Government-employed Clinicians’ Views of Barriers and Facilitators of Adherence to, and Effectiveness of, Child Sexual Abuse Assessment and Treatment, in Government Health Facilities: A Case Study of Suleja, Niger State, Nigeria.

Abstract

Background: Several studies from sub-Saharan Africa demonstrate the critical importance of identifying and addressing the facilitators and barriers that shape the effectiveness of, and adherence to, Child Sexual Abuse (CSA) assessment and treatment. Addressing these factors appears to be central to ensuring the quality and impact of CSA care and to improving survivors’ recovery outcomes. However, in Nigeria, efforts to systematically study these factors remain limited, despite the high prevalence of CSA, especially in Suleja, with the available evidence often sparse, inconclusive, or of sub-optimal methodological quality. Furthermore, available evidence from the broader sub-Saharan African literature demonstrates that CSA-related facilitators and barriers are complex and context-specific, supporting the need for localised inquiry to inform relevant recommendations. In response to these gaps, this study explored clinicians’ understandings of their roles and responsibilities in delivering CSA care; examined the barriers and facilitators of adherence to, and effectiveness of, CSA assessment and treatment within government health facilities in Suleja, Nigeria; and analysed the possible relationships between the barriers and facilitators, including their context-dependent nature, if present, to understand how their interactions shape clinicians’ care processes.

Methodology and Methods: This study employed a qualitative case study design and in-person Key Informant Interviews with 24 purposively sampled clinicians directly involved in the assessment and treatment of CSA, in government health facilities, in Suleja. The data were analysed using the codebook approach to thematic analysis.

Results: This study, based on participants’ accounts, outlined the typical steps clinicians follow when assessing and treating child sexual abuse in Suleja, providing essential contextual grounding for the barriers and facilitators identified in this study. CSA clinical care was described as a sequential process involving mandatory engagement with law enforcement, interviewing and screening, the provision of medical and psychosocial interventions, and referral to higher-level facilities as required. Follow-up care was also identified as a core component of CSA clinical practice, including repeat testing, counselling, and treatment of infections. This study also identified a complex interplay of facilitators and barriers influencing the effectiveness of, and adherence to, child sexual abuse assessment and treatment in government health facilities, according to clinicians in Suleja. Facilitators included adequate clinician availability, high quality of care, an enabling referral system, positive clinician attributes and actions, as well as support from NGOs, communities, and caregivers. Additional facilitators were identified, including appropriate clinician education and expertise, effective collaboration with law enforcement, favourable patient and caregiver attitudes, and financial capacity that enabled access and adherence to care. Conversely, barriers arose from sub-optimal quality of care, challenging beliefs and actions among survivors or caregivers, counterproductive clinician behaviours, and inadequacies in clinician recruitment, education, and expertise. Perpetrator-related actions and status, logistical constraints, challenging interactions with law enforcement, and weaknesses within the referral system further hindered the effectiveness of, and adherence to, CSA assessment and treatment. This study also demonstrated that the identified barriers and facilitators interact, are context-dependent, and clinicians strategically implement facilitators to address specific barriers.

Conclusion: To strengthen the health sector’s response to CSA in Suleja, a comprehensive strategy is required to address barriers and strengthen the facilitators identified by this study. This approach would include focusing on workforce retention through targeted incentives, capacity building, and equitable workload distribution. Quality of care and efforts to protect patients’ dignity and privacy should also be institutionalised through supervision, performance appraisals, and infrastructure improvements. Additionally, consistent availability of clinical resources, standardised referral systems, and integration of NGOs and community actors would be essential to enhance service delivery. Clinician behaviour may also be improved through mandatory training in ethics, communication, and child-centred clinical care, while financial access may be expanded through subsidies, insurance coverage, and outreach services. Lastly, addressing socio-cultural barriers through community sensitisation and involvement is critical. Despite anticipated challenges of limited resources and entrenched norms, prioritising CSA within health budgets, leveraging partnerships, and innovative service delivery models can support effective implementation of these strategies.

Date of Award	22 Apr 2026
Original language	English
Awarding Institution	University of Bath
Supervisor	Jo Cranwell (Supervisor) & Nkasiobim Nebo (Supervisor)