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Research - (2023) Volume 17, Issue 6

Sexual violence, its outcome and associated factors among female from conflict affected setting, Ethiopia

Derebe Madoro1* and Aneleay Cherinet2
 
1Dilla University, Department of Psychiatry, College of Medicine and Health Sciences, Dilla, Ethiopia
2Dilla University, Department of midwifery, College of Medicine and Health Sciences, Dilla, Ethiopia
 
*Correspondence: Derebe Madoro, Dilla University, Department of Psychiatry, College of Medicine and Health Sciences, Dilla, Ethiopia, Email:

Received: 02-Jun-2023, Manuscript No. Iphsj-23-13792; , Pre QC No. Iphsj-23-13792 (PQ); Reviewed: 19-Jun-2023, QC No. Iphsj-23-13792; Revised: 24-Jun-2023, Manuscript No. Iphsj-23-13792(R); Published: 30-Jun-2023, DOI: 10.36648/1791- 809X.17.6.1028

Abstract

Background: The security of students traveling to school is threatened by conflict. Sexual assaults against women who are in conflict settings were more common. In addition to having an adverse effect on girls' reproductive and psychological health, this lowers their academic performance. Despite being one of the countries most impacted by conflict, Ethiopia, there is little literature on the subject. Therefore, the purpose of this study was to assess sexual violence among female students in a conflict-affected area in south Ethiopia, as well as its effects and related variables.

Methods: A cross-sectional study based on an institution was carried out in south Ethiopia from April 1 to April 30, 2022. Through a simple random sample technique, 417 female respondents in all took part in the survey. The Childhood Experience of Care and Abuse Questionnaire were used to measure sexual violence (CECA-Q). With the use of bivariate and multivariate logistic regression, the relationship between the result and independent factors was examined. The 95% confidence interval was used to determine statistical significance at p 0.05.

Results: A 417 respondents were participated with a 98.5% response rate. Sexual violence was reported about 39.7% with a 95% CI (37.1, 42.7). The following factors were discovered to be significantly associated with sexual violence: Insufficient adherence to the code (AOR=4.27, 95 % CI 2.78 to 6.09); family history of violence (AOR=3.01, 95% CI=2.66 to 6.12); residing alone (AOR=3.57, 95% CI 2.06 to 6.19); no household conversation on health related issues (AOR=2.23, 95% CI 1.29 to 3.87); and a family that has been internally relocated (AOR=1.8, 95% CI=1.97 to 3.35). Out of 166 (39.7%) survivors of sexual abuse, 16 (9.6%) underwent miscarriages, and 26 (15.7%) experienced unwanted pregnancies. Psychological distress, PTSD, alcoholism, suicide, and homicide rates were reported to be 38%, 28.3%, 14.5%, 10.2%, and 9%, respectively.

Conclusion: As a result, the ministries of health, education, and humanitarian groups should cooperate to offer regular psychosocial assistance at schools as well as the proper intervention for pupils who have been affected by a conflict. In areas afflicted by war, the rule of law should be vigorously enforced to prevent sexual assault.

Keywords

Sexual violence; Outcome; Conflict setting; Female Student; Ethiopia

Introduction

Conflict can result in higher levels of gender-based violence against women and girls, including arbitrary killings, torture, sexual violence and forced marriage [1]. Across many of the world’s poorest countries, armed conflict continues to destroy not just school infrastructure, but also the hopes and ambitions of a whole generation of children [2, 3]. Conflict leads death or displacement of teachers and students(4). Example: more than two-thirds of teachers in primary and secondary schools were killed or displaced as a result of the Rwandan genocide [5].

Schools and educational infrastructure are destroyed or damaged. As a result of the violence in Bosnia and Herzegovina, 50% of its schools needed to be rebuilt or renovated; The lengthy civil conflict in Mozambique resulted in the destruction or closure of 58% of the country's primary schools; In Iraq, 85% [6]. The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) also states in its January 6, 2022 Northern Ethiopia report that the conflict's effects on education have prevented millions of students from attending school for more than a year in some places.

Children's safety while traveling to and from school and attending class is threatened by conflict. Girls may be kept from school by their parents in fear of violence against female students [6]. 12.6 million Of the 28.5 million primary school-age children in conflictaffected nations do not attend school, while 5.3 million live in South and West Asia, and 4 million live in the Arab States. The vast majority, 95%, live in low and lower middle income countries [7]. Girls, who make up 55% of the total, are the worst affected, as they are often victims of rape and other sexual violence that accompanies armed conflicts(military violence against education staff, students, teachers) [8, 9].

