthesis as policymakers and donors (see S4 Table). Tables 4A,B
A total of eight studies with quantitative data had findings presents the summary of study findings and the CERQual
relevant to the review.18–25 Meta-analysis was not possible confidence assessments; table 4A presents barriers and
due to wide variations in study designs, measures and table 4B presents enablers.
outcomes. Instead, descriptions of relevant findings from
quantitative studies including data found in results and Governance and leadership
discussion sections are presented (table 3). Enablers and Laws, policies and procedures
barriers that emerged from the quantitative studies are Supportive laws and policies on violence against women
incorporated into the thematic synthesis. gave OSCs legitimacy and generated high-level commit-
ment from government officials (moderate confidence
Qualitative synthesis (MC)).10 11 26–28 Some OSCs that lacked standardised oper-
Nineteen studies used qualitative methods and 16 ating procedures (SOPs) struggled to provide consistently
used mixed methods. Perspectives varied by study, high-quality care (MC).10 15 16 28 30 31 The implementation
including survivors, staff and other stakeholders such of many SOPs faced significant challenges due to lack of
12 Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883Table 4A Summary of findings: barriers
CERQual Confidence
Third order First order themes confidence assessment
themes Second order themes barriers Contributing studies level explanation Illustrative examples
Leadership and Laws, policies and Unclear, 10 11 15 29–31 Moderate Six studies with ‘The 1996 MOH circular
governance procedures uncontextualised minor to significant did not specify how
or unavailable OSC methodological the centres should be
policies and procedures limitations. Fairly created… In reality, it
thick data from 13 was very much left at the
countries, including discretion of each hospital’s
one multi-country director to develop its own
study of 11 countries procedures.’
in the Asia-Pacific (Malaysia, 15)
region. Fairly high
coherence.
Governing bodies Ineffective advisory Low Three studies ‘…some members of the
meetings and . with moderate committees … were not
committees to significant regularly participating, or
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
methodological had not been updated
limitations. Adequate by their officials who had
data but only from participated in meetings.
two countries. Level In all four districts a couple
of coherence unclear of (advisory committee)
due to limited members were unaware of
data, but findings their [OSC].’
were similar across (Nepal, 38)
studies
Lack of oversight 10 11 27 30 36 38–40 Moderate 10 studies with ‘There’s no oversight or
and supervision from minor to significant monitoring of any of these
governing bodies methodological institutions… There is no
limitations. Fairly monitoring of any kind.
thick data from eight Accountability of the
countries. High government is zero.’
coherence. (India, 46)
Continued
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Table 4A Continued
CERQual Confidence
Third order First order themes confidence assessment
themes Second order themes barriers Contributing studies level explanation Illustrative examples
Poor transfers of 35 36 39 Low Three studies with Poor relationships largely
management minor to significant seemed the result of a
BMJ Global Health
methodological poorly handled transition
limitations. Fairly from a NGO service to a
thick data from two Thuthuzela Centre (TCC).
countries. Unable to At two sites respondents
assess coherence reported arriving at work
as only three 1 day to be met by National
contributing studies Prosecuting Authority staff,
from two countries, and the announcement ‘This
but findings were is now our TCC.’
similar among (South Africa, 43)
studies.
Political will Lack of political will and 10–12 15 27 29 31 33 36 High 13 studies with ‘The OSCCs are physically
government investment 38–42 minor to significant there but then they are not
on issues of IPV/SV methodological staffed …I felt that they
limitations. Thick (Ministry of Health) were
data from 12 not willing to put in extra
countries. Moderate money….I think it is just a
to high coherence. political will, it was not their
priority.’
(Malaysia, 15)
Health system Equipment and Lack of basic medical 11–13 15 26 27 30 35–39 41 High 15 studies with ‘There were insufficient
resources supplies supplies, facility 42 44 minor to significant examination tables, focus
equipment and survivor methodological lights, and medico-legal
comfort items limitations. Thick investigation materials and
data from 14 no rape or post exposure
countries. High prophylaxis kits.’
coherence. (Nepal, 38) ’Another
challenge is we don’t have
panties for adult woman
so when one is raped she
has to leave now the panty
for DNA then they go now
without panties.’
(South Africa, 13)
Continued
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883Table 4A Continued
CERQual Confidence
Third order First order themes confidence assessment
themes Second order themes barriers Contributing studies level explanation Illustrative examples
Information and Poor documentation 11 13 19 26–29 31 34 40 41 High 14 studies with ‘Some staff at specialised
monitoring and data management 45 46 minor to significant and district hospitals were
systems methodological sometimes unsure how to
limitations. Thick proceed with IPV cases,
data from 22 what injury to document, in
countries. High what detail, how and what
coherence. questions to ask, where to
refer women.’
(Malaysia, 16)
Lack of facility-level 12 13 27–30 34 36 40 45 46 High 11 studies with ‘The team has little capacity
monitoring mechanisms minor to significant or tools to systematically
methodological collect and aggregate
limitations. Thick data. No analysis of all the
data from 22 available data to inform
countries, including the programme and guide
multi-country studies implementation is currently
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
from Africa and the being undertaken.’
Asia-Pacific region. (Rwanda, 52)
Reasonable level of
coherence.
