health care services for victims/survivors … · yolanda paredes - gaitan . ipas, nicaragua....

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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. BillingsKaren Padilla

Ipas, USA

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

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Antecedents and Context

Model of health care provided to women victims/survivors

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Early Detection

Counseling

Medical care

Information systems

Follow-up

Promotion and

Prevention

Referral and Counter-Referral

Clinical support

Legal support

Emotional and psychological

support

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.

Presenter

Presentation Notes

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

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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

LAWSACTS

RESOLUTIONSPROTOCOLS

MANUALS

PROTOCOLSGUIDESFORMS

MEDICAL RECORDS

•OB & GYN SERVICES•EMERGENCY ROOM•PRIMARY HEALTH SERVICES•LABORATORY•DISINFECTION AND STERILIZATION AREA•SUPPORT SERVICES (ENVIRONMENTAL )

Methods & Activities

http://www.ipas.org/Publications/asset_upload_file523_4350.pdf

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Equipment Management

(maintenance)

Infection Control &Patient Safety•Sterilization•Waste management

InformationManagement• Forms•Analysis•Custody

Medication Management

Physical Environment•Showers

•Restrooms•Ventilation

Additional check list


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PanamaCosta Rica

NicaraguaEl Salvador

HondurasGuatemala

Bel

ize

CENTRAL AMERICA

4 countries visited NicaraguaGuatemalaHondurasEl Salvador

OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR 2008-2009


•54 health care facilitieswere selected

•49 were visited

OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL

SALVADOR 2008-20098

Strengths

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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.

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27%22%

73%

COMPLETE1

2

1b

RESULTS: HUMAN RESOURCES (TEAMS)

COMPLETE TEAM:•Physician and /or Nurse•Psychologist and /or Social Worker

•Lawyer and/or others (social worker if psychologist present)

HEALTH PROVIDERS WITH COMPLETE AND INCOMPLETE TEAMS

Only one personattending

(Physician or Psychologist)N=49


INCOMPLETE

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RESULTS:REFERRAL AND COUNTER-REFERRAL


• HOSPITAL LEVEL II or III • INFECTIOUS DISEASES

PROGRAM• HIV PROGRAM• LABORATORY

• FORENSIC SERVICES

• HEALTH CARE PROVIDER

LEVEL I AND IIInterview

and physical

exam

Interview and

physical exam

Interview and

physical exam

Sometimes interview to fill out HIV test forms

FLOW OF ATTENTION VSSVCOUNTRY “C” FEBRUARY 2009

VDRL VAGINAL SMEAR

VAGINAL SMEAR

CULTURE

RAPID HIV TESTING ELISA

RAPID CHLAMYDIA

TESTINGNicaragua N=19 12 10 2 12 3 2Guatemala n=10 6 6 2 6 2 3Honduras n=9 6 5 3 6 5 1El Salvador n=11 5 3 0 5 0 0

0

2

4

6

8

10

12

14#

of h

ealth

car

e fa

cilit

ies

Biological Samples for Diagnosis Health Porpuses


VDRL=venereal disease research laboratory

RES

ULT

S: C

AR

E

yesno65%

35%

Presence of Laboratory

1

2

LABORATORY SERVICES

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.


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RES

ULT

S: C

AR

E

©Paredes-Gaitan Y.

Horizontal Laminar Flow Workstation??

Presenter

Presentation Notes

CABINA DE FLUJO LAMINAR

OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR 20091312 or 15 o C

TEMPERATURE

Paredes-Gaitan Y.©

Paredes-Gaitan Y.©

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2 or 8 oCT

EM

PER

ATU

RE

KIT STORAGE

SPECIMEN STORAGE2 -8 o C

2 -30 o C

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TRANSPORTATION REQUIREMENTS FOR INFECTIOUS SUBSTANCES

TR

AN

SPO

RTA

TIO

N

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PREVENTIVE AND PREDICTIVE MAINTENANCE

©Paredes-Gaitan Y.©Paredes-Gaitan Y.

