- (2015) Volume 7, Issue 2
Gebregizabeher Yohannes, Mekuria Kassa*, Gerezgiher Buruh, Ashenafi Damte, Atsede Fantahun
Department of Nursing Mekelle University, Tigray, Ethiopia
Corresponding Author:
Mekuria Kassa
Assistant Professor Department of Nursing
Mekelle University, Tigray, Ethiopia
E-mail: Mekuriakassa85@yahoo.com
Background: Sexual violence is ubiquitous; it occurs in every culture, in all levels of society and in every country of the world. Violence against women is usually targeted at women and girls due to their unequal treatment nature in society. It can takes place in the home, on the streets, in schools, in the workplace, in farm areas, refugee camps which is perpetrated by persons in positions of power. It includes physical acts, such as unwanted touching. Moreover, violence against women has become an international public health and human right issue over the past decades.
Objective: To assess the prevalence of sexual violence and associated factors among commercial sex workers in Mekelle city, Northern Tigray, Ethiopia, 2014.
Methods: A community based cross sectional study was conducted among 250 commercial sex workers in Mekelle city. Simple random sampling technique method was used to select the study participants. Structured and pretested interview questionnaire was used to collect the data. The collected data was coded, entered, cleaned and analyzed using SPSS version 20.0. Binary logistic regression model was used to test association between independent and dependent variables.
Keywords
Sexual violence, Commercial sex worker, Mekelle city
Introduction
Sexual violence is ubiquitous; it occurs in every culture, in all levels of society and in every country of the world. According to the World Health Organization, violence against women is a universal phenomenon that persists in all countries of the world, and the perpetrators are often well known to the victims/survivors. Violence against women is usually targeted at women and girls due to their unequal treatment nature in society. It can takes place in the home, on the streets, in schools, in the workplace, in farm areas, refugee camps which is perpetrated by persons in positions of power [1].
It includes physical acts, such as unwanted touching, rape, sexual harassment, threats, and peeping Violence against women has become an international public health and human right issue over the past decades. Young girls may be forced to exchange sex for life necessities such as food, sanitary towels, clothes and or money to support themselves i.e. commercial sex. The potential reproductive and sexual health are numerous consequences like unwanted pregnancy, sexually transmitted infections (STIs), sexual dysfunction and increased preponderance for adoption of risky sexual behaviors. The mental health consequences of sexual violence can be just as serious and long lasting [2].
Sex work, or prostitution, is the provision of sexual services for money or its equivalent. Sex workers may be male, female, or transgendered, and the boundaries of sex work are vague, ranging from erotic displays without physical contact with the client, through to high risk unprotected sexual intercourse with numerous clients. Individuals may occasionally and opportunistically exact a fee or gift for a sexual favor without perceiving themselves to be sex workers or they may engage more or less full time in the explicitly commercial provision of sex services; yet sex work is typically stigmatized and often criminalized [3].
Significance of the study: Few local studies conducted in different parts of the country however, no study tried to identify prevalence and associated factors of sexual violence among commercial sex worker in this study area. The aim of this study was to generate new information on prevalence and factors associated with sexual violence. The finding of this study will be help full for nurses, midwives and other health workers who are working in reproductive health centers in the study area and could use the result from this research as a baseline in their health education session to minimize sexual violence. Furthermore, the finding of this study will be beneficial to the policy makers, health care providers, stake holders, religious and public leaders, civil society and commercial sex workers organizations with relevant information for future planning and interventions of appropriate strategies to protect commercial sex worker from sexual violence. It also used as a base line for future studies.
