The role of the healthcare sector in the prevention of sexual violence against sub-Saharan transmigrants in Morocco: a study of knowledge, attitudes and practices of healthcare workers

van den Ameele et al. BMC Health Services Research 2013, 13:77 http://www.biomedcentral.com/1472-6963/13/77 RESEARCH ARTICLE Open Access The role of the healthcare sector in the prevention of sexual violence against subSaharan transmigrants in Morocco: a study of knowledge, attitudes and practices of healthcare workers Seline van den Ameele1*, Ines Keygnaert1, Alima Rachidi2, Kristien Roelens1 and Marleen Temmerman1 Abstract Background: Sub-Saharan transmigrants in Morocco are extremely vulnerable to sexual violence. From a public health perspective, the healthcare system is globally considered an important partner in the prevention of sexual violence. The aim of this study is twofold. In a first phase, we aimed to identify the current role and position of the Moroccan healthcare sector in the prevention of sexual violence against sub-Saharan transmigrants. In a second phase, we wanted these results and available guidelines to be the topic of a participatory process with local stakeholders in order to formulate recommendations for a more desirable prevention of sexual violence against sub-Saharan transmigrants by the Moroccan healthcare sector. Methods: Knowledge, attitudes and practices of healthcare workers in Morocco concerning sexual violence against sub-Saharan transmigrants and its prevention were firstly explored in semi-structured interviews after which they were discussed in a participatory process resulting in the formulation of recommendations. Results: All participants (n=24) acknowledged the need for desirable prevention of sexual violence against transmigrants. Furthermore, important barriers in tertiary prevention practices, i.e. psychosocial and judicial referral and long-term follow-up, and in secondary prevention attitudes, i.e. active identification of victims were identified. Moreover, existing services for Moroccan victims of sexual violence currently do not address the sub-Saharan population. Thus, transmigrants are bound to rely on the aid of civil society. Conclusions: This research demonstrates the low accessibility of existing Moroccan services for sub-Saharan migrants. In particular, there is an absence of prevention initiatives addressing sexual violence against the subSaharan transmigrant population. Although healthcare workers do wish to develop prevention initiatives, they are dealing with structural difficulties and a lack of expertise. Recommendations adapted to the context of sub-Saharan transmigrants in Morocco are suggested. Keywords: Sub-Saharan migrants, Morocco, Sexual violence, Health services, Prevention * Correspondence: 1 ICRH- International Centre for Reproductive Health, Faculty of Medicine & Health Sciences, Ghent University, De Pintelaan 185 - P3, Ghent 9000, Belgium Full list of author information is available at the end of the article © 2013 van den Ameele et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. van den Ameele et al. BMC Health Services Research 2013, 13:77 http://www.biomedcentral.com/1472-6963/13/77 Background Transmigrants in Morocco Yearly, an estimated 65,000 to 120,000 sub-Saharan Africans cross North Africa on their way to Europe. These sub-Saharan migrants try to survive in the Maghreb countries as a region of transit, until they have saved enough to fund further migration to Europe, hence the term ‘transmigrants’. However, only one-third of these transmigrants eventually continues to Europe, as this has become increasingly difficult due to strict European immigration and Neighbourhood policies [1-3]. As a result, Northern Africa has become a region of destination rather than a region of transit. Approximately 10,000 to 15,000 sub-Saharan transmigrants are currently living in Morocco [2,4,5]. Sexual violence as a public health problem According to the World Health Organization (WHO), the problem of sexual violence is a public health issue [6,7]. Healthcare workers are ideally placed to recognize and intervene in sexual violence since they are frequently consulted by victims for years after the violation and are often confronted with its physical and mental health consequences.. Furthermore, healthcare workers offer long-term services, have contact with a broad range of people in both early and late stages of victimization and should offer physically and emotionally safe care in a non-judgemental and supportive way [8-10]. The healthcare sector’s response to sexual victimization can be situated in three phases of problem development: prevention of victimization; identification of persons in a violent situation and early intervention; and care for the victim after victimization (primary, secondary and tertiary prevention, respectively). In practice, healthcare’s main role concerns secondary and tertiary prevention [11-13]. Several consistent, international guidelines exist regarding the role of the healthcare sector in tertiary prevention of sexual violence. They address immediate care for victims, long-term follow-up and psychosocial and legal referral [10,13,14]. Since these guidelines do not provide an elaborated strategy for every unique context, the actual planning and implementation of sexual violence prevention and response programs relies on collaboration and partnerships with target communities, governments and national and international non-governmental organizations (NGO’s) [13]. Concerning secondary prevention, no consistent standard of care is currently globally accepted [10,15]. This can be attributed to reluctance of healthcare workers to screen their patients, to insufficient evidence on the impact of screening over the long term or to lack of effective interventions following identification [15-17]. Nevertheless, many victims of sexual violence consult healthcare workers because of masked consequences of violence (i.e. anxiety, chronic pain, Page 2 of 12 irritable bowel syndrome. . .). Yet, because of shame or fear to be blamed, victims rarely raise the topic of sexual violence spontaneously. Hence, the undisclosed violence can result in a negative line of thought concerning the experience with increasing isolation, feelings of guilt, shame and worthlessness. Without any intervention, it is assumed that symptoms persist, aggravate and that the risk of revictimization increases [10,11,18]. Research on women’s perceptions of being asked about sexual violence revealed that most women find it appropriate to be asked about it by healthcare workers as the latter are regarded as reliable and having knowledge on adequate care and referral possibilities. Women find it easier if the healthcare worker opens up the dialogue and empowers them to talk about their experiences. Risk of stigmatizing or offending should be reduced by ens (...truncated)