Module 5: Referrals and Follow-up for GBV Care and Services

In this module, you will learn about how to connect GBV survivors to services that are available at your health centre or refer them to services outside your health centre if necessary. You will learn about how to increase the likelihood that a survivor will access these services and how you can follow up to make sure that the survivor has received the services.

Learning Objectives

By the end of this module, you will be able to:

• List services offered in most health centres.
• List barriers to survivors following up with referrals.
• Describe strategies for increasing referral uptake by survivors.
• Identify referral networks.

Learning Activities

• Reading: Lerato’s Story (5 min)
  

  Lerato is a 16-year-old woman who presented to the clinic reporting being raped by three of her boyfriend’s friends two days ago. She is worried she could have gotten pregnant during the attack. She also reports difficulty coping with the experience and is feeling afraid and guilty, and she hasn’t been able to sleep. She also expresses concerns that they will “do this to someone else” and worries that her parents will find out.

  Lerato needs additional care that is not available at this primary health centre.

  Take a moment to think about how you would discuss referrals with Lerato. What referrals would you provide? What information and encouragement would you give?

  In this module, you will learn about providing and following up on referrals for further care for patients like Lerato.

• Reading: Services at Health Centres (5 min)

  Most health clinics provide the following services for post-violence care:

  • Basic history taking and documentation
  • Pregnancy testing and emergency contraception
  • HIV diagnostic testing and counselling and provision of post-exposure prophylaxis
  • Prophylaxis for sexually transmitted infections
  • Vaccination for hepatitis B and tetanus
  • Evaluation and treatment of physical injuries
  • Referrals to police and social support sectors

  If there are social workers or sexual assault counsellors on-site at the facility, they can provide trauma counseling.

  In most health centres, patients cannot be referred to receive forensic examination services or collection of evidence services within the same facility.

• Reading: Barriers to Referral Uptake & Follow-up (5 min)

  Referrals for services within the same facility or to another facility are often needed for GBV survivors. However, survivors may not take up referrals or return for follow-up appointments for many reasons. The most common barriers to referral uptake are:

  • Stigma: Social taboos and stigmatization of GBV survivors, especially male survivors, sex workers, and LGBTQ survivors
  • Travel: Distance to referral services
  • Confidentiality: Risk of personal information becoming public, especially when shared between facilities and service providers
  • Time: Balancing long travel and wait times for referral services with personal and professional responsibilities
  • Unfamiliarity: Referral facilities, services, or staff unfamiliar to the survivor
  • Value: Uncertainty about the necessity or value of the referral or follow-up services. Survivors may ask themselves "is it worth it?"

  Questions to ask to identify barriers:

  • “Is this [the referral or follow-up appointment] something you feel you can do? If not, why not?”
  • “What worries you about seeing the [social worker, etc.]?”
  • “Would it help for you to have a ride or to arrange for childcare when you go for the appointment?”
  • “How can I support you to come to your follow-up appointment?”

  Do not promise services you cannot fullfil.

• Reading: Services for Survivors with Extra Needs (5 min)

  Survivors who belong to or identify as part of certain groups may benefit from specialised services that are designed to address their specific needs.

  Groups that may benefit from specialised resources include:

  • Youth
  • LGBTI (lesbian, gay, bisexual, transgender, intersex) survivors
  • People with physical or intellectual disabilities
  • Older persons
  • Refugees and migrants
  • Sex workers

  A survivor may or may not tell you that they have extra needs. Sometimes the need may be visible to you, such as certain physical disabilities or age. Sometimes it will be hidden, such as a hearing impairment or sexual orientation. If you are unsure of how to help a survivor who may have extra needs, ask them what you can do to help them.

  It is helpful to know which organisations in your referral network offer these special services. Access to specialised services increases referral uptake and can result in better outcomes for survivors.

• Knowledge Check: Barriers to Referral Uptake and Follow-up (10 min)

  1Which of the following services are generally available at a primary health centre? Select all that apply.

  1. Basic history taking and documentation
  2. Evaluation and treatment of injuries
  3. Forensic examination
  4. Testing, counselling and prophylaxis for HIV (PEP)
  5. Social worker/psychologist/psychiatrist services

  Clear Feedback

  A, B, and D are correct. Forensic examination and evidence collection must take place in a designated facility. In most cases, survivors must be referred elsewhere for psychological and/or social work services.

  2Which of the following services are usually available at a primary health centre? Select all that apply

  1. Collection of evidence
  2. Pregnancy testing and emergency contraception
  3. Vaccination for hepatitis B and tetanus
  4. Prophylaxis for sexually transmitted infections
  5. Children’s clinics

  Clear Feedback

  B, C, and D. These services are usually available at a primary health centre.

  Read the following scenarios, then select the reason or reasons that the survivor may not have taken the referral.

