Perspective Chapter: Integrating Follow-up Care Management for Assessment and Management of Rape Survivors Diagnosed with PTSD and Depression in Primary Health Care Settings

Abstract

Rape is very high in South Africa. It predisposes rape survivors to many health care problems, including the risk of contracting human immunodeficiency virus, sexually transmitted infections, falling pregnant, and long mental health effects. PTSD and depression are regarded as the most common mental health effects diagnosed among rape survivors, and they require long term mental health care management. In the current era, follow-up care management for rape survivors is mostly done at Thuthuzela Care Centres. However, rape survivors do not often go for follow-up care, because these centres are mostly far from them. Thus, this problem can be addressed by integrating the management of these long-term disorders within the primary health care settings in South Africa, because most people have access to their nearby clinics. This chapter aims to describe ways of integrating follow-up care management for continuous assessment and management of rape survivors diagnosed with PTSD and depression through task-shifting these duties to nurses working within the primary health care settings in South Africa. The chapter focuses on the mental health care status of rape survivors diagnosed with PTSD and depression. Training of nurses is essential to manage rape survivors diagnosed with PTSD and depression in primary health care.

1. Introduction

Rape is an illegal act typically involving sexual intercourse performed forcibly or threatened by bodily harm against the survivors’ will [1]. Rape is a public health concern affecting everyone worldwide, but South Africa is known as the country reporting a high prevalence of rape. South Africa reported about 10,006 cases from 2020 to 2021 [2]. Rape has many effects. It predisposes rape survivors to contract human immunodeficiency virus (HIV), sexually transmitted infections (STIs), pregnancy, physical injuries, and mental health disorders [3]. Despite this, post-traumatic stress disorders (PTSD) and depression are the commonest mental health disorders [4, 5]. PTSD is defined as a set of four clusters of symptoms that include intrusive and recurring memories of the trauma, avoidance of trauma-related stimuli, numbing and/or unfavorable changes in mood or cognitions related to the trauma, and changes in reactivity and arousal [6]. Depression is a negative affective state characterized by feelings ranging from unhappiness and discontent to extreme sadness, pessimism, and hopelessness that interfere with daily life. Various physical, cognitive, and social changes, such as altered eating or sleeping habits, lack of energy or motivation, difficulty concentrating or making decisions, and withdrawal from social activities, are also common [6].

The preferred non-pharmacological treatment given among rape survivors diagnosed with PTSD and depression includes cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), family therapy, and exposure therapy (ET) [7, 8]. In South Africa, a model of post-sexual assault care has been integrated into the public health system, with dedicated sexual assault centers in major urban towns. The care model is based on intersectoral collaboration, with a collaboration between medical personnel, police, and social support services [9]. Standard of care at these facilities currently includes forensic medical examination, HIV testing with pretest and posttest counseling, pregnancy testing and emergency contraception, STD treatment, HIV post-exposure prophylaxis (PEP), and trauma debriefing [9]. However, the mental health care needs of rape survivors are not met in these services. Often they are not even referred to specialized services [10, 11]. In addition, many people who have PTSD are hesitant to seek treatment in specialized mental health care settings [12]. Therefore, there is a need to develop a strategy that can be used to cater to the mental health needs of rape survivors.

In South Africa, the decentralization and integration of the management of rape survivors diagnosed with PTSD and depression into primary health care settings must be considered to cater for their mental health care needs. One reason is that there are far too few mental health care practitioners, particularly in the public health sector (which serves 80% of the population) and particularly in rural areas [13]. Primary care is a logical setting to target early and management efforts of PTSD and depression because: (1) it facilitates the early identification of patients who require treatment; (2) most mental health services are delivered through primary care [8], so primary care provides greater access, and thus broader population coverage, than treatment delivered exclusively in specialized care populations; and (3) mental health care delivered in a primary care context may constitute a more acceptable treatment option [12].

Professional nurses are frontline workers, making up the largest number within the health care system [14] and mainly in primary health care. Professional nurses are doing mental health nursing in undergraduates. Some further their studies in advanced postgraduate mental health nursing qualifications. Those that completed their undergraduate 4-year diploma and a degree in nursing [15] and postgraduate nursing are registered with the South African Nursing Council to render care to patients [16]. Therefore, nurses need to integrate follow-up care of rape survivors for assessment and management of PTSD and depression in primary health care settings through task shifting. In this chapter, the authors described the mental health status of rape survivors diagnosed with PTSD and depression in South Africa. The skills and training of nurses in mental health nursing are described in this chapter. The importance of task-shifting mental health care for rape survivors diagnosed with PTSD and depression among nurses is described in this chapter.