Methodology
Study area and period
The Study was conducted in Mekelle city, which is the capital city of Tigray regional state and it is located 783 km far from Addis Ababa. The city is divided in to seven sub cities, 32 Kebeles. There are 2190 bars and146 hotels in the city. According to the projected census of 2007, conducted by the Central Statistical Agency of Ethiopia (CSA), Mekelle city has a total population of 301,642, in 2011. There are a total number of 2868 commercial sex workers residing in the city. The study was conducted from April 1-18, 2014
Sample size determination and sampling procedure
Sample size was computed using single population proportion formula with the estimated prevalence of sexual violence commercial sex workers 20% in Adama city [5]. Level of confidence 95% and margin of error 5%. Since the study population is less than 10,000, the sample size was calculated with the correction formula. No = NXn/N+nnf= 2868 x 246/2868+246 N=2868 nf= 227 n=246 with 10% of none response rate, a total of 250 commercial sex workers were included in the study. Since, there are seven sub cities (kifleketema) in Mekelle city. These entire sub cities (kifleketema) were included in the study. Proportion to size allocation was made to the seven sub cities (kifleketema) based on the number of commercial sex workers (CSWs) found in each sub city (Kifleketema) and then Simple random sampling technique was employed to select the study participants from each sub city (kifleketema). A list of commercial sex workers (CSWs) found in each sub city (kifleketema) was obtained from Transaction program and used as a sampling frame.
Data collection procedure & measurement
The dependent variable was Sexual violence and independent variables were:
Socio demographic characteristics of women (Ethnicity, Religion, occupation of clients,
Education status, monthly income, place of birth, age and family size).
Behavioral and Individual factors (Alcohol, drug use, chat chewing Smoking , Saving capacity)
Reproductive history (Age at marriage, Age at delivery, Family size, Future number of children, STI).
Data quality assurance
The data collection instrument was structured questionnaire. The questionnaire was prepared in English and translated to Tigrigna and adapted from previous similar studies. A language teacher translated the English version to Tigrigna. Seven diploma nurse data collectors and one BSc nurse supervisor were recruited based on their fluent in speak, read, write and listen Tigrigna and were trained for two days by the principal investigator about the purpose of the study, techniques of interviewing subjects and record responses accurately and uniformly. After identifying the study subjects, informed consent was obtained to confirm willingness and confidentiality issue was ensured to all of the study subjects and then face to face interview data collection technique was implemented. The questionnaire was pretested in twenty (5%) commercial sex workers in Wukuro town which have similar sociodemographic characteristics with the study area before the starting of the actual study. The result was not included in analysis of the study. Based on pre-test the questionnaire was modified and rearranged. In the study, data was collected by the seven trained data collectors. The questionnaires were checked for completeness on moment bases by immediate supervisors.
Data management and analysis
The questionnaires were checked for completeness, coded and entered into SPSS version 20.0 for cleaning and analysis. Statistical descriptions were calculated, quantitative variables were summarized using mean and standard deviation. Frequency distributions and percentage were also calculated for the categorical variables. The data was presented in the tables and charts.
Logistic regression model was used to identify factors associated with sexual violence. All variables that show significant association by bivariate analysis were included in a multivariate logistic regression analysis to determine independent predictors of the sexual violence. Adjusted Odds Ratio (AOR) with their 95% confidence interval (CI) was determined and p-value less than 0.05 were considered as significant association between dependent and independent variables.
Ethical clearance
The research proposal was approved and clearance was obtained from the Institutional Research Review board of Mekelle University College of Health Sciences. Formal letter of permission was obtained from Mekelle zone health office, and from each administration. Participation in the study was voluntarily and the participants were not obligate to answer any question they do not wish to answer. They were informed the right to drop it any time if participants felt discomfort with the question. The participants were not gained any direct benefit for being they participated.
Participants in this study were not exposed to any possible risk; any information given by participants was kept strictly confidential. Moreover, individual verbal consent of the study participant also was obtained and the data collectors were with a letter of approval from the sub city administration and all the collected data was kept in secured place.
Result
A total of 250 commercial sex workers were participated in the study making a response rate of 100%. Majority of the respondents 119(47.60%) were between the age of 20-24 with a mean age of 24.04(SD ± 4.3) and the age ranges from 17 up to 47 years. Majority were Tigray in ethnicity 175(70%), Orthodox in Christianity 224 (89.60%) and 87(34.80%) attended elementary school.
