Table 4A

Summary of findings: barriers

Third order themesSecond order themesFirst order themes
barriers
Contributing studiesCERQual confidence levelConfidence assessment
explanation
Illustrative examples
Leadership and governanceLaws, policies and proceduresUnclear, uncontextualised or unavailable OSC policies and procedures10 11 15 29–31ModerateSix studies with minor to significant methodological limitations. Fairly thick data from 13 countries, including one multi-country study of 11 countries in the Asia-Pacific region. Fairly high coherence.‘The 1996 MOH circular did not specify how the centres should be created… In reality, it was very much left at the discretion of each hospital’s director to develop its own procedures.’
(Malaysia, 15)
Governing bodiesIneffective advisory meetings and committeesLow
.
Three studies with moderate to significant methodological limitations. Adequate data but only from two countries. Level of coherence unclear due to limited data, but findings were similar across studies‘…some members of the committees … were not regularly participating, or had not been updated by their officials who had participated in meetings. In all four districts a couple of (advisory committee) members were unaware of their [OSC].’
(Nepal, 38)
Lack of oversight and supervision from governing bodies10 11 27 30 36 38–40Moderate10 studies with minor to significant methodological limitations. Fairly thick data from eight countries. High coherence.‘There’s no oversight or monitoring of any of these institutions… There is no monitoring of any kind. Accountability of the government is zero.’
(India, 46)
Poor transfers of management35 36 39LowThree studies with minor to significant methodological limitations. Fairly thick data from two countries. Unable to assess coherence as only three contributing studies from two countries, but findings were similar among studies.Poor relationships largely seemed the result of a poorly handled transition from a NGO service to a Thuthuzela Centre (TCC). At two sites respondents reported arriving at work 1 day to be met by National Prosecuting Authority staff, and the announcement ‘This is now our TCC.’
(South Africa, 43)
Political willLack of political will and government investment on issues of IPV/SV10–12 15 27 29 31 33 36 38–42High13 studies with minor to significant methodological limitations. Thick data from 12 countries. Moderate to high coherence.‘The OSCCs are physically there but then they are not staffed …I felt that they (Ministry of Health) were not willing to put in extra money….I think it is just a political will, it was not their priority.’
(Malaysia, 15)
Health system resourcesEquipment and suppliesLack of basic medical supplies, facility equipment and survivor comfort items11–13 15 26 27 30 35–39 41 42 44High15 studies with minor to significant methodological limitations. Thick data from 14 countries. High coherence.‘There were insufficient examination tables, focus lights, and medico-legal investigation materials and no rape or post exposure prophylaxis kits.’
(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)
Information and monitoringPoor documentation and data management systems11 13 19 26–29 31 34 40 41 45 46High14 studies with minor to significant methodological limitations. Thick data from 22 countries. High coherence.‘Some staff at specialised and district hospitals were sometimes unsure how to proceed with IPV cases, what injury to document, in what detail, how and what questions to ask, where to refer women.’
(Malaysia, 16)
Lack of facility-level monitoring mechanisms12 13 27–30 34 36 40 45 46High11 studies with minor to significant methodological limitations. Thick data from 22 countries, including multi-country studies from Africa and the Asia-Pacific region. Reasonable level of coherence.‘The team has little capacity or tools to systematically collect and aggregate data. No analysis of all the available data to inform the programme and guide implementation is currently being undertaken.’
(Rwanda, 52)
Operation costsOperation costs not feasible in low-resource settings10 12 15 27–30 33 35 36 38 46Moderate11 studies with minor to significant methodological limitations. Relatively thick data from 17 countries. Reasonable level of coherence.‘Some OSC services were disrupted by funding constraints; one centre ran without electricity, water, and telephone lines for long stretches of time due to cost.’
(South Africa, 44)
Lack of designated budgets and budget transparency10 30 35–37 45LowSix studies with minor to significant methodological limitations. Adequate data from four countries. High level of coherence.‘In Malaysia, the OSCs budget was under the emergency department, which resulted in no dedicated budget for OSCs.’
(Malaysia, 15).
Unsustainable, donor-dependent funding sources27 30 35 36 38 42 45 47 48ModerateNine studies with minor to significant methodological limitations. Fairly thick data from six countries, and three from South Africa. High level of coherence.‘When a contract with one donor ended, it lead five organisations in South Africa, that were reliant on this donor’s funding, to terminate OSC services.’