Globally, one in three adolescent girls’ reports had their first sexual experience as a result of coercion [10]. Sexual abuse is common in Sub-Saharan African educational institutions including Ethiopia. Teenagers can experience bullying at school, which can take the form of unwelcome touching or verbal abuse. It can also be more overtly violent as in cases where girls are sexually assaulted (raped) in or near school premises [11, 12]. Studies have shown that sexual violence against girls by older male students and teachers is very common and more than 40% of school girls have experienced some form of sexual abuse at some point in their lives. This leads to lower girls’ educational attainment and increases absenteeism and dropout rates. The above problem tends to be increased in the conflict affected setting.

For example, the UNFPA study estimated that rates of GBV were three times greater among displaced women than among nondisplaced women (15.2% vs. 5.3%) (15). A majority (66%) of GBV survivors among non-displaced women knew their perpetrator personally. In contrast, proportionally more displaced GBV survivors experienced violence at the hands of strangers and of demobilized soldiers returning home.

Both married and unmarried women engage in transactional sexual behaviors as a result of financial hardship. Some women engaged in haphazard sexual encounters to gain access to cash so they could support their families as a result of financial insecurity, the unemployment of their spouses, for instance, as well as a lack of social support (13, 14). Having regular boy-friends, being sexually active, having female or male friends who drink alcohol, students witnessed their mothers being beaten by their partners or husband and joining public school were significantly associated with gender-based violence.

Studies have shown that sexual violence against women leads to a number of problems including unwanted pregnancy, increased risk of HIV/AIDS infection and other sexually transmitted infections (STIs), gynaecological problems, feeling of worthlessness, depression, fear and guilty feeling about sex, powerlessness, shame, difficulty in trusting people, post-traumatic stress disorder (PTSD), and even suicide. Additionally, it exposes girls and women in schools to social repercussions like low academic performance, social withdrawal, having many relationships, turning down friends, abusing drugs and alcohol, and even prostitution.

Scarce literature is available on the nature and extent of sexual violence against female students from conflict affected setting in Ethiopia. Even though previous studies indicate that schools are highly susceptible to sexual and gender-based violence, the problem has not been adequately addressed in the educational sector.

Methods and Materials

Study design, period and setting

An institutional based cross-sectional study was conducted from March 1 to 30/2022. The study conducted among female high school students located in conflict affected setting of south Ethiopia.

Participants

The female students who were academically active and present in the schools during data collection period were included in the study, whereas, female students who were critically ill and difficulties to respond the questionnaires were excluded.

Sample size and sampling procedure

A sample size was determined by using a single population proportion formula by taking the prevalence of sexual abuse 50%, because no study done in conflict affect setting in Ethiopia. In addition, 4% of margin of error, 95% confidence interval and by assuming 10% non-response rate. The final sample size found to be 423.

The sample size was proportionally allocated to the number of female students in each high school (six high schools were located around conflict affected setting) to assure that the sample size was representative. Lastly, a straightforward random sample procedure was used to choose study participants.

Study variables

The dependent variable in this study was sexual abuse. Independent variables included socio demographic factors (age, marital status, religion, parents education status, family’s occupation, residency, family income), conflicted related factors(internally displaced family, witnessed violence, destruction of resources), clinicalrelated factors (history of mental illness, family history of mental illness, pre-existing medical illness), and psychosocial factors (social support, history of childhood abuse, lack of parental control, weak rule of law, living with) sexual related factors (age of perpetrator, number of perpetrator, relationship of perpetrator, place of incident, recurrence of incident, sexually abusive peer), behavioural factors (khat, alcohol and cigarette).

Data collection procedure

Using pretested questionnaires, the data was gathered by six Bsc nurses under the usual supervision of three psychiatry specialists. To ensure uniformity, the questionnaire was translated from English into Amharic and back again. Data collectors were given instructions on how to interview respondents and clarify any unclear questions as well as the goal of the study. Additionally, they received instruction on how to get the informed consent of respondents for participation and on ethical norms.

Data collection tools

Sexual violence was measured by pre-tasted and self-administered questionnaires which was adapted from the standard ‘‘Childhood Experience of Care and Abuse Questionnaire (CECA-Q) Chronbach alpha for this study is 0.87. In this study, female students selfreported involvement in any sexual activity in following conflict that she did not fully comprehend and was unable to give informed consent to or forcefully sexual activities.

