3.1 Sociodemographic characteristics of SVVs interviewed
Figure 2 shows that the VSVs coming from Bukavu city are mostly minors (67% of them are below 18 years old); those coming from rural South-Kivu are young to middle age adult women (78% of them had 18 to 45 years old). There was a total dependence (p-value< 0.0001) between the origin and age of SVVs. This was explained by the fact that in Bukavu City, the rape of minors is increasingly recurrent and is perpetrated by civilian men (in most cases, a relative to the victim). In rural South-Kivu areas (Kabare, Walungu, Kalehe, Fizi, Uvira, and Mwenga territories), sexual violence is mainly by armed forces and is more likely to be perpetrated against young adult women.
Regarding religion, about 48% of VSVs were Catholics; 42% were Protestants; 2% were Muslims, and 8% were others religions. In terms of education, 56% had officially started school, half of them had not completed elementary (primary) school and only 8% had a high school certificate. They were mostly farmers for adults (74%), students (22%) in primary and secondary schools for minors and the others were engaged in other activities (trade, handicraft, etc.). Some of these women had already given birth (>20%) after sexual violence and others (~16%) were expecting children who would most likely never know their fathers, ethnicities, religions and lives in a bleak environment. These victims are constantly troubled by the uncertainty of the life of their children born from rape. It is a great obstacle to their moral, social, religious and even decision-making development.
3.2 Expectations of VSVs on arrival at PH
The findings from our qualitative inquiry demonstrated that the VSVs admitted at PH had various expectations and needs on arrival depending on their social identity and residence locations. For instance, the VSVs coming from remote areas with on-going armed conflicts mentioned concerns related to their security in the post-treatment period and the risks of re-victimization that this could incur. Conversely, those who came from urban neighbourhood, with relative security raised various concerns related to their legal reparation and on-going access to other support services. VSVs admitted at PH expected for physical and psychological restoration, and they needed socio-economic reintegration and legal support. Some victims indicated that they hoped to regain their dignity, and that their pain will be healed. Therefore, they were expecting to leave PH stronger than they were at on the day of their arrival. Before reaching PH, new patients typically received testimonies and sensitization from previous patients as well as local stakeholders. They hoped that the time at PH would enable them to live again with people who take care of them, encourage them, motivate them, and help them to resume their lives on the right basis.
BOX1
“I came to Panzi because I could not stand it any longer. I had been totally destroyed by the perpetrators. I was no longer a person. I did not need anything anymore (...), my whole body was destroyed; I couldn't sleep anymore because the pain was enormous. These people ruined my whole life, (...). I knew that father Mukwege (Medical Director of PH) and his team would first treat me and then take care of the rest of my life [Kabwe (pseudonym), 33-year-old]’’.
These VSVs declared that they were also looted as perpetrators have taken away everything that they possessed (money, clothes, destroyed houses, killed husbands and other family members, etc.). Faced with this context, they also hoped for a socio-economic reintegration in which they would be accompanied in their communities and would receive subsidies to allow them start afresh with their economic activities. Apart from those coming from Bukavu or those who have already complained to the courts, women from rural areas thought less about legal procedures. They were able to reposition this in their expectations after the sensitization and support sessions with Panzi staff. Ultimately, VSVs admitted to Panzi hoped that the holistic care they received from Panzi should be accessible, safe, and participative. They testified that they knew better their problems, had a greater understanding of the environments from which they came, and needed to recover their dignity quickly.
3.3 SVVs’ satisfactions with the holistic car model
Table 1 provides an assessment of the quality of care received by women victims of sexual violence during their stay at PH.