Concerning to the marital status 59(23.60%) of the respondents were married before they engaged to the commercial sex workers. Concerning to the educational status, more than one third of 87(34.80%) were attended elementary school. Pertaining to the occupational status of the respondent’s family, majority was farmer 99(39.60%). Majority 109(43.60%) of the respondent earn a monthly income of 1000 -2000 ETB with median of 1000 and live alone during the study period 144(57.60%) (Table 1).
| Variables | Frequency | % |
|---|---|---|
| Age in years | ||
| 15-19 | 33 | 13.20 |
| 20-24 | 119 | 47.60 |
| 25-29 | 75 | 30.00 |
| >30 | 23 | 9.20 |
| Families occupation | ||
| Farmers | 99 | 39.60 |
| Daily workers | 62 | 24.80 |
| Government employee | 42 | 16.80 |
| Privet employee | 20 | 8.20 |
| Own business | 27 | 10.80 |
| Ethnicity | ||
| Tigray | 175 | 70.00 |
| Amhara | 68 | 27.20 |
| Others | 7 | 2.80 |
| Religion | ||
| Orthodox | 224 | 89.60 |
| Muslim | 17 | 6.80 |
| Others | 9 | 3.60 |
| Monthly income | ||
| Less than 1000 | 65 | 26.00 |
| 1000-1999 | 109 | 43.60 |
| 2000-2999 | 65 | 26.00 |
| 3000 & above | 1 | 4.40 |
| Marital status before being CSW | ||
| Married | 59 | 23.60 |
| Unmarried | 191 | 76.40 |
| Place of growth | ||
| urban | 240 | 96.00 |
| rural | 10 | 4.00 |
Table 1. Socio demographic characteristics of respondents in Mekelle city, Northern Ethiopia, 2014. (n=250)
Reproductive health issues
46(18.40%) of the respondents were got marriage under the age of 18 years with a mean age of 16.9 (SD ± 2.1). Majority 206(82.40%) of the respondent had their first sex intercourse at the age of 15-19 with mean age of 17(SD ± 5.7). Pertaining to abortion 68(27%) of the participant had abortion in their life time, out of this 24(35.3) had repeated abortion. Information related to STI indicates that 43(17%) of the respondents had STI, out of this 24(9.6%) goes to treatment. Moreover, gonorrhea was the most common type of STI observed or reported in the commercial sex workers 11(45.8%) (Table 2).
| Variables | Frequency | % |
|---|---|---|
| Age of marriage in year(n=59) | ||
| Less than | 39 | 66.10 |
| 18 and above | 20 | 33.90 |
| Age of first sex intercourse in years (n=250) | ||
| Less than | 25 | 10.00 |
| 15-19 | 206 | 82.40 |
| >20-24 | 19 | 7.60 |
| Ever gave birth(n=250) | ||
| Yes | 99 | 39.60 |
| No | 151 | 60.40 |
| Ever had abortion (n=250) | ||
| Yes | 68 | 27.20 |
| No | 182 | 72.80 |
| Have you ever face STI(n=250) | ||
| Yes 43 17.20 | 43 | 17.20 |
| No | 207 | 82.80 |
| Ever managed STI(n=43) | ||
| Yes | 24 | 55.80 |
| No | 19 | 44.20 |
| Types of STIs(n=250) | ||
| Syphilis | 10 | 41.70 |
| Gonorrhea | 11 | 45.80 |
| Chancroid | 03 | 12.50 |
| Contraceptive ever used(n=250) | ||
| Yes | 173 | 69.20 |
| No | 77 | 30.80 |
Table 2. Reproductive health of respondent in Mekelle city, Tigray Region, Ethiopia, 2014
Health related and individual factors of respondents
Regarding information related to personal habit 114(44%), 170(68%) and 114(45.60%) of the respondents were smoking cigarette, use alcohol and chewing chat respectively. Moreover, 80(32%) of the respondents took drug, out of this 53(65.40%) for the purpose of stress relief. one hundred nighty seven (78.80%) and 109(43.60%) of the respondents were stays in commercial workers for 1-4 years and mentioned shortage of money for their engagement to the work respectively. Moreover, 220(88%) of the respondent use condom during sexual intercourse, out of this 158(71.80%) respond that they use always. civil servants were the major clients of the work mentioned by 114(45.60%) of the respondents. In the commercial sex work their clients for sexual need, 189(75.60%) were merchants, 114(45.60%) were civil employee, 30(12.00%) were drivers, 27(10.80%) were soldiers and 52(20.80%) were other different clients from the society (Table 3).