Outcome of sexual abuse in this study was assessed using self-reported, chart review and using standard tools to assess psychological effect (PTSD, psychological distress, suicide, alcohol dependency and homicidal ideas) and reproductive health consequences. Gynaecological complaints following sexual violence were assessed using questions adapted from literatures. HIV status was assessed using self-reported and chart review [13].

Post-traumatic stress disorder (PTSD) assessed using the Post Traumatic Stress for dsm5 (PCL-5) which is an easily administered self-report rating scale for assessing the 20 DSM-5 symptoms of PTSD. A total score is computed by adding the 20 items, so that possible scores range from 0 to 80 with a five Likert scale( 0= Not at all, 1= A little bit, 2 =Moderately, 3=Quite a bit, 4= Extremely) with a cut point of ≥33. Validity and reliability of the PCL-5 has been tested and proven on displaced peoples and refugees in a number of countries like, in Iraq internal consistency (cronbach’s alpha =0.85) Zimbabwe internal consistency (cronbach’s alpha =0.92).

Significant Psychological Distress Scores (SRQ scores≥6)was used to assess psychological distress. Suicide attempt and alcohol psychological dependency measured using whether had attempted suicide in a life-time and in the last 12 month and CAGE questionnaire respectively.

Social support is measured using the Oslo-3 social support scale, which ranges from 3 to 14. Those who score 3 to 8 are considered to have poor social support, those who score 9-11 are considered to have moderate social support, and those who score 12 to 14 are considered to have strong social support (34). Yes/no response questionnaires were used to collect data on socio-demographics, substance use history, clinical factors, conflict-related factors, and which were operationalized according to various literatures.

Operational definition

Sexual abuse experience: In this study, female students selfreported involvement in any sexual activity following conflict that she did not fully comprehend and was unable to give informed consent to or forcefully sexual activities. Physical forms of sexual abuse include: fondling, oral-genital contact, rape or attempted rape, and use of a child for pornography. Indecent exposure, blunt discussion of sex intended to shock a child or pique her interest, letting the child see or hear sexual acts or materials, and having sex in front of the child are all examples of non-physical types of sexual abuse. Rape: a type of sexual assault usually involves sexual intercourse or other forms of sexual penetration carried out against a person without the consent of the person

Statistical analysis

Epidata version 4.2 was used to clean, code, and input data, which was then exported to SPSS V.24 for analysis using descriptive methods, and the data was summarized using text and tables. Associations between sexual violence and relevant factors were found using logistic regression analysis. Variables having a P-value of less than two in bivariable logistic regression were incorporated into the multivariable logistic regression model. A P-value of less than 0.05 was considered statistically significant, and the strength of associations was determined using an adjusted odds ratio (AOR) with a 95 % confidence interval (CI).

Results

Socio-demographic characteristics of the respondents

A total of 417 female students were fully participated in this study with a response rate of 98.5%. Most of (63.8%) participants were between the age of 15-19 years with a mean and standard deviation of 16±2.6 years. Majority of the respondents 395(94.7%) were single and 202(48.4%) were protestant Christianity followers. About 228(54.7%) of the study participants were living in rural area (Table 1).

Variable Frequency(n=417) Percent (%)
Age    
    15-19 266 63.8
    20 and above 151 36.2
Religion    
    Orthodox 85 20.4
    Muslim 62 14.9
    Protestant 202 48.4
    Catholic 68 16.3
Family occupational status    
  Farming 167 40.1
  Merchant/private 102 24.6
  Government employee 89 21.3
  House wife 59 14
Marital status    
  Single 395 94.7
  Married 22 5.3
Residence    
  Urban 189 45.3
  Rural 228 54.7
Family income    
>5000 208 49.9
5000-9999 111 26.6
10000 and more 98 23.5
Family size    
>5 275 65.9
5 and above 142 34.1
 

Table1.  Distribution of participants by socio-demographic factors among female students in conflict affected setting, Ethiopia, 2022 (n=417).

Characteristics of perpetrators and sexual related factors

In 166 cases of sexual assault, extra-familial individuals committed 75% of the rapes, while family members committed the remaining 15%. Commonly reported extra-familial perpetrators were peers (schoolmates) (23%), school teachers (15.8%), boyfriends (24.8%), neighbours (14.6%), 10% aid workers and unrecognized persons (strangers) (6.9%). Almost half (51.3%) of respondents who started sex had multiple (two or more) lifetime sexual partners. Two hundred thirty four (56.1%) of the study subjects had open discussions with their parents about sexual and reproductive health issues while the rest didn’t.