Operation costs Operation costs not 10 12 15 27–30 33 35 36 38 Moderate 11 studies with ‘Some OSC services were
feasible in low-resource 46 minor to significant disrupted by funding
settings methodological constraints; one centre ran
limitations. Relatively without electricity, water,
thick data from and telephone lines for long
17 countries. stretches of time due to
Reasonable level of cost.’
coherence. (South Africa, 44)
Lack of designated 10 30 35–37 45 Low Six studies with ‘In Malaysia, the OSCs
budgets and budget minor to significant budget was under the
transparency methodological emergency department,
limitations. Adequate which resulted in no
data from four dedicated budget for OSCs.’
countries. High level (Malaysia, 15).
of coherence.
Continued
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1516
Table 4A Continued
CERQual Confidence
BMJ Global Health
Third order First order themes confidence assessment
themes Second order themes barriers Contributing studies level explanation Illustrative examples
Unsustainable, donor- 27 30 35 36 38 42 45 47 48 Moderate Nine studies with ‘When a contract with one
dependent funding minor to significant donor ended, it lead five
sources methodological organisations in South
limitations. Fairly Africa, that were reliant on
thick data from this donor’s funding, to
six countries, and terminate OSC services.’
three from South (South Africa, 43)
Africa. High level of
coherence.
9 13 15 21 25 27 28 30 31 35 38–41 46 47
Service delivery Quality of care Lack of adequate High 16 studies with ‘We are asked to speak with
psychosocial services minor to significant the victims and help them,
and staff methodological but we don’t have expert
limitations. Thick psychologists. I have read
data from 14 some books but … it’s not
countries. High level the same.’
of coherence. (India, 46)
In an evaluation of 12
centres in Pakistan, only one
had a psychiatrist.
(Pakistan, 47)
Failure to provide health 13 27 30 34 35 45 Low Three studies with ‘The health information
information minor to significant given to the participants was
methodological also lacking, with the victims
limitations. Thin data not informed about the risk
from three countries. of contracting STIs/HIV or
Adequate level of becoming pregnant.’
coherence. (South Africa, 31)
Continued
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883Table 4A Continued
CERQual Confidence
Third order First order themes confidence assessment
themes Second order themes barriers Contributing studies level explanation Illustrative examples
Ineffective clinical care 15 27 29–31 Moderate Five studies with ‘In the absence of clear
protocols minor to significant guidelines and protocols,
methodological clinical services related to
limitations. Fairly GBV remain inconsistent
thick data from 13 and ad hoc …Without
countries, including protocols, there is some
one multi-country concern that many
study of 11 countries healthcare workers will only
in the Asia-Pacific treat physical injuries and
region. High even pass judgement about
coherence. the survivor’s role in the
abuse.’
(Timor-Leste, 11)
Lack of long-term 19 22 26–31 33 35 36 38 40 Moderate Nine studies with ‘We are not able to assure
support and follow-up 41 49 minor to significant them because there is no
services methodological follow-up; when they get out
Olson RMcK, et al. BMJ Global Health 2020;5:e001883. doi:10.1136/bmjgh-2019-001883
limitations. Fairly of here, everything is like we
thick data from 12 are finished with them.’
countries throughout (Zambia, 14)
Africa and Asia. High
level of coherence.
Compromised 19 22 27 59 High 12 studies with ‘One victim’s father fought
confidentiality and minor to significant with the hospital ward
privacy methodological sisters for the patient files…
limitations. Fairly we have to make a system
thick data from 14 such that perpetrators and
countries. High level victims will be anonymous.’
of coherence. (Nepal, 56)
Lack of security at OSC 27 30 36 38 49 Low Five studies with ‘What our safety is
minor to significant concerned, we are alone
methodological here over weekends and
limitations. Adequate at night, and that is quite a
data from three risk.’
countries. High level (South Africa, 13)
of coherence.
Continued
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1718
Table 4A Continued
CERQual Confidence
Third order First order themes confidence assessment
themes Second order themes barriers Contributing studies level explanation Illustrative examples
Lack of child and 15 27 30 33 38 46 Low Six studies with ‘Neither NGO-owned OSC
adolescent-friendly minor to significant had special provisions
BMJ Global Health
services and methodological for… infants and children
environment limitations. Fairly in their written guidelines
thick data from five or protocols for the clinical
countries. High level management of sexual
of coherence. and gender based violence
(SGBV).’
(Kenya, Zambia, 12)
Accessibility High out-of-pocket 13 25 26 29 30 39 41–43 45 Moderate 11 studies with ‘Referrals by [OSCs] to other
costs to survivors for 50 minor to significant hospitals for cases such
referral services methodological as skin grafts, or to an eye
limitations. hospital or for psychiatric
Moderately thick treatment showed no results
data from 20 due to shortages of funds
countries, including that prevented survivors
four studies from going there.’
reporting on India. (Nepal, 38)
Moderate level of
coherence.
Lack of services on 11 12 21 25 27 31 33 35–38 High 14 studies with ‘Now in my case also, such
night and weekends 42 43 46 minor to significant incidents happened at
methodological night, kerosene was poured
limitations. Thick on me, they tried to kill
data from 10 me, beat me, I couldn’t go
countries. High anywhere…For the whole
coherence. night I kept sitting like that.’
(India, 51)
Long wait times 13 22 25 26 30 33 35 38 48 Moderate Nine studies with ‘The OCMC staff nurses
minor to significant were at times unable to
methodological provide timely services
limitations. Adequate due to their workloads
data from 10 and consequently some
countries. High survivors had to wait several
coherence. hours.’
(Nepal, 38)
Continued
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