| Variable | Frequency | % |
|---|---|---|
| Smoking | ||
| yes | 110 | 44.00 |
| no | 139 | 56.00 |
| Alcohol use | ||
| yes | 170 | 68.00 |
| no | 80 | 32.00 |
| Chat chewing | ||
| yes | 114 | 45.60 |
| no | 136 | 54.40 |
| Drug use | ||
| yes | 81 | 32.00 |
| No | 167 | 60.00 |
| Reason for drug use | ||
| To relief stress | 53 | 65.40 |
| Peer pressure | 13 | 16.00 |
| Other reasons | 15 | 18.60 |
| Duration in the commercial sex work | ||
| 1-4 years | 197 | 78.80 |
| 5-9 years | 45 | 18.00 |
| 10 or more years | 8 | 3.20 |
| Reason for commercial sex workers | ||
| Shortage of money | 109 | 43.60 |
| Death of family | 20 | 8.00 |
| Parent divorce | 34 | 13.60 |
| Conflict with family members | 18 | 7.20 |
| My own divorce | 23 | 9.20 |
| Other reason | 46 | 18.40 |
| Client of the work | ||
| Merchants | 27 | 10.80 |
| Civil | 114 | 45.60 |
| Soldiers | 27 | 10.80 |
| Drivers | 30 | 12.00 |
| Students | 52 | 20.80 |
| Condom use during sexual intercourse | ||
| Yes | 220 | 88.00 |
| No | 30 | 12.00 |
| Frequency of condom use | ||
| Always | 158 | 71.80 |
| Most of the time | 62 | 24.80 |
Table 3. Health related and individual factors of respondents in Mekelle city, Tigray, Region, Ethiopia, 2014(N=250).
In this study 189(75.60%) commercial sex workers had violence in the Mekelle City. Out of the total 167(66.80%), 155(62%) and 131(52.45%) of the respondents faced sexual assault and unwanted touch and asking uncommon type of sexual intercourse, respectively. Beside this, a significant number of the respondent face violence by forceful sexual intercourse 109(43.60%), trauma with force full sex intercourse 114(45.60%) and involuntary sexual intercourse without condom 139(55.60%). The composite measure of violence show that, 189(75.60%) of the respondent face violence whereas the remaining 60(24%) did not face. The composite measure of violence indicates that, 189(75.60%) of the respondents had violence in their life time (Figure 1).
Figure 1. Prevalence of sexual violence among female commercial sex workers in Mekelle city2014. (n=250).
Factors Associated with sexual violence among commercial sex workers
The odds of having sexual violence was 5 among commercial sex workers (CSWs) who were able to read and write compared to the higher educated commercial sex workers (CSWs) with (AOR=5.38, 95% CI=1.15-25.20. Similarly, the odds of elementary and secondary school commercial sex workers (CSWs) were 5 compared to university or college completed commercial sex workers (CSWs) with (AOR=4.8, 95% CI (1.43-16.13) and (AOR=4.96, 95% CI (1.41-17.46) respectively. Marital status before starting commercial sex workers (CSWs) was significantly associated with violence of commercial sex workers (CSWs); the odd of violence was 4 among married women compared to the unmarried women before they start commercial sex workers (CSWs) with (AOR=3.85, 95% CI (1.34-11.09) (Table 4).