  3Scenario 1: Gloria is a 34-year-old divorced mother of four. She works full time and sings in her church choir. She comes to the health centre to be treated after being sexually assaulted by her neighbor who was taking care of her kids while she was at work. He coerced and threatened her by threatening to harm her children and refusing to leave until she agreed to have sex with him. Whilst talking with the nurse, Gloria seems determined to take care of herself and to avail herself of the treatments offered. However, when the nurse says that she must go to another facility in order to gather evidence for a criminal case and to an NGO across town to access a support group, Gloria appears to shrink in her seat and becomes tired and defeated. What might Gloria be feeling? Select the best answer or answers based on the information in the scenario.

  1. She feels stigmatized or fears that she will be judged.
  2. She is worried because she does not have time off from work or childcare.
  3. She seems uncertain of the value of the referred services.
  4. She is worried about the time and money it takes to get to the NGO across town.

  Clear Feedback

  A and D are the best answers. While Gloria may be feeling all of these things, the scenario focuses on worries about time and distance to access the services she wants.

  4Scenario 2: Refilwe is 18 years old. She comes alone to the health center because she is being beaten by her boyfriend. Her mother is no longer living and the young woman is scared to tell her aunt that she has been dating and does not want to tell her family about the relationship violence. Her boyfriend is much older and provides material things and financial support for Refilwe and her siblings, which is desperately needed since their mother died. During her appointment, Refilwe and the nurse who provides her care establish a good relationship. Refilwe seems to trust the nurse and starts to open up more and more. However, when the nurse hands Refilwe the referral slips to take to the social worker for counselling, Refilwe becomes nervous and very quiet. What might Refilwe be feeling? Select the best answer or answers based on the information in the scenario.

  1. She is worried about the distance to get to the social worker.
  2. She doesn’t understand what a social worker does.
  3. She is nervous because the social worker/facility are unfamiliar.

  Clear Feedback

  C is the best answer. While Refilwe may be feeling all of these things, the scenario focuses on worries about having to encounter new and unfamiliar care providers now that Refilwe has established a trusting relationship with the nurse at the health centre.

  5Scenario 3: Blessing is 25 years old. He comes to the health centre in a neighbouring area to seek help after being sexually assaulted by a man he went on a date with the previous night. He was worried about going to the health centre in his own neighbourhood because no one there knows that he is gay. He gets very nervous and angry when the nurse offers him referrals to a special facility in his neighborhood for additional care and treatment. What might Blessing be feeling? Select the best answer or answers based on the information in the scenario.

  1. He is worried about confidentiality
  2. He is worried about stigma
  3. He is upset because he works and doesn’t have time to visit a different health facility

  Clear Feedback

  A and B are the best answers. While Blessing may be feeling all of these things, the scenario focuses on worries about stigma and confidentiality.

• Reading: Strategies to Increase Referral and Follow-up Appointment Uptake (10 min)

  There are several things that the facility and staff can do to increase the likelihood that a survivor will take up a referral or follow-up appointment. Click or tap on each tap to learn more.

  • Getting started
  • Knowing your referrals
  • Making an appointment
  • Attending an appointment
  • Providing follow-up

  Getting started

  The first step you should take with a patient is to explain the purpose of the referral and the referred or follow-up services. Emphasize that the referred service is something important to the survivor’s health—both physical and mental health.

  Make sure to ask the patient if she has any questions, and try to answer any questions the survivor may have. Proactively discuss any possible barriers with the survivor, such as balancing seeking healthcare with work demands, childcare, or transport. Help the survivor problem-solve and make a specific plan to address the barrier. For example, you might help the survivor think of people in her life who can babysit while she attends a healthcare appointment, or if a friend could drive her to appointments.

  Knowing your referrals

  Referrals are not only a way for you to provide a patient with a health care professional, but also a way of recommending or vouching for the referred service. Know the clinic you are referring your patient to, how they function, and if they are an appropriate fit for your particular patient. If you have met the people or seen the facility yourself, you can say, “I know them personally, I’ve talked to them. They are good.” While this is not always possible, when you do have this kind of information, it may increase the survivor’s confidence in the referral.

  Where possible, give the survivor a choice of possibilities and facilities. This gives the survivor some power and control in the process, and she can choose the facility where she is most comfortable or makes most sense for her. You can help survivors think through pros and cons of following up at a specific facility (e.g., balancing cost with location). For survivors who can read, write down the referral information for them, omitting details if needed to protect their privacy.

  Making an appointment

  When possible, it is best to make a referral or follow-up appointment with the survivor while she is still meeting with you. Simply handing her a number for the referral is not as effective as making the appointment with her; there are several barriers to a survivor taking up a referral, so helping her to make an appointment makes it easier for her to take the first step.