Prevalence and forms of sexual violence

In this study the proportion of female students who reported at least one form of sexual abuse was 166(39.7%) with 95% CI (37.1, 42.7). Out of total, 33% (95% CI 30.5–40.7) of participants were reported verbal form of sexual abuse (verbal harassment), 40% (95% CI 38.5–46.7) of them reported unwelcomed touch/body contact, and 27% (95% CI 24.3, 33.7) reported rape. 34% of sexual abuse was took place in the hotels, 19% in the perpetrator’s home, 21% in the survivors’ homes, and the rest in the field/ outside home.

The majority 55.0% of the rape victims didn’t report the case to anybody and only 21.0% disclosed their case to someone else, 10.3% reported to their friends, 3.7% reported to legal bodies, and 10% of them were reported to their parents. The main reasons for not reporting the incidence were 30.3% because of fear of perpetrators, 18.8% because of fear of their families, 30.7% because of fear of stigma, and the remaining 20.2% of them didn’t know what to do.

Psycho social, conflict related, behavioural, and clinical related factors

Regarding psychosocial factors, 167(40%) of participants had moderate social support and 186(44.7%) had family history of violence. Out of total 226(54.2%) of respondents were from internally displaced family and 84(20.1%) of respondents had history of current khat chewing. Concerning clinical characteristics, 79(18.9%) of participants had history of mental illness (Table 2).


Explanatory variables
Frequency (n) Percentage (%)
Social support    
Good 101 24.2
Moderate 167 40
Poor 149 35.8
History of childhood abuse    
Yes 145 34.8
No 272 65.2
Insufficient adherence to the code    
No 204 48.9
Yes 213 51.1
Family history of violence    
Yes 211 50.6
No 206 49.4
Lack of parental control    
  Yes 175 42.9
  No  242 57.1
Living with    
Alone 97 23.3
Both Parents 198 47.5
Single parents 87 20.9
Friends/relatives 35 8.3
 Internally relocated  family    
Yes 226 54.2
 No 191 45.8
Destruction of resources    
Yes 183 43.9
No 234 56.1
Prior history of mental illness    
Yes 79 18.9
 No 338 81.1
Medical illness    
Yes 96 23
No 321 77
Family history of mental illness    
Yes 88 21.1
No 329 78.9
Sexually abusive peer    
Yes 105 25.2
No 312 74.8
No household conversation    
Yes 234 56.1
No 183 44.9
Alcohol current use    
Yes 76 18.2
No  341 81.8
Khat current use    
Yes 84 20.1
No 333 79.9
Ciggarate current use    
Yes 25 5.9
No  392 94.1

Table 2.Psycho social, behavioral, Sexual and clinical related factors among female students in conflict affected setting, Ethiopia, 2022(n=417).

Outcome/health consequences of sexual abuse

Reproductive health consequences

Among the total of 166 sexual abuse survivors 31(18.7%) developed abnormal virginal discharge, 26(15.7) experienced unwanted pregnancies and 16(9.6%) underwent an abortion (Table 3).


Variables
Frequency(n) Percentage (%)
Psychological consequences    
Alcohol dependence 24 14.5
Post-traumatic stress disorder 47 28.3
Psychological distress 63 38
Suicidal attempt 17 10.2
Homicidal ideas 15 9
Poor educational achievement 76 45.8
Gynecological complaint    
Abnormal vaginal discharge 31 18.7
Chronic lower abdominal pain 8 4.8
Abnormal vaginal bleeding  29 17.5
Unwanted pregnancy  26 15.7
Sexual dysfunction 11 6.6
Abortion 13 7.8
HIV serological status positive  9 5.4
Others * 16 9.6

Table3. Outcome of sexual violence among female students in conflict affected setting, Ethiopia, 2022(n=166).

Psychological consequences

Out of a total 166 sexual abuse survivors, regarding mental health/ psychological consequences of sexual abuse like psychological distress, post-traumatic stress disorder, alcohol dependency, suicide, and homicide were reported about 38%, 28.3%, 14.5%, 10.2%, and 9% respectively, and 46% had poor educational achievement.

Factors associated with sexual violence

Family history of violence, a family that has been internally relocated, insufficient adherence to the code, no household conversation on health - related issues, and residing alone were significantly associated with sexual violence among respondents in multivariate logistic regression, with a p-value of 0.05.