(South Africa, 43)
Service deliveryQuality of careLack of adequate psychosocial services and staff9 13 15 21 25 27 28 30 31 35 38–41 46 47High16 studies with minor to significant methodological limitations. Thick data from 14 countries. High level of coherence.‘We are asked to speak with the victims and help them, but we don’t have expert psychologists. I have read some books but … it’s not the same.’
(India, 46)
In an evaluation of 12 centres in Pakistan, only one had a psychiatrist.
(Pakistan, 47)
Failure to provide health information13 27 30 34 35 45LowThree studies with minor to significant methodological limitations. Thin data from three countries. Adequate level of coherence.‘The health information given to the participants was also lacking, with the victims not informed about the risk of contracting STIs/HIV or becoming pregnant.’
(South Africa, 31)
Ineffective clinical care protocols15 27 29–31ModerateFive studies with minor to significant methodological limitations. Fairly thick data from 13 countries, including one multi-country study of 11 countries in the Asia-Pacific region. High coherence.‘In the absence of clear guidelines and protocols, clinical services related to GBV remain inconsistent and ad hoc …Without protocols, there is some concern that many healthcare workers will only treat physical injuries and even pass judgement about the survivor’s role in the abuse.’
(Timor-Leste, 11)
Lack of long-term support and follow-up services19 22 26–31 33 35 36 38 40 41 49ModerateNine studies with minor to significant methodological limitations. Fairly thick data from 12 countries throughout Africa and Asia. High level of coherence.‘We are not able to assure them because there is no follow-up; when they get out of here, everything is like we are finished with them.’
(Zambia, 14)
Compromised confidentiality and privacy19 22 27 59High12 studies with minor to significant methodological limitations. Fairly thick data from 14 countries. High level of coherence.‘One victim’s father fought with the hospital ward sisters for the patient files…we have to make a system such that perpetrators and victims will be anonymous.’
(Nepal, 56)
Lack of security at OSC27 30 36 38 49LowFive studies with minor to significant methodological limitations. Adequate data from three countries. High level of coherence.‘What our safety is concerned, we are alone here over weekends and at night, and that is quite a risk.’
(South Africa, 13)
Lack of child and adolescent-friendly services and environment15 27 30 33 38 46LowSix studies with minor to significant methodological limitations. Fairly thick data from five countries. High level of coherence.‘Neither NGO-owned OSC had special provisions for… infants and children in their written guidelines or protocols for the clinical management of sexual and gender based violence (SGBV).’
(Kenya, Zambia, 12)
AccessibilityHigh out-of-pocket costs to survivors for referral services13 25 26 29 30 39 41–43 45 50Moderate11 studies with minor to significant methodological limitations. Moderately thick data from 20 countries, including four studies reporting on India. Moderate level of coherence.‘Referrals by [OSCs] to other hospitals for cases such as skin grafts, or to an eye hospital or for psychiatric treatment showed no results due to shortages of funds that prevented survivors from going there.’
(Nepal, 38)
Lack of services on night and weekends11 12 21 25 27 31 33 35–38 42 43 46High14 studies with minor to significant methodological limitations. Thick data from 10 countries. High coherence.‘Now in my case also, such incidents happened at night, kerosene was poured on me, they tried to kill me, beat me, I couldn’t go anywhere…For the whole night I kept sitting like that.’
(India, 51)
Long wait times13 22 25 26 30 33 35 38 48ModerateNine studies with minor to significant methodological limitations. Adequate data from 10 countries. High coherence.‘The OCMC staff nurses were at times unable to provide timely services due to their workloads and consequently some survivors had to wait several hours.’
(Nepal, 38)
Lack of transportation to OSC15 27 30 33 38 46Moderate12 studies with minor to significant methodological limitations. Fairly thick data from 13 countries, many countries in Africa, including four studies reporting on South Africa. Non-African contexts include studies from Bangladesh, Pakistan, Papua New Guinea, and Nepal. High level of coherence.‘The biggest hurdle we are facing is the lack of transport because…in most cases it is the victim who pays for all transport costs.’
(Zambia, 14)
If employed, some survivors could not afford the time off work to make regular trips to the TCC and, if unemployed, did not possess the means for such travel.