Table 1 Patient satisfaction with holistic care received
Activities
|
Bukavu
|
Outside Bukavu
|
Outside South-Kivu
|
Overall situation
|
Sign
|
Score
|
%
|
Score
|
%
|
Score
|
%
|
Score
|
%
|
Home follow-up
|
4.17
|
83.3%
|
4.35
|
87.0%
|
4.00
|
80.0%
|
4.32
|
86.4%
|
**
|
Catering
|
4.00
|
80.0%
|
4.20
|
84.0%
|
4.00
|
80.0%
|
4.18
|
83.6%
|
|
Accommodation
|
4.50
|
90.0%
|
4.36
|
87.3%
|
4.11
|
82.2%
|
4.35
|
87.1%
|
|
Surgery
|
4.60
|
92.0%
|
4.36
|
87.2%
|
4.33
|
86.7%
|
4.37
|
87.4%
|
|
Medical
|
4.33
|
86.7%
|
4.24
|
84.9%
|
4.00
|
80.0%
|
4.23
|
84.7%
|
|
Legal
|
4.20
|
84.0%
|
4.15
|
82.9%
|
4.00
|
80.0%
|
4.14
|
82.9%
|
|
Psychological
|
4.50
|
90.0%
|
4.44
|
88.7%
|
4.29
|
85.7%
|
4.43
|
88.6%
|
|
Social support
|
4.33
|
86.7%
|
4.41
|
88.1%
|
3.88
|
77.5%
|
4.38
|
87.5%
|
**
|
Ergotherapy
|
4.40
|
88.0%
|
4.18
|
83.5%
|
4.33
|
86.7%
|
4.19
|
83.9%
|
|
General
|
4.83
|
96.7%
|
4.46
|
89.2%
|
4.11
|
82.2%
|
4.45
|
89.1%
|
*
|
*Significant at p-value threshold of 5% and ** Significant at p-value threshold of 10%.
|
The result from the quantitative analysis demonstrated the overall satisfaction of the client from the support services. We found more than 80% of VSVs treated at PH are satisfied with the variety of care provided in each pillar. Based on their origins in Table 1, the Chi-square test indicated that satisfaction rate is 86% (p<10%) of the home visiting or follow-up of the support workers during and after the treatment and 88% (p<10%) of the social support they received both at the hospital and in their communities. In relation with the holistic care model, 89 % (p<5%) of the respondents mentioned that the healthcare services they received from the PH exceeded their expectations and wished that PH could continue supporting them mentally and financially for an effective reintegration in their communities. The legal follow-up is conducted by the legal clinic team, which is in charge of raising awareness of human rights, particularly women's rights, and following up on the patients' legal files. The socio-economic reintegration of patients begins at the PH by raising awareness and evaluating the needs for the reintegration of each woman. The home visits for follow-up are then organized to ensure the continuation of the socio-economic reintegration support and to attempt social reintegration in the respective communities of the VSV. PH promotes a patient-centred approach to treatment. The role of the psycho-social assistants (commonly known as darling mothers, referred to as ‘'Maman chérie'' in French) is to involve the patient in the entire process of her care.
BOX2
‘’ (...) everywhere I have been, it is only at PH where I have found that every patient has a darling Mama. They look after us and support us during this difficult time. It is true that the doctors treated me, but it is through the guidance of my darling mama, I am who I am today [Yvette (pseudonym), a 30-year-old]’’.
Given their limited educational background, the VSVs struggled to evaluate the medical care they received. They reported that they had pain before and, following treatment, the pain had disappeared. Furthermore, we identified unsuccessful fistula reparation experiences for certain (≤ 2%) VSVs, guiding their assessment of the medical service received.
3.4 Unmet needs within the holistic care model
VSVs had reported that the care received at PH did not guarantee their complete security. VSVs living outside Bukavu city (>60%) acknowledged that Panzi is far unable to reassure them of the security in their communities (p-value <1%). The perpetrators live in the community and still exert a certain threat to the victims.
BOX3
‘’ (...) I am proud of my current status. PH has just given a new sense to my life. The whole time I was here I could not really complain. However, I am grateful to the Panzi officials and the nursing staff. One thing I fear is that I will be going home soon. I am still in danger of ending up with that ferocious man who abused me with all his gang of criminals. I know that Panzi has done everything for me but I realize that it is unable to continue providing my security when I will be back home. This is what still bothers me (...); [Antoinnette (pseudonym, 26-year-old woman]’’.
The accessibility of care depends on the distance between PH and certain parts of the province of South-Kivu, and even the country. Patients from neighbouring provinces have reported that it is difficult for them to get to Panzi in order to receive quality holistic care.
BOX4
‘’ (...) from our place in Kalemie, we know that Father Dr. Mukwege is the defender and repairer of abused women. I did not hesitate to think about coming to Panzi to receive treatment. At home, there is no road to reach here and it takes a long time to be here even by boat. Only on arrival, I knew that I could be protected from sexually transmitted diseases if I were on time [Sephora (pseudonym), 33-year-old].’’
Despite all the efforts made by PH, the care of VSVs is faced with several challenges. There are still challenges to the effective implementation of a standard protocol for the care of VSVs that promises dignity and respect for the woman; non-discrimination in care and information, and respect for confidentiality. In order to get out of the chaotic situation in which they find themselves, victims say that the care at the PH must also include rehabilitation and support for family members and/or the community.