Low-cost non-professional interventions for victims of sexual violence: A systematic review

Highlights

• Fourteen studies were identified that have investigated ten different low-cost non-professional interventions.

• The quality of the reviewed studies was sufficient.

• Almost all of the developed low-cost non-professional interventions were effective to a lesser or greater extent.

• Almost all of the studies reviewed were performed in the USA.

• None of the studies included a long-term follow-up period or victimized men.

Abstract

In low-income countries many victims of sexual violence with mental health problems do not have access to specialized and costly evidence-based therapeutic interventions. For this reason, it is important to gain insight in the effectiveness of low-cost non-professional interventions for these victims of sexual violence. For this purpose, a systematic review was conducted using PsycINFO and PubMed. In total, 14 intervention-studies among victims of sexual violence were identified, studying 10 different low-cost non-professional interventions published between 1990 and 2018. Results showed that almost all interventions were effective to a lesser or greater extent. For this reason, described low-cost non-professional interventions are of interest for victims of sexual violence as well as for mental health policy makers in low-income countries. However, almost all studies were performed in the USA, and none of the studies included a long-term follow-up period or victimized men. Therefore, future studies on the effectiveness of these interventions in low-income countries including a long-term follow-up period and men, are highly recommended.

Introduction

The World Health Organization (WHO, 2013) has estimated that 35% of the women worldwide have experienced either physical and/or sexual intimate partner violence (IPV) or non-partner sexual violence. Sexual violence is not limited to adults. Two meta-analyses have shown child sexual abuse (CSA) prevalence of 18–20% for girls and 8% for boys across studies worldwide (Pereda, Guilera, Forns, & Gómez-Benito, 2009a; Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). However, the range of prevalence rates between countries differed dramatically (0–53% among girls and 0–60% among boys, cf. Pereda, Guilera, Forns, & Gómez-Benito, 2009b). Several studies have found higher prevalence rates in Africa than elsewhere, but inconsistent findings exist with regard to other regions (Pereda et al., 2009a; Stoltenborgh et al., 2011). The WHO (2013) has estimated a lifetime prevalence of physical and/or sexual violence among women (>15 years) of 45.6% in Africa and 40.2% in the South-East Asia. Extreme proportions of sexual violence are found in sub-Saharan Africa and India. Almost half of the Kenyan girls experience sexual violence before the age of 18 (Sommarin, Kilbane, Mercy, Moloney-Kitts, & Ligiero, 2014). A recent report of UNICEF has reported that in 38 low- and middle-income countries, up to 17 million adult women experienced forced sex in childhood (UNICEF, 2017).

The adverse effects of sexual violence on physical and mental health are well documented (Dillon, Hussain, Loxton, & Rahman, 2013; Hornor, 2010; Ivanov, Platonova, & Kozlovskaya, 2015; Kamiya, Timonen, & Kenny, 2016). With respect to mental health, numerous studies have linked sexual violence with posttraumatic stress disorder (PTSD) and depression (Dillon et al., 2013; Kamiya et al., 2016; Scott et al., 2018). In addition, sexual violence is associated with an increased risk of generalized anxiety, substance abuse, suicidal ideation and suicide attempts (Dillon et al., 2013; Hornor, 2010; Kamiya et al., 2016). Furthermore, the adverse effects are not restricted to physical and mental health problems. Sexual violence is also negatively associated with school attendance and achievement, employment, and lifetime productivity (Rivera-Rivera, Allen-Leigh, Rodriguez-Ortega, Chavez-Ayala, & Lazcano-Ponce, 2007; Tjaden & Thoennes, 2006).

For the treatment of trauma-related mental disorders in general, effective treatment is available. This is especially the case for PTSD, such as trauma exposure-based or trauma-focussed cognitive behaviour therapy (CBT) and eye movement desensitization reprocessing (EMDR; Cooper, Metcalf, & Phelps, 2014; Kline, Cooper, Rytwinksi, & Feeny, 2018). With respect to sexual violence-related PTSD, studies have shown that CBT, as well as EMDR, are effective in reducing event-related PTSD among adults (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013; Regehr, Alaggia, Dennis, Pitts, & Saini, 2013) and children (Gillies, Taylor, Gray, O'Brien, & D'Abrew, 2013; Leenarts, Diehle, Doreleijers, Jansma, & Lindauer, 2013). In current guidelines on the treatment of PTSD, CBT and EMDR appear to be the first choice of treatment (American Psychiatric Association, 2010; National Institute for Health and Clinical Excellence, 2005).

The extent to which professional mental health care and effective treatments for victims are available depends on, among others, the economic development and costs for mental health care in the countries victims live in (Koenen et al., 2017). In many low and middle-income countries mental health care systems and expertise are simply absent or only available for victimized residents with a relatively high social economic status (SES). For instance, in countries such as Burundi, Malawi, and Niger the gross national income (GNI) per capita is respectively US$280, US$360, and US$380 (The World Bank, 2018). These GNIs are much lower compared to the United States (US$62.850) and the United Kingdom (US$41.340; The World Bank, 2018), were many professional interventions have been investigated. In countries with a low GNI per capita, the percentage of household spending is higher as compared to countries with a high GNI per capita. As a result, individuals in low-income countries simply do not have financial resources left to afford professional mental health care. If low-cost non-professional interventions are effective to a certain extent, victims of sexual violence in especially low and middle-income countries may benefit from these interventions (as an alternative for relatively costly effective, although proven effective, therapies such as CBT and EMDR). The relevance of the development of such low-cost non-professional interventions is further demonstrated by the high prevalence of violence and sexual violence in these countries, as mentioned in the first paragraph.

Although systematic reviews mentioned above have shown the effectiveness of professional interventions, systematic reviews about the effectiveness of low-cost non-professional interventions on mental health for victims of sexual violence are lacking. The aim of the present systematic review is to fill this gap of knowledge, which is especially relevant for victims in low-income countries where resources to provide evidence-based treatment to all victims, are almost absent. The purpose of the present systematic review is to assess which low-cost non-professional interventions for victims of sexual violence have been developed, and to assess their effectiveness for the improvement of mental health.