2. Mental health care status of rape survivors diagnosed with PTSD and depression in South Africa

PTSD and depression are common among survivors seeking health care in Thuthuzela Care Centres post-rape experiences in South Africa [5, 9]. Several studies reported poor integration of mental health care services for rape survivors seeking treatment in Thuthuzela Care Centres in South Africa [5, 17, 18]. Many factors affect the integration of mental health services for rape survivors seeking help in Thuthuzela Care Centres. One of the factors is a significant mismatch in South Africa between the scope of the Childhood Sexual Abuse (CSA) problem and the expected psychological and the availability of services for children [9]. Despite this, the Republic of South Africa documented that all children survivors of CSA are required to get therapeutic care under the Children’s Amendment Act [19]. Nevertheless, data suggest that very few children have access to or are referred to specialized services to mitigate the possible detrimental impacts of abuse [11, 20]. Furthermore, one study reported that adult rape survivors who reported rape in Thuthuzela Care Centres were not given follow-up care to screen and manage PTSD post-rape experiences [10].

Apart from that, mental health care management for rape survivors diagnosed with PTSD and depression requires about 12 sessions with the therapist when using treatment modalities such as cognitive behavioral therapy (CBT), exposure therapy (ET), and cognitive processing therapy (CPT), etc. [7, 8]. This type of care is mostly given in specialized care services such as hospitals [12]. Hence, it is impossible to manage rape survivors diagnosed with these disorders in Thuthuzela Care Centres. Most rape survivors live in poverty, are unemployed, and depend on the government to provide them with social grants [21]. Additionally, most rape survivors stay in rural areas far from Thuthuzela Care Centres because they are stationed in urban areas [21]. Hence, the need for decentralization and integration of mental health care services in the primary health care setting is to promote access to the health care system. Furthermore, while decentralized and integrated primary mental health care is at the heart of many low- and middle-income countries’ (LMICs) mental health policies, implementation remains a challenge, particularly for victims of violence [22, 23]. This is also the case for rape survivors diagnosed with PTSD and depression.

Previous studies indicated that the high frequency of trauma and sexual assault in South Africa might necessitate a more extensive approach to rape management, particularly mental health consequences, to be included in existing policy [24]. The extensive approach to mental health care management among rape survivors diagnosed with PTSD and depression is the decentralization and integration of follow-up care of these services into primary health care. Primary health cares are accessible to everyone, because most villages have a nearby clinic where one can go for a consultation. In post-apartheid in South Africa, a deinstitutionalized and integrated primary health care system was crucial for enhancing access, improving service quality within a human rights framework, and reorganizing mental health services [18]. These initiatives were also outlined in the Department of Health’s White Paper system Transdoemation [25] and the new Mental Health Act (MHCA), No. 17 of 2002 [26]. Despite this, the integration and decentralization of management of rape survivors diagnosed with PTSD and depression are not implemented in South Africa.

3. The importance of task-shifting mental health care management of rape survivors diagnosed with PTSD and depression to nurses

Task shifting (also known as task sharing) is defined as “the rational redistribution of tasks among health workforce teams [27]”. Task shifting as an approach has some roots in HIV and AIDS care, particularly in developing countries where human resource shortages and the burden on public health systems have been severe, limiting access to antiretroviral therapy (ART) [28].

Recent research has found that task-shifting models provide higher-quality, more cost-effective care to more HIV-infected patients than physician-centered models, and that they have increased access to ART [29]. Access to ART is good in South Africa and is led by professional nurses trained in Nurse-Initiated Management of Ante-Retroviral Treatment (NIMART) [30]. Therefore, the same model can be followed for task shifting, disseminating, and integrating mental health services for rape survivors who are diagnosed with PTSD and depression in primary health care in South Africa.

One study reported that interventions incorporating mental health into primary care or community services without utilizing specialist services were the most cost-effective in reviewing mental illness costs and the cost-effectiveness of treatments [31]. Lund and Flisher [32] created a South African context- and need-specific model for calculating the costs of implementing an integrated community mental health service, emphasizing the cost-effectiveness of addressing mental health needs in communities through task-shifting approaches. However, specialist services will always be required regardless of how innovative and effective task-shifting approaches close the mental health treatment gap [33]. Thus, most medical examinations are offered by medical doctors within the South African context. In this regard, it is worth mentioning that nurses can provide medical services such as post-exposure prophylaxis (PEP) for HIV, prophylaxis for other sexually transmitted infections, emergency contraception, treatment of injuries, and even forensic examinations for rape survivors.

