Data from the questionnaires and the multiple-choice examinations that were completed by the health care providers was entered and analysed using Stata 12.0. The datasets were merged and linked using the unique codes that were generated by the health care providers. All data that could be linked were used in the analysis while missing data for variables were excluded. The cleaning and coding of variables that were not included in the publications are not presented here. This included the actual number of survivors consulted as most providers gave estimates or provided a generic response (e.g. 3 patients/week), hours of training, content of in-service training, motivations for working in the service, and relationships at home and with family.
The proportion of rape survivors that are seen by the provider was pre-coded on the questionnaire into five categories and was used as such in the data analyses: 0% – 20%, 21% –
92 40%, 41% – 60%, 61% – 80%, and 81% - 100%. Total time in the services were categorised into three groups: less than 10 years in services, 10 to 19 years in service and 20 or more years in service. The total time that a provider was working at their current facility was categorise into similar groups although the second group was cut off at 14 years and the third group consisted of providers who worked at their current facility for 15 years or more.
Data of the experience or perpetration of rape or IPV were categorised into three groups. The first group comprised of providers who had neither experienced or perpetrated rape or IPV, the second consisted of female providers who had experienced rape or IPV and the third, male providers who were perpetrators of abuse. The experience or perpetration of rape was combined with that of IPV due to the small numbers of providers in each category, which would affect the inferential data analysis procedures.
The following new variables were generated from the collected data: a “rape attitude score”, a “gender-related attitude score”, an “empathy score”, and measures of knowledge and confidence in providing post-rape care services and appearing in court. The rape attitude score was obtained by adding the responses for the 21 statements on rape myths while the scores for two statements that were phrased in the positive were reversed before being added. The maximum possible score was thus 84 with a higher score reflecting a more appropriate attitude towards rape. A gender attitude score was developed in a similar fashion using 21 relevant statements with the scores of five statements being reversed before totalling. A higher score reflected a more gender sensitive health care provider. Finally, an empathy score was developed using the four statements with a five-level Likert scale. The maximum potential score was 20 and a higher score reflected a more empathetic provider. As scores are only generated for variables that have no missing data when added in Stata, an average score was imputed for a response if only one response was missing. This was done for 17 responses on rape attitudes, 16 responses on gender attitudes, and 5 responses for the empathy score when the data analysis was done for publication three (Chapter 6). No imputations were made if more than one response was missing. The Cronbach’s alpha for the rape attitude score was 0.82, 0.76 for the gender attitude score and 0.77 for the empathy score.
93 The level of knowledge was assessed through the multiple-choice questions where one mark was allocated for each correct answer and there was no negative marking. Nine questions with a failure rate of more than 90% at the pre-training assessment were excluded resulting in a total of 66 questions (Table 10).
Table 10. Questions that were removed from the analysis
Content Pre-training score
Law and judicial processes (Sexual Offences and Related Matters Amendment Act)
6.3%
Sexual rights 6.3%
Examination and evidence collection in adults (non-genital injuries) 8.9%
Examination and evidence collection in children 5.4%
Examination and evidence collection in children 2.7%
Documentation 8.0%
Documentation 9.8%
Documentation 2.7%
Vicarious trauma 9.8%
Confidence was self-reported by health care providers using a score of one to indicate ‘no confidence’ and ten ‘total confidence’ in providing ten aspects of the service. These included confidence in examining an adult survivor, completing an evidence collection kit with an adult, completing a J88 form, examining a paediatric survivor, providing pre-test counselling for HIV, discussing common psychological symptoms and how to cope with these, supporting adherence with PEP, talking with survivors about sexuality, sexual health and condom use after rape, talking with parents about supporting children who have been sexually assaulted, managing HIV prevention in patients who have other medical conditions, and explaining findings in court. As with the rape attitude, gender attitude and empathy score, an average score was imputed if a single response was missing to calculate the confidence score for publication three (Chapter 6). This was done in 10 instances for the confidence score.
Both the knowledge and confidence scores were totalled, converted into percentages and categorized. Providers with a percentage score of 50 or more were considered to have high levels of baseline knowledge. For publication two, providers with a percentage score of 80 or more were considered to have high levels of baseline confidence but this was adjusted to a
94 percentage score of 70 for publication three. For publication three (Chapter 6), change in knowledge and confidence were calculated by subtracting baseline (pre-intervention) percentage scores from the post-intervention scores. A four-level variable was generated to categorise baseline percentage knowledge and confidence scores that was used in the analysis of publication three. The first group consisted of health care providers with high knowledge (score of ≥50%) and confidence (score of ≥70%) at baseline; followed by group two with low knowledge (score of <50%) and high confidence (score of ≥70%); group three with high knowledge (score of ≥50%) and low confidence (score of <70%); and finally group four with low knowledge (score of <50%) and confidence (score of <70%) at baseline.
In both publications descriptive statistics were first calculated and presented before bivariate analysis was conducted. In publication two (Chapter 5) it was hypothesized that provider socio- demographics (older age, male sex, being a nurse, providers working outside of Gauteng and KZN, providers who have not experienced IPV, providers with no previous training on post-rape care or counselling, longer lengths of service, and providers with less appropriate gender, rape and empathy scores), facility characteristics (working in a clinic, not having a crisis centre in the facility), and provider experience with service provision (not having examined patients or examined less patients, not having completed a J88 form) would be associated a lower knowledge and confidence in providing post-rape services. Two logistic regression models were therefore built to test this hypothesis for knowledge and confidence separately. In building the models, variables that were found to have a p value of <0.20 on bivariate analysis with baseline knowledge and confidence percentage scores were tested for the final model. This included sex, age, rank, experience or perpetration of rape or IPV, rape attitude score, total time working, whether the provider had examined a survivor in the last 3 months and completed a J88 form, and whether the provider was previously trained on counselling for the model on baseline percentage knowledge scores, while only three variables were tested in the model for baseline percentage confidence levels: whether the provider worked in a facility that had a crisis centre, whether the provider had examined a survivor in the last 3 months and completed a J88 form, and proportion of survivors seen of those who come to the facility. Those that continued to have a p value of ≤0.05 were retained in the final logistic models for knowledge and confidence.
95 For publication three (Chapter 6) it was hypothesized that the two week training programme would significantly increase knowledge and confidence in health care providers, and that provider attitudes before training would predict knowledge and confidence after training. To begin, paired t-tests were conducted to investigate for significant changes in percentage knowledge and confidence in providing post-rape care after the training. The question of whether provider attitudes before training would predict knowledge and confidence after training was examined by building a multiple regression model of factors associated with higher knowledge and confidence. Similar to the technique used above, backward selection was done using variables that were found to have a p value of <0.20 to develop the final linear regression models for change in knowledge and confidence. The following variables were found to be significant with bivariate analysis and were therefore tested in the final model for percentage change in knowledge: provincial location of the health care provider, time working in current facility, proportion of survivors seen of those who come to the facility, country where provider underwent undergraduate training and baseline knowledge and confidence levels. For the model on change in percentage confidence, the following variables were tested in the final model: provincial location of the health care provider, level of facility where provider worked, experience or perpetration of IPV, time working in current facility, whether the provider had examined a survivor in the last 3 months and completed a J88 form, proportion of survivors seen of those who come to the facility, and baseline knowledge and confidence levels. The final models comprised of variables that maintained a p value of ≤0.05 while adjusting for baseline knowledge and confidence levels.