| Variables | Violence (n=250) | COR | AOR | ||||
|---|---|---|---|---|---|---|---|
| Yes No | |||||||
| Educational status | |||||||
| None read and write | 19(10.10) | 7(11.50) | 3.17(0.79-12.75) | 5.56(0.89-34.90) | |||
| Read and write | 43(22.80) | 18(29.50) | 2.79(0.82-9.45) | 5.38(1.15-25.20)* | |||
| Elementary school | 70(37.00) | 17(27.90) | 4.8(1.43-16.13) | 6.96(1.55-31.25)* | |||
| High school | 51(27.00) | 12(19.90) | 4.96(1.41-17.46) | 7.93(1.65-38.16)* | |||
| College or university | 6(3.20) | 7(11.50) | 1.00 | 1.00 | |||
| Marital Status | |||||||
| Yes | 52(27.50) | 7(11.50) | 2.93(1.25-6.85) | 3.85(1.34-11.09)* | |||
| No | 137(72.50) | 54(88.50) | 1.00 | 1.00 | |||
| Income of women in birr | |||||||
| Less than 1000 | 36(19.00) | 29(47.50) | 1.00 | 1.00 | |||
| 1000-1999 | 85(45.00) | 24(39.30) | 2.85(1.47-5.56) | 2.44(1.12-5.37)* | |||
| 2000-2999 | 59(31.20) | 6(9.80) | 7.92(2.99-20.94) | 7.94(2.46-25.58)* | |||
| 3000 and above | 9(4.80) | 2(3.30) | 3.63(0.73-18.12) | 3.28(0.54-9.80) | |||
| Smoking | |||||||
| Yes | 92(48.70) | 19(31.10) | 2.09(1.13-3.86) | 1.37(0.58-3.25) | |||
| No | 97(51.30) | 42(68.70) | 1.00 | 1.00 | |||
| Chat chewing | |||||||
| Yes | 94(49.70) | 20(32.80) | 2.03(1.11-3.72) | 1.68(0.26-1.73) | |||
| No | 95(50.30) | 41(67.20) | 1.00 | 1.00 | |||
| Drug use | |||||||
| Yes | 75(39.70) | 6(9.80) | 6.03(2.47-14.70) | 5.37(1.78-16.21)* | |||
| No | 114(60.30) | 55(90.20 | 1.00 | 1.00 | |||
| Duration in the CSW in year |
|||||||
| 1-4 | 159(84.10) | 38(62.30) | 12.55(2.44-16.64 | 11.57(1.56-85.60)* | |||
| 5-9 years | 28(14.80) | 17(27.90) | 4.94(0.89-27.32) | 4.57(0.57-39.88) | |||
| 10 or more years | 2(1.10) | 6(9.80) | 1.00 | 1.00 | |||
| Client type | |||||||
| Merchants | 21(11.10) | 6(9.80) | 2.19(0.75-6.35) | 1.82(.46-7.24) | |||
| Civil employee | 93(49.20) | 21(34.40) | 2.77(1.33-5.76) | 2.18(.89-5.34) | |||
| Soldiers | 19(10.10) | 8(13.10) | 1.48(0.55-4.02) | 1.21(.36-4.07) | |||
| Drivers | 24(12.70) | 6(9.80) | 2.5(0.87-7.20) | 2.68(.73-9.80) | |||
| Students | 32(16.90) | 20(32.80) | 1.00 | 1.00 | |||
* Significantly associated at p<0.05
Table 4. Factors associated with sexual violence among sexual workers in Mekelle city, Tigray region, Ethiopia March, 2014
Discussion
This community-based study had attempted to identify the magnitude of violence in female commercial sex workers and factors associated with sexual work in Mekelle city. Violence against women has become an international public health and human right issue over the past decades. Forms of gender violence include sexual violence, sexual abuse, sexual harassment, sexual exploitation, early or forced marriage, discrimination, and female genital mutilation [6].
This study revealed that the prevalence of sexual violence among commercial sex workers was 75.6%. This finding was consistent with a study done in New York City (73%), Andhra Pradesh, India (77%) Namibia (72%) and [7-9]. This could be due to the fact that Ethiopia is one of the developing counties of the world. However it was higher as compared with a study done in Adama Town (59 %), Bahr-dar (11.4%) and Canada 57% [10-12]. The difference could be due to methodology and socioeconomic characteristics. But the prevalence of sexual violence among the commercial sex workers of this study is lower compared to the study done in Bangladesh of which 94% of female workers had experienced violence from clients, soldier, gate keepers, intimate partners or neighbors [13]. This difference could be due the time and political commitment difference.
This study revealed that out of the total respondents 43% have been forced for sexual intercourse. This finding was similar with a study done in Mexico it was between 41% and 51%. However this finding was higher as compared with the finding of Adama Town 8%, a review of literatures in developing countries (22%), Canada (25%) and Addis Ababa (5%), Western Showa (10%) and Agaro (3%) [14-16]. This difference could be due to the time gap among these studies and difference in socioeconomic status of the respondents .and there may be lack of awareness about human right.