Hence, it is essential to shift, if not decentralize, the management of rape survivors diagnosed with PTSD and depression to professional nurses in the primary health care clinics. Also, when the task shifting is done in the primary health care setting, the management of rape survivors diagnosed with PTSD and depression can benefit society if carried out by professional nurses. This can be aided through preservice inclusion of management of rape survivors diagnosed with PTSD and depression among nurses in undergraduate training and in-service training among all professional nurses already in practice.

4. Skills and training of nurses in mental health care management of mental health care disorders within the primary health care setting

Currently, no studies reported training of nurses in mental health care management of rape survivors diagnosed with PTSD and depression. Instead, studies have documented both lack of skills and training of nurses in mental health care management of mental health disorders. One study reported a lack of training and supervision by hospital mental health teams, resulting in a lack of knowledge in managing patients with mental disorders [34]. It was further stated that this practice has a negative impact on the integration of mental health care into primary health care [35]. Furthermore, the World Health Organization (WHO) found that most health care workers in primary health care settings do not receive adequate mental health care training [34]. Again, nurses’ lack of knowledge in managing patients with mental health disorders has resulted in the underdiagnosis of most mental health conditions in primary health care [36]. The study found that primary health care nurses managing patients at the clinic were not adequately qualified to provide all of the services that are provided in clinics that use a one-stop-shop approach [37]. In addition, it was revealed that some mental health patients are treated by registered nurses who do not have Psychiatric Nursing Science qualifications. This practice may result in mental health patients being misdiagnosed, leading to mental illness relapse [18]. Although the lack of skills and training of nurses in relation to mental health care management of patients diagnosed with mental health disorders is argued from a general overview of the literature review, it may impact the decentralization and integration of rape survivors diagnosed with PTSD and depression consulting in PHC settings.

Despite this, some studies have reported that nurses are trained to provide mental health care management among patients. The nurses that register for a 4-year degree or diploma are taught psychiatric nursing, and when they complete their courses, they are placed either in the hospital or primary health care to care for the patients consulting in these settings. Furthermore, the literature review illustrated that to ensure that mental health conditions are appropriately identified and managed, primary health care clinics must have psychiatric-trained nurses on staff [15]. Furthermore, most nurses have a 4-year Diploma in Nursing, indicating that psychiatric nursing training is well represented in primary health care clinics [15]. Despite this, nurses with a 4-year diploma or degree do not have adequate skills and knowledge to manage patients presenting with mental health disorders in primary health care settings [15, 38]. These findings indicate a need for capacitating these nurses to provide mental health care among patients consulting in primary health care, considering that they were trained to provide mental health nursing. In support of this, Bowlers [39] reported that for disseminating information and guidelines and practice-based education, continuing education is required for nurses. This will aid in improving diagnostic skills and psychological therapy for psychiatric patients [39].

In addition, nurses reported that they require in-service training for empowerment, quality care, and increasing staff motivation when providing mental health care management to patients [40]. In South Africa, some nurses are trained for an advanced diploma in psychiatric nursing. However, placing nurses with advanced psychiatric nursing is uncommon in primary health care settings because they are placed in mental health care institutions when they complete their studies. Therefore, we suggest that nurses who have completed advanced psychiatry in nursing must also be placed in primary health care mainly to render mental health care services among clients reporting mental health disorders, including rape survivors diagnosed with PTSD and depression.

In addition, mental health care management of rape survivors must be done by nurses studying for a postgraduate diploma in forensic nursing. Currently, South Africa’s postgraduate diploma in forensic nursing is not accredited [41]. Again, most nursing universities are re-curriculating their postgraduate courses to ensure that forensic nursing is one of the postgraduate diplomas that the South African Nursing Council accredits. Therefore, it will be imperative to include mental health care management for rape survivors in their curriculum, such as placing them in primary health care settings to offer the management of rape survivors diagnosed with PTSD and depression and working in collaboration with those that are trained for mental health care at the undergraduate and postgraduate levels, thus, improving mental health care services for rape survivors in South Africa.

5. Conclusions

The mental health care status of rape survivors diagnosed with PTSD and depression in South Africa should be prioritized and afforded the necessary attention and follow-up care to help reintegrate them back into society. There is a considerable need to improve nursing skills in providing mental health and managing depression and PTSD within the primary health care setting. The training of nurses must target the undergraduate nurses who will be doing forensic nursing diploma by including mental health care management in their curricula. The in-service training must be provided for nurses with mental health care postgraduate diplomas to improve their skills in managing PTSD and depression, particularly in primary health care settings.

Conflict of interest

The authors declare no conflict of interest.