Our results demonstrate that all participants recognize the need for desirable prevention of sexual violence against transmigrants. We identified important barriers in tertiary prevention practices, i.e. psychosocial and judicial referral and long-term follow-up, and in secondary prevention attitudes, i.e. active identification of victims. Existing services for Moroccan victims of sexual violence do not yet address the sub-Saharan population. Thus, transmigrants are bound to rely on the aid of the civil society.
Discussion of methods
Initially, our sampling aim was to include first-line healthcare workers confronted with both the Moroccan as well as the sub-Saharan population. However, in the field, these inclusion criteria appeared to be too vigorous and unrealistic, as there seem to exist two parallel circuits in which respectively sub-Saharan healthcare workers see sub-Saharan patients, and Moroccan healthcare workers see predominantly native Moroccan patients. Only a few Moroccan healthcare workers active within the public sector also work in an NGO and have experience with both populations. Therefore, recruitment was refocused on key-persons and key-organizations specialized in either sexual violence in general in Morocco, or in healthcare for sub-Saharan transmigrants in Morocco.
Despite extensive recruitment efforts in all 4 cities, only one fourth of the responding healthcare workers that were included, are operating outside of Rabat. This reflects a relatively higher density of services for sub-Saharan transmigrants in the capital.
For Moroccan patients as well as for transmigrants, the organization of the Moroccan network engaged in reproductive and sexual health lacks transparency and structure. This lack hampered the search for participants and resulted in a false early saturation of sampling. At the end of the period of field research, however, some new actors turned up. The high rate of non-responders and of refusals from the public healthcare sector, due to a reported lack of experience with sub-Saharan patients or with sexual violence in general, consequently results in an underrepresentation of the public healthcare sector. This can be seen as important information, as this might reflect lack of knowledge, taboo, anxiety and low accessibility, especially bearing in mind the high prevalence of sexual violence in Morocco .
The areas of field research, i.e. Rabat, Casablanca, Tanger and Fes, were contingent on the larger Belgian-Moroccan research project and they aimed to cover areas in Morocco sheltering the largest number of residing sub-Saharan transmigrants. Several participants reported a high incidence of sexual violence in Oujda and in the Algerian border region. As there is only one participant with working-experience in Oujda, this might have biased the results and underestimated the urgency of a response to sexual violence in this area.
Using a KAP-questionnaire to identify current practices forces researchers to rely on the veracity of the answers of the participants. Awareness of the importance of some practices could influence participants towards desirable answering. However, we believe that the diverse profile of participants and critical analysis of results together with transmigrants and healthcare workers, helped to diminish the impact of this possible bias when drawing conclusions on current practices.
The criteria of Lincoln and Guba were applied to ensure reliability of our research. Confirmability, dependability and credibility in particular were strengthened by participation of healthcare workers and transmigrants during the whole research project and by verification of the results by experts at a local seminar. Difficulties in recruitment and underrepresentation of the public healthcare sector might however reduce credibility of our research [40, 41].
Prevalence and determinants of sexual violence
The responding healthcare workers were aware of the existence of sexual violence against women and children and of the particular vulnerability of transmigrants. Simultaneous research of Keygnaert et al.  confirms the high incidence of sexual violence, 89% of 154 interviewed transmigrants reported a total of 548 acts of violence in their close environment. These acts involved sexual violence in 45% of the cases. Notwithstanding the fact that transmigrants in the research of Keygnaert et al.  reported male victims in 36% of the reported cases of rape, most health workers interviewed in this study are not convinced of the occurrence of male victimization.
Despite the estimated high frequency of sexual violence, the responding health workers indicated that they rarely came into contact with victims. This discrepancy makes an underestimation by healthcare workers of actual contact with victims of sexual violence very probable.