Presenter

Presentation Notes

Prev and predic programs were found in few institutions


AnalgesicsEmergency contracepti

on

Prophylaxis STI Prophylaxis

VIH

Treatment STI

Treatment HIV & AIDS

% of health providers with 80% 80% 60% 30% 60% 20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% o

f hea

lth fa

cilit

ies

Medications Found at the Facility (Country “ B”)

One facility did not offer clinical service, only emotional support

RES

ULT

S: C

AR

E

Presenter

Presentation Notes


RES

ULT

S: C

AR

E

NICARAGUA GUATEMALA HONDURASEL

SALVADOR

Legal abortion 0% 0% 0% 0%Adoption 16% 30% 78% 0%Prenatal care 74% 50% 33% 36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

# of

hea

lth

faci

litie

s

Services Offered to Women Pregnant as a Result of Sexual Violence

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98%

2%Type of Sterilization Used

STEAM STERILIZATION

DRY HEAT STERILIZERS (OVEN)

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parameters of steam sterilization: steam, pressure, temperature,

and time.

©Paredes-Gaitan Y.

RES

ULT

S: C

LIN

ICAL

EQ

UIP

MEN

T

©Paredes-Gaitan Y.

n = 43 reportedsterilization

STEAM STERILIZATION(Autoclave)

OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR 2008- 200920

The steam cycle should be monitored by mechanical,

chemical, and biological monitors XR

ESU

LTS:

CLI

NIC

AL

EQU

IPM

ENT

NICARAGUA GUATEMALA HONDURAS EL SALVADOR

USE 6% 22% 12% 11%DO NOT USE 94% 78% 88% 89%

0%10%20%30%40%50%60%70%80%90%

100%

% o

f hea

lth fa

cilit

ies

Monitoring Sterilization Use of Biological Monitors

Presenter

Presentation Notes

http://images.google.com/imgres?imgurl=http://www.doctordepotonline.com/mall/3M 1222.jpg&imgrefurl=http://www.doctordepotonline.com/mall/PAge149 SterilizationPouches.asp&usg=__WxeWSmkSdzxuK3KIugyHuMZzX7o=&h=359&w=400&sz=20&hl=en&start=2&um=1&tbnid=3gnMMDKrPuwffM:&tbnh=111&tbnw=124&prev=/images?q=3M%E2%84%A2+Comply%E2%84%A2+Steam+Indicator+Tape&hl=en&sa=N&um=1�

Unknown concentrations

Inadequate storage

No existence of guidelines

OBSERVATION HEALTH SETTINGS VSSV, NICARAGUA, GUATEMALA, HONDURAS & EL SALVADOR 2008- 200921

Chemical DisinfectantsHypochlorite (chlorine

disinfectant) was the most widely used.

©Paredes-Gaitan Y.

RES

ULT

S: C

LIN

ICAL

EQ

UIP

MEN

T

22

21%

32%26%

16%

5%

Country "A"SV SPECIFIC RECORD

MEDICAL RECORD

MEDICAL RECORD + SV SPECIFIC RECORDOTHERS

NONE


RESULTS: INFORMATION SYSTEMDocumentation

20%

10%

10%

20%

40%

Country "B"SV SPECIFIC RECORD

MEDICAL RECORD

MEDICAL RECORD + SV SPECIFIC RECORD

OTHERS

NONE


GENERAL INFORMATION

TYPE OF VIOLENCE

CHIEF COMPLAINT &ACTIONS

CHALLENGES

Few restrooms

Showers (only one)

Privacy Vs. Ventilation

No privacy in emergency rooms


Access to gowns to cover up yes

Private bathroom no

Equipment for physcial exam yes

Auditory privacy no

Visual privacy no

Door, screen, or curtain yes

Chair(s) yes

RESULTS: SERVICE DELIVERY AREA

RESULTS: SERVICE DELIVERY AREA Equipment for physical exam


OtoscopeMobile Light source

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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 .


RECOMMENDATIONS


Delivery service area

Information System

Human resources

•Educationand prevention•Manuals &protocols

•Health providertraining

Integral service

•Diagnostictests

•Equipment

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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


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THANKSGRACIAS

health care services for victims/survivors … · yolanda paredes - gaitan . ipas, nicaragua....

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