Different studies suggest that the exact cause of gender violence revealed that cross-cultural, hierarchal gender relation perpetuated through gender socializations and the socioeconomic inequalities of society are integrally related to violence against women [17]. This is also similar with this finding in which the most cause of sexual violence mentioned in this study was drug abuse, smoking, having low socio economic status and having low educational status. This study indicated that the odd of sexual violence were 3 times among married as compared unmarried women. The finding in this study is similar with result in Debre- Birhan which suggests that married women were 2.4 time more likely to have violence as compared with unmarried (OR=2.4, 95% CI;1.15,4.93) [18]. There might be due to psychological problem associated with their former husband which in turn may be the cause for them to join this work. Educational status of those commercial sex workers were a potent predictor of violence.
Accordingly commercial sex workers; who were able to read and write, completed elementary school and high school had the odds of 5 compared with university or college completed commercial sex workers (CSWs). This was different from a study conducted in Adama which revealed that education of female commercial sex workers were not associated with violence, in contrast to this study the college or university graduated commercial sex workers were violated [19]. This difference could be due to time and sample size difference. In this study monthly income had significant association; those who earn a monthly income of 1000-1999 ETB were violated with the odds of 3. This finding is similar to the study conducted in Adama in which those who earn a monthly income of 1000-1999 (AOR=5.51, 95% CI (1.62- 15.52) and 2000birr to 2999, [(AOR=7.27, 95% CI=1.60-32.52)] [20]. This could be the commercial sex workers may engage themselves to risk sexual activity for the matter of money and may be due to the fact that low income increases dependency.
Commercial sex workers stayed in the work for 1-4 years were violated with the odds of 12 compared to those who stayed 10 years and more (AOR=11.57, 95% CI(1.56-85.6). This finding was different from study conducted in Adama and Debre-markos which showed no association between length of stay in the work and sexual violence [21-23]. This difference could be due to time difference and the fact that as this work is a new environment, it may challenge them until they adapt the new environment.
The odds of sexual violence were 5 among drug user commercial sex workers (CSWs) compared with their counterparts. It was in line with the study conducted in Canada (AOR=1.5, 95% CI=1.02- 2.41) [24-28]. This could be due to the fact that the drug use among these commercial sex workers may lead them to risky behavior and finally end up with making an activity without their control. Our finding also supports by a study done in Ukraine indicated that 50% of drug users face psychological violence, and 49% drug user physical violence [29].
Strength
This study aimed at identifying a problem of special group which was at high risk for acquiring different problems including sexual violence. The strength of this study is the use of adapted instruments for sexual violence which is developed enabled to make the comparison of findings with other national and international literatures to be valid.
Limitations
Since the study was cross-sectional it may not be strong to demonstrate direct cause and effect between dependent and independent variables.
Conclusion and Recommendations
Conclusion
The prevalence of sexual violence among the commercial sex workers was high. Even though early marriage was not problem among the commercial sex workers, early initiation of Sex was prevalent. Substance abuse was practiced by majority of the commercial sex workers. The condom utilization among the commercial sex workers was not good. The early marriage before the commercial sex work, education status, monthly income, drug use, duration of stay in their work and having soldier as clients could influence sexual violence.
Recommendations
Based on the findings of the study, the following recommendations are proposed
Policy makers: Since education is the basic social service and those graduated from college or higher education, avoiding drug use, late marriages is the preventive aspect of sexual violence in the commercial sex workers. I would like to inform the policy makers to promote education for females and discourage late marriage and to empower females to make decision in the sexual health related issues.
Health sector: The regional health bureau should provide training on how to avoid sexual violence.
The zonal health office should formulate strategy to reduce commercial sex work violence and regulate the drug use in the city
Education sector: Provide education to young females to the higher education level to all community
Health professionals: Should educate the commercial sex workers about problem solving and conflict handling issues with their clients during they face differences in idea. Should educate on consistent use of condom and avoiding substance abuse.
Women affair: Advocate keeping human rights towards the commercial sex workers and early initiation of sex.
Researchers: To conduct further studies on reasons of sexual violence among commercial sex worker.
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