Determinants of sexual violence indicated by our participants were similar to those reported by the interviewed transmigrants in the research of Keygnaert et al. . Although the vulnerability of Moroccan people is emphasized, participants were aware of an extreme vulnerability of sub-Saharan transmigrants, and this on all levels of the socio-ecological model.
Attitudes of healthcare workers in their response to sexual violence roughly match the suggested approach of the UNHCR guidelines . These attitudes are put into practice without any adaptation to the local context nor standardization. There is a lack of knowledge and there are structural difficulties in long-term follow-up, psychosocial and judicial referral, which has repercussions on current practices. Awareness of the importance of psychosocial support might bias the response of participants towards desirable behaviour when reporting their practices. The numerous obstacles that were revealed suggest a discrepancy between reported and actual practices.
The lack of transparent procedures and the presence of structural and legal difficulties account for a discrepancy between attitudes and practices within the legal aspects of the healthcare response to sexual violence.
There hardly is any long-term follow-up, as it is hindered by the attitude that the responsibility of the physician ends when physical problems are healed. Physical long term-consequences of sexual violence were not taken into account and follow-up was believed to be the domain of psychologists. The intrinsic mobility of the transmigrant population might complicate actual follow-up.
Most participants do not recognize the usefulness of active victim identification practices. Several participants indicated that systematic screening of potential victims would not help to reduce sexual violence. They motivated this point of view by stating that the highest prevalence of violence was found at the border. They deem care unnecessary for victims of violence that has already taken place during the route of migration. This illustrates a lack of knowledge concerning the utility of secondary prevention.
It is difficult to draw conclusions from the responses of the 10 participants stating that they systematically broach the topic of sexual violence when suspecting it. Questions related to the signs of violence demonstrated that the healthcare workers were mainly alerted to immediate consequences of sexual violence.
The results suggest that in current practice, unless there are obvious signs of sexual violence, the majority of healthcare workers prefers to adopt an open, but passive attitude. Most participants were motivated to identify victims of sexual violence, but their current lack of competences and of appropriate interventions makes the healthcare workers to wait for the victims’ initiative.
The barriers at the levels of knowledge, attitudes and practices, which were identified in this study, are similar to those identified in research on screening for intimate partner violence by healthcare workers [11, 15, 16, 19, 37]. Bearing in mind current opinion on women’s perceptions of being asked about sexual violence, a first challenge on this prevention level seems to be awareness-raising and adequate training of healthcare workers in order to help them understand the behaviour and needs of victims of sexual violence [19, 20].
Role of the public healthcare sector versus NGO’s
The gap between the public healthcare sector and NGO’s is striking in the Moroccan healthcare system. All participants, with the exception of participants working exclusively in the public health sector, indicated that healthcare for transmigrants lies entirely in the hands of NGO’s. Although transmigrants’ access to the public health sector is possibly in theory, many barriers were mentioned. These findings confirm the reported low accessibility of Moroccan public healthcare for migrants in earlier research [4, 23, 24].
It is unclear to what extent the participants’ perceptions are influenced by the fact that they are familiar with either NGO’s or public services. The limited number of healthcare workers working exclusively in the public sector does not allow their opinions to be compared to those working in NGO’s. Nevertheless, the opinions of participants working in both settings largely correspond to those working exclusively in NGO’s.
In Rabat and Casablanca we came upon many valuable initiatives promoting the integration of transmigrants into the Moroccan healthcare system. Most of these initiatives were organized by and in collaboration with the Moroccan government. We consider the improvement of governmental support for these initiatives as essential.
Needs of the healthcare sector regarding sexual violence
ur interviews revealed a current absence of prevention measures, as well as an unequivocal wish for prevention initiatives. The most prominent need reported is adequate training of healthcare workers. Many participants working only with transmigrants seem uninformed about existing initiatives for Moroccan victims of sexual violence. Hence these existing initiatives are not optimally being used for transmigrants. However, the assistance for Moroccan victims is not problem-free either. These projects for Moroccan victims only started recently and need further development.