  Make sure you know the service hours of the facilities to which you are referring, and that these hours align with your patient’s availability. Some facilities in hospitals offer 24-hour service 365 days per year; other facilities may have extended evening and weekend hours.

  Make sure the survivor knows that most services can be accessed any time; there is no time limit except for the following:

  • Emergency contraception, HIV PEP, STI prophylaxis, and the collection of forensic evidence all should be provided/done as soon as possible.
  • Emergency contraception must be started as soon as possible, up to 120 hours after exposure, in order to be effective.
  • HIV PEP must be started as soon as possible, up to 72 hours after exposure, in order to be effective.

  Attending an appointment

  If possible, it is highly encouraged for providers to accompany survivors to referral appointments. However, if you are not available to accompany a patient, try to designate someone who can, such as a community health worker. If the survivor has a trusted person with them, explore the possibility of that person (or someone else) being a “care buddy” to help make sure the survivor attends their referral appointments.

  Providing follow-up

  Once a referral or follow-up appointment has been scheduled, make a plan to check in with the survivor to see if they kept the appointment. You can contact the survivor directly to ask about how the appointment went or use the CHW or outreach worker to enquire about the appointment as part of follow-up home-based care. In some circumstances, you can find out whether the appointment was kept, but no other information, directly from the referred or follow-up service provider. In other cases, providers will not share this information to protect patient confidentiality. In cases where it is appropriate to receive the back-referral documentation, check to make sure you have received it from the referred provider and that it is part of the survivor’s medical record.

  If the survivor did not keep the appointment, engage them directly or work with the social worker to reschedule or provide additional counselling to prepare for referral and address any barriers. It is important to know why the survivor did not keep the appointment. That information can help you provide solutions for the survivor, as well as help improve services overall.

• Reading: Mapping Your Referral Network (5 min)

  In the text box below, list the services you would need to refer Lerato for if she were a patient at your facility.

  Clear Compare Answer

  Depending on what services are available at your facility, you may need to refer her for

  • Mental health services, including counselling
  • Police, to make a formal report
  • CTOP
  • Refugee Violence Prevention Programme
  • Spa, for relaxation massage
  • STI and HIV testing
  • HIV PEP follow-up appointment at 28 days
  • HIV Care and Treatment Programme
  • Emergency contraception consultation
  • Check-in with the social worker at 28 days
  • Surgery for internal injuries

  Mapping Resources

  It’s important to map the resources in your geographical area and referral network. This will help you give accurate information to survivors, help them choose the best facility, and assist in finding solutions to barriers that can interfere with them attending the scheduled appointment.

  Collaboration and communication between service providers should be set up ahead of time. Get to know the names and services of providers in your network.

  Use available resources to link survivors to services and follow-up. For example, you may want to connect Lerato to a community health worker (CHW). You would need to make sure she is comfortable receiving visits from the CHW before sending the CHW on a home visit specifically for GBV follow-up.

  Take a moment to reflect on these questions. You will discuss them at your next in-person session.

  • How do you determine who can provide services?
  • What information do you keep about referral service providers?
  • How often is this information updated?
  • Who is responsible for updating this information?
• Reading: Key Points (5 min)

  Here are some key points from this module.

  • Health centres are not always equipped to offer all the services a GBV survivor might need. Therefore, survivors must be referred elsewhere to obtain the needed services.
  • There are many possible barriers to a survivor taking up a referral. It is critical to problem-solve and find solutions to those barriers so that the survivor can get the needed services.
  • Establishing a strong referral network will not only help survivors get the services they need, but will also make the process easier for staff at the health centre.
  • Making personal connections with people in your referral network will make your network stronger than if you just have a list of names and numbers.
  • The health centre must have a procedure for keeping referral network information current.
• References
  • ¹Campbell, Jacquelyn. “Assessment and Referral and Referral for GBV”, Presentation, Notes from IGWG GBV Event at PRB, Screening and Response: Making Referrals Work, June 23, 2015>
  • ²Eckhoff, Sarah. “Did They Get There? Lesson Learned from Implementation of Referral Mechanisms in Kenya and Mozambique.” Notes from IGWG GBV Event at PRB, Screening and Response: Making Referrals Work, June 23, 2015
  • ³Vu, A & Wirtz, Andrea & Bundgaard, S & Nair, A & Luttah, G & Ngugi, S & Glass, Nancy. (2017). Feasibility and acceptability of a universal screening and referral protocol for gender-based violence with women seeking care in health clinics in Dadaab refugee camps in Kenya. Global Mental Health. 4. 10.1017/gmh.2017.18.
  • ⁴World Health Organization, Health care for woman subjected to intimate partner violence or sexual violence: A Clinical Handbook, field-testing version, 2014.