(South Africa, 43)
Lack of access to rural populations26 27 33 35 42 43 59ModerateSeven studies with minor to significant methodological limitations. Fairly thick data from 11 countries. High level of coherence.‘There was a need to bring more (OSC) services directly to (rural) communities via mobile-support clinics, providing bicycles for counselling staff; or the provision of transport vouchers or refunds for clients.’
(Zambia, 53)
Lack of community awareness of OSC services21 27 29 30 36 37 39 43 45 48 51 59High13 studies with minor to significant methodological limitations. Thick data from 14 countries. High coherence.‘Walk-in patients in our one stop centres are very few. Not much awareness.
(India, 46)
“(The OSC) was largely deserted despite awareness raising efforts.’
(S. Africa, 44)
AcceptabilityLack of representative staff30 37 42 43 47LowFive studies with minor to significant methodological limitations. Thick data from three countries (Bangladesh, India and Nepal). Adequate coherence.‘Women rarely come to police stations to lodge complaints, mainly because the majority of officers are men.’
(Bangladesh, 54)
Hostile and sceptical community beliefs and attitudes15 26 30 35 36 43LowSix studies with minor to significant methodological limitations. Adequate data from seven countries. Adequate coherence.‘People say, ‘You should not go there. Don’t go to the doctor and don’t go to the police.’ ‘Let’s resolve this matter here at home.’’
(Kenya, Zambia, 12)
Contextual variationsHospital-based OSCs expensive and not feasible in rural and/or non-tertiary care settings10 11 14 28LowFour studies with minor to significant methodological limitations. Fairly thin data. Moderate coherence.‘It is a reality that this(hospital-based)model can be very costly for hospitals with sparse human resources.’
Kenya and Zambia, 11)
Hospital-based OSCs decrease priority of other services (eg, legal, justice, social services)28 30LowTwo studies with moderate to significant methodological limitations. Thin data from two countries. High coherence.‘Health facility-based OSCs provide the broadest range of health and psychological services for survivors. However, their linkage to the legal and justice systems is weak.’
(Mongolia, 36)
Stand-alone OSCs increase risk of stigmatisation15 33 47LowThree studies with moderate to significant methodological limitations. Fairly thin data from three countries. Moderate coherence.‘It took me a lot of courage before I finally came. When people see you on these benches (in the waiting area), they will say you are one of those women who are normally beaten.’
(Kenya, 55)
Stand-alone OSCs not equipped to meet medical needs of survivors15 27 33LowThree studies with moderate to significant methodological limitations. Fairly thin data from three countries. Moderate coherence.‘In the stand-alone model, medical staff are not available 24 hours a day, and survivors need to be driven and escorted to a health facility for services not available at the stand-alone centres (eg, surgery, stitches, x-rays), also during which time evidence may be lost.’
(Zambia, 41)
NGO-run OSCs less available to allow continuity of care26LowOne study with significant methodological limitations. Thin data. Unable to assess coherence.‘Coordination of voluntary organisation is very poor. NGOs are not available always to ensure the continuity of service.’
(Bangladesh, 34)
CoordinationInterprofessional collaborationWeak multi-sectoral collaboration, including lack of equal recognition and respect of implementing partners9–11 15 23 25–30 33 35–39 42 43 45–48 50 51 60High27 studies with minor to significant methodological limitations. Thick data from 17 countries. Fairly high coherence.‘In some countries, there are a number of different agencies running different OSCCs in different sites… The lack of coordination between these different agencies leads to issues with consistency of care.’
(PNG, 11)
Multiple stops/fragmented services11 15 30 31 34 39 48ModerateSeven studies with minor to significant methodological limitations. Fairly thick data from six countries. High coherence.‘It is clear that instead of being a “one stop”, the process may at times be lengthy and fragmented.’
(Malaysia, 16)
‘It’s a failed project. The concept was that police investigations, medical, and legal help, all would be provided in one place.’
(India, 46)
Lack of information sharing between OSC sites26 27 29 39 45LowFive studies with minor to significant methodological limitations. Thin data from 14 countries. Thinness likely due to the difficulty in providing significant detail on inaction (lack of sharing). Reasonable level of coherence.‘The new one stop centres devised by the government had failed to consult existing centres or learn from them.’