The odds of having sexual violence among female students who Family history of violence were 3 times higher when compared to counterpart (AOR=3.01, 95% CI=2.66, 6.12). When compared to their counterparts, those who were residing alone were 3.57 times more likely to have sexual violence (AOR=3.57, 95% CI 2.06 to 6.19). When compared to counterparts, those who had no household conversation on health - related issues were 2.23 times more likely to have sexual violence (AOR=2.23, 95 % CI 1.29 to 3.87). The risk of sexual violence was 4.27 times higher in participants with insufficient adherence to the code practiced (AOR=4.27, 95 % CI 2.78 to 6.09). The odds of having sexual violence among participants from a family that has been internally relocated were 1.8times higher as compared to counterpart (AOR=1.8, 95% CI=1.97, 3.35) (Table 4).


Explanatory variables
Sexual abuse COR, (95% CI) AOR, (95%CI)
Yes No
Age
15-19 139 127 1.23(0.89, 7.61) 2.1(0.97, 4.01)
20 and above 71 80 1 1
Insufficient adherence to the code
No 42 162 1 1
Yes 113 100 5.13(3.95, 8.24) 4.27(2.78, 6.09)**
Internally relocated  family
Yes 76 150 2.11(1.95, 4.15)=1.5 1.8(1.97, 3.35)*
No 37 154 1 1
No household conversation on health
Yes
No 90 144 2.47(1.04, 4.63) 2.23(1.29, 3.87) **
37 146 1 1
Current alcohol use
Yes 18 58 1.22(0.88, 1.76) 0.68(0.44, 1.06)
No 69 272 1 1
Social support
Poor 60 41 2.05(1.02, 4.21) 2.17(0.84, 5.60)
Moderate 82 85 1.35(0.91, 2.07) 0.80(0.46, 1.41)
Strong 62 87 1 1
Living with
Alone 37 60 2.87(2.03, 5.31) 3.57(2.06, 6.19) **
With single parents 15 72 0.97(0.51, 1.86) 1.19(0.62, 2.26)
With friends/relatives 6 29 0.96(0.71, 2.19) 1.46(0.80, 2.68)
With both parents 35 163 1 1
Family history of violence
Yes 127 84 2.64( 1.75, 3.92) 3.01(2.66, 6.12)**
No 75 131 1 1

Table 4.  Bi-variable and multivariable binary logistic regression analysis showing association between factors and sexual violence among female students in conflict affected setting in south Ethiopia 2022(n=417).

Discussion

Sexual violence in the conflict affected setting is the major public health problem. In this study the proportion of female students who reported at least one form of sexual abuse was 166(39.7%) with 9 5% CI (37.1, 42.7). Out of total, 33% (95% CI 30.5-40.7) of participants were reported verbal form of sexual abuse (verbal harassment), 40% (95% CI 38.5-46.7) of them reported unwelcomed touch/body contact, and 27% (95% CI 24.3, 33.7) reported rape.

This findings is similar with study done in Nigeria,42.3%(36), Bahir Dar city, 37.3%(37), and Wolaita Sodo, 37.2 Similarly, the result in this study is higher than study conducted Addis Ababa 12.7% Haramaya 27.8% College women27%, Madawalabu 10.9%. Aletewondo, and Hawassa 14.3%. In contrarily, the result is lower than study conducted in Ethiopia 67.7%(36), higher education institutions of Ethiopia 49.4%(43), Northern Nigeria 58.8%(44), Gondar 35.1%(45), Bahir Dar 71.1%.(46), Debre Markos 57.3% Debrebrahan 54.9% and Awassa,59.9. The possible discrepancy could be socio cultural difference and study settings, previous study was conducted in out of conflict area, whereas, this study conducted in female students from conflict affected setting. Methodological differences like the study population difference (university female students, college female students and high school female students), regarding measurement, most of the previous studies used WHO gender based violence questionnaire, whereas in this study, Childhood Experience of Care and Abuse Questionnaire (CECA-Q) was used, and this could be another reason.

The risk of sexual violence was 4.27 times higher in participants with insufficient adherence to the code practiced. The normalization of violence, combined with rampant impunity, creates a favourable scenario for continuous violations of women’s rights. The persistence and exacerbation of violence are also explained in the context of the war against drugs, which has led to an expansion and normalization of extreme violence in general. The weakness of the State and the underlying impunity fostered a scenario in which women suffered not only from highly unequal conditions at work but also became more likely to be victims of crimes and human rights violations while the perpetrators of those crimes faced limited consequences. Sufficient adherence to the code and rule of law enables conditions in which violence flourishes.

The odds of having sexual violence among participants from a family that has been internally relocated were 1.8times higher as compared to counterpart. Displacement is significantly connected with both the recent year and lifetime prevalence of sexual assault. Displaced women are 9-10% more likely than nondisplaced women to encounter sexual violence at some point in their lives, and 6-8% more likely to have experienced it in the previous year. Each displacement related risk factor increases a woman’s risk of lifetime sexual violence by 6%t even after adjusting for other risk factors.

When compared to counterparts, those who had family history of violence were 3 times more likely to have sexual violence. Observing domestic violence can lead children to develop an array of age-dependent negative effects.

Research in this are has focused on the cognitive, behavioural, and emotional effects of violence. Children who observed violence in the home and children who are abused may display many similar psychological effects. Child witnesses display inappropriate attitudes about violence as a means of resolving conflict and indicate a greater willingness to use violence themselves.

No household conversation on health - related issues with their family and or friends has increased sexual violence almost 2.23 times. This finding was a consistent study at Wolaita Sodo University that showed that discussions of sexual issues with her partner reduced 74% of the risks of sexual violence. One of the ways that teenagers might postpone their first sexual experience or prevent sexual and physical assault is by having a conversation with their parents about sexual and reproductive health issues. Teenagers should be taught about the human reproductive system, issues around sexual and reproductive health, and acceptable family responsibilities.

When compared to their counterparts, those who were residing alone were 3.57 times more likely to have sexual violence. These findings are in line with the studies done among high school students in Arbaminch town, Ethiopia, in Harar, and southeast Nigeria and Dire Dawa. The answer could be that parents are more concerned about their daughter than their friends and relatives, which can reduce the likelihood of sexual abuse occurring to children who live with them [14].

Conclusion

High rate of sexual violence was found among conflict affected female students. Family history of violence, a family that has been internally relocated, insufficient adherence to the code, no household conversation on health - related issues, and residing alone were significantly associated with sexual violence among respondents. Therefore, the ministry of health, ministry of education and humanitarian organizations should work collaboratively in providing consistent school based psychosocial support and appropriate intervention for conflict affected students. Comparative and longitudinal study was recommended to other researchers to see the long term effect of sexual violence of conflict in recent conflict of north Ethiopia.

The Study's Strengths and Limitations

For first, this is the first research of its kind in Ethiopia, involving female students from conflict-affected areas. Second, it included crucial elements that had previously been left out of earlier research. The study's use of an updated, standardized, and validated instrument to measure the outcome variable was one of its strengths. The fact that only female students from south Ethiopian regions afflicted by violence were included was one of the limitations.

Keywords

Sexual violence; Outcome; Conflict setting; Female Student; Ethiopia

Introduction

Conflict can result in higher levels of gender-based violence against women and girls, including arbitrary killings, torture, sexual violence and forced marriage [1]. Across many of the world’s poorest countries, armed conflict continues to destroy not just school infrastructure, but also the hopes and ambitions of a whole generation of children [2, 3]. Conflict leads death or displacement of teachers and students(4). Example: more than two-thirds of teachers in primary and secondary schools were killed or displaced as a result of the Rwandan genocide [5].

Schools and educational infrastructure are destroyed or damaged. As a result of the violence in Bosnia and Herzegovina, 50% of its schools needed to be rebuilt or renovated; The lengthy civil conflict in Mozambique resulted in the destruction or closure of 58% of the country's primary schools; In Iraq, 85% [6]. The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) also states in its January 6, 2022 Northern Ethiopia report that the conflict's effects on education have prevented millions of students from attending school for more than a year in some places.

Children's safety while traveling to and from school and attending class is threatened by conflict. Girls may be kept from school by their parents in fear of violence against female students [6]. 12.6 million Of the 28.5 million primary school-age children in conflictaffected nations do not attend school, while 5.3 million live in South and West Asia, and 4 million live in the Arab States. The vast majority, 95%, live in low and lower middle income countries [7]. Girls, who make up 55% of the total, are the worst affected, as they are often victims of rape and other sexual violence that accompanies armed conflicts(military violence against education staff, students, teachers) [8, 9].