(India, 46)
Patient navigation and referralsWeak referral networks and lack of referral options9 11 15 27–30 34 36 37 41 47 50 51High14 studies with minor to significant methodological limitations. Fairly thick data from 16 countries. High coherence.‘Both centres encountered problems of underutilisation due to lack of referrals.’
(South Africa, 44)
Navigation challenges within facility15 30 48LowThree studies with minor to moderate methodological limitations. Adequate data but only from three countries. Moderate level of coherence.‘There was also no information available in citizen’s charters, receptions, outpatient departments, emergency departments and in corridors, thus making it difficult for survivors to locate OCMCs.’
(Nepal, 38)
Clarity of roles and responsibilitiesUnclear responsibilities and lack of ownership of implementing partners10 27 29 30 33 35 36 38 39Moderate11 studies with minor to significant methodological limitations. Fairly thick data from 14 countries. Fairly high coherence.‘The assessment team found generally limited horizontal coordination and collaboration between the district-level stakeholders represented on DCCs. This has resulted in inadequate ownership and awareness of OCMC services.’
(Nepal, 38)
Unclear staff responsibilities and roles19 28 30 35 38 39 44 45LowEight studies with minor to significant methodological limitations. Fairly thick data from five countries. High coherence.‘There seems to be a widespread uncertainty among providers about what their role should include.’
(Malaysia, 51)
Human workforce and developmentKnowledge, attitudes and behavioursLack of OSC staff knowledge on IPV/SV27 29 30 34 36 44 48ModerateNine studies with minor to significant methodological limitations. Fairly thick data from 15 countries. Adequate coherence.‘Only a quarter of the providers in Penang mentioned sexual abuse among the types of acts that may characterise domestic violence.’
(Malaysia, 51)
Harmful staff attitudes on IPV and SV13 19 28 30 34 38 42–44High11 studies with minor to significant methodological limitations. Thick data from 13 countries. High coherence.‘Some of them, it is especially those young girls like 14, 15 and 16 years, they also expose themselves to situations that encourage somebody to rape them. Like when we have dancing and the way they behave, sometimes their behaviours itself, the way they walk.’
(Uganda, 14)
Harmful behaviours of healthcare workers19 38 42 43 48LowFive studies with minor to moderate methodological limitations. Thick data from five countries (Bangladesh, India, Kenya, Malaysia, and South Africa). High coherence.‘A major problem is that often the victim is treated badly. When she is admitted in the hospital the doctors and nurses do not behave well with the victim and they assume 'she is a bad girl.' They see her as the problem, ‘someone who asked for the problem.’
(Bangladesh, 49)
Corruption and mistreatment by police15 26 34 38 42 43 47 48High10 studies with minor to moderate methodological limitations. Thick data from 11 countries. High coherence.Some police officers were found to accept bribes from perpetrators in exchange for dropping survivors’ cases.
(Kenya and Zambia, 12)
Training and developmentInadequate training on trauma informed care and OSC operations9 11 15 19 27 29–31 33 34 38 40 41 44–46High15 studies with minor to moderate methodological limitations. Thick data from 16 countries. High coherence.‘More than half of staff at the OSC had never participated in a staff training in OSC management, even after years of working at the OSC.’
(Malaysia, 28)
Staffing and conditionsHealthcare worker time constraints10 11 27 30 34 35 41–44 47Moderate11 studies with minor to moderate methodological limitations. Thick data from six countries. High coherence.‘We don’t have enough time to go in the separate room, to take a long history, so we are not going to ask the reasons why she was battered and go in deep depth on that… it’s just ‘ok, next patient… next patient.’’
(Malaysia, 51)
Insufficient staff11 25–27 29–31 33–38 40 42 44 46 47High18 studies with minor to moderate methodological limitations. Thick data from 15 countries. High coherence.‘Even if they want to come, there are not enough staff, so they cannot come.’
(Malaysia, 16)
Staff burnout16 33 44 45 50LowFive studies with minor to significant methodological limitations. Thick data from five countries. High coherence.‘What I am doing now, I feel it is not enough… I feel very depressed because I can’t do much.’
(Malaysia, 51)
  • CERQual, Confidence in the Evidence from Reviews of Qualitative Research; GBV, gender-based violence; IPV, intimate partner violence; MOH, Ministry of Health; NGO, non-governmental organisation; OSC, one stop centre; OSCC, one stop crisis centre; STI, sexually transmitted infections; SV, sexual violence.