Globally, one in three adolescent girls’ reports had their first sexual experience as a result of coercion [10]. Sexual abuse is common in Sub-Saharan African educational institutions including Ethiopia. Teenagers can experience bullying at school, which can take the form of unwelcome touching or verbal abuse. It can also be more overtly violent as in cases where girls are sexually assaulted (raped) in or near school premises [11, 12]. Studies have shown that sexual violence against girls by older male students and teachers is very common and more than 40% of school girls have experienced some form of sexual abuse at some point in their lives. This leads to lower girls’ educational attainment and increases absenteeism and dropout rates. The above problem tends to be increased in the conflict affected setting.

For example, the UNFPA study estimated that rates of GBV were three times greater among displaced women than among nondisplaced women (15.2% vs. 5.3%) (15). A majority (66%) of GBV survivors among non-displaced women knew their perpetrator personally. In contrast, proportionally more displaced GBV survivors experienced violence at the hands of strangers and of demobilized soldiers returning home.

Both married and unmarried women engage in transactional sexual behaviors as a result of financial hardship. Some women engaged in haphazard sexual encounters to gain access to cash so they could support their families as a result of financial insecurity, the unemployment of their spouses, for instance, as well as a lack of social support (13, 14). Having regular boy-friends, being sexually active, having female or male friends who drink alcohol, students witnessed their mothers being beaten by their partners or husband and joining public school were significantly associated with gender-based violence.

Studies have shown that sexual violence against women leads to a number of problems including unwanted pregnancy, increased risk of HIV/AIDS infection and other sexually transmitted infections (STIs), gynaecological problems, feeling of worthlessness, depression, fear and guilty feeling about sex, powerlessness, shame, difficulty in trusting people, post-traumatic stress disorder (PTSD), and even suicide. Additionally, it exposes girls and women in schools to social repercussions like low academic performance, social withdrawal, having many relationships, turning down friends, abusing drugs and alcohol, and even prostitution.

Scarce literature is available on the nature and extent of sexual violence against female students from conflict affected setting in Ethiopia. Even though previous studies indicate that schools are highly susceptible to sexual and gender-based violence, the problem has not been adequately addressed in the educational sector.

Methods and Materials

Study design, period and setting

An institutional based cross-sectional study was conducted from March 1 to 30/2022. The study conducted among female high school students located in conflict affected setting of south Ethiopia.

Participants

The female students who were academically active and present in the schools during data collection period were included in the study, whereas, female students who were critically ill and difficulties to respond the questionnaires were excluded.

Sample size and sampling procedure

A sample size was determined by using a single population proportion formula by taking the prevalence of sexual abuse 50%, because no study done in conflict affect setting in Ethiopia. In addition, 4% of margin of error, 95% confidence interval and by assuming 10% non-response rate. The final sample size found to be 423.

The sample size was proportionally allocated to the number of female students in each high school (six high schools were located around conflict affected setting) to assure that the sample size was representative. Lastly, a straightforward random sample procedure was used to choose study participants.

Study variables

The dependent variable in this study was sexual abuse. Independent variables included socio demographic factors (age, marital status, religion, parents education status, family’s occupation, residency, family income), conflicted related factors(internally displaced family, witnessed violence, destruction of resources), clinicalrelated factors (history of mental illness, family history of mental illness, pre-existing medical illness), and psychosocial factors (social support, history of childhood abuse, lack of parental control, weak rule of law, living with) sexual related factors (age of perpetrator, number of perpetrator, relationship of perpetrator, place of incident, recurrence of incident, sexually abusive peer), behavioural factors (khat, alcohol and cigarette).

Data collection procedure

Using pretested questionnaires, the data was gathered by six Bsc nurses under the usual supervision of three psychiatry specialists. To ensure uniformity, the questionnaire was translated from English into Amharic and back again. Data collectors were given instructions on how to interview respondents and clarify any unclear questions as well as the goal of the study. Additionally, they received instruction on how to get the informed consent of respondents for participation and on ethical norms.

Data collection tools

Sexual violence was measured by pre-tasted and self-administered questionnaires which was adapted from the standard ‘‘Childhood Experience of Care and Abuse Questionnaire (CECA-Q) Chronbach alpha for this study is 0.87. In this study, female students selfreported involvement in any sexual activity in following conflict that she did not fully comprehend and was unable to give informed consent to or forcefully sexual activities.

Outcome of sexual abuse in this study was assessed using self-reported, chart review and using standard tools to assess psychological effect (PTSD, psychological distress, suicide, alcohol dependency and homicidal ideas) and reproductive health consequences. Gynaecological complaints following sexual violence were assessed using questions adapted from literatures. HIV status was assessed using self-reported and chart review [13].

Post-traumatic stress disorder (PTSD) assessed using the Post Traumatic Stress for dsm5 (PCL-5) which is an easily administered self-report rating scale for assessing the 20 DSM-5 symptoms of PTSD. A total score is computed by adding the 20 items, so that possible scores range from 0 to 80 with a five Likert scale( 0= Not at all, 1= A little bit, 2 =Moderately, 3=Quite a bit, 4= Extremely) with a cut point of ≥33. Validity and reliability of the PCL-5 has been tested and proven on displaced peoples and refugees in a number of countries like, in Iraq internal consistency (cronbach’s alpha =0.85) Zimbabwe internal consistency (cronbach’s alpha =0.92).

Significant Psychological Distress Scores (SRQ scores≥6)was used to assess psychological distress. Suicide attempt and alcohol psychological dependency measured using whether had attempted suicide in a life-time and in the last 12 month and CAGE questionnaire respectively.

Social support is measured using the Oslo-3 social support scale, which ranges from 3 to 14. Those who score 3 to 8 are considered to have poor social support, those who score 9-11 are considered to have moderate social support, and those who score 12 to 14 are considered to have strong social support (34). Yes/no response questionnaires were used to collect data on socio-demographics, substance use history, clinical factors, conflict-related factors, and which were operationalized according to various literatures.

Operational definition

Sexual abuse experience: In this study, female students selfreported involvement in any sexual activity following conflict that she did not fully comprehend and was unable to give informed consent to or forcefully sexual activities. Physical forms of sexual abuse include: fondling, oral-genital contact, rape or attempted rape, and use of a child for pornography. Indecent exposure, blunt discussion of sex intended to shock a child or pique her interest, letting the child see or hear sexual acts or materials, and having sex in front of the child are all examples of non-physical types of sexual abuse. Rape: a type of sexual assault usually involves sexual intercourse or other forms of sexual penetration carried out against a person without the consent of the person

Statistical analysis

Epidata version 4.2 was used to clean, code, and input data, which was then exported to SPSS V.24 for analysis using descriptive methods, and the data was summarized using text and tables. Associations between sexual violence and relevant factors were found using logistic regression analysis. Variables having a P-value of less than two in bivariable logistic regression were incorporated into the multivariable logistic regression model. A P-value of less than 0.05 was considered statistically significant, and the strength of associations was determined using an adjusted odds ratio (AOR) with a 95 % confidence interval (CI).

Results

Socio-demographic characteristics of the respondents

A total of 417 female students were fully participated in this study with a response rate of 98.5%. Most of (63.8%) participants were between the age of 15-19 years with a mean and standard deviation of 16±2.6 years. Majority of the respondents 395(94.7%) were single and 202(48.4%) were protestant Christianity followers. About 228(54.7%) of the study participants were living in rural area (Table 1).

Variable Frequency(n=417) Percent (%)
Age    
    15-19 266 63.8
    20 and above 151 36.2
Religion    
    Orthodox 85 20.4
    Muslim 62 14.9
    Protestant 202 48.4
    Catholic 68 16.3
Family occupational status    
  Farming 167 40.1
  Merchant/private 102 24.6
  Government employee 89 21.3
  House wife 59 14
Marital status    
  Single 395 94.7
  Married 22 5.3
Residence    
  Urban 189 45.3
  Rural 228 54.7
Family income    
>5000 208 49.9
5000-9999 111 26.6
10000 and more 98 23.5
Family size    
>5 275 65.9
5 and above 142 34.1
 

Table1.  Distribution of participants by socio-demographic factors among female students in conflict affected setting, Ethiopia, 2022 (n=417).

Characteristics of perpetrators and sexual related factors

In 166 cases of sexual assault, extra-familial individuals committed 75% of the rapes, while family members committed the remaining 15%. Commonly reported extra-familial perpetrators were peers (schoolmates) (23%), school teachers (15.8%), boyfriends (24.8%), neighbours (14.6%), 10% aid workers and unrecognized persons (strangers) (6.9%). Almost half (51.3%) of respondents who started sex had multiple (two or more) lifetime sexual partners. Two hundred thirty four (56.1%) of the study subjects had open discussions with their parents about sexual and reproductive health issues while the rest didn’t.

Prevalence and forms of sexual violence

In this study the proportion of female students who reported at least one form of sexual abuse was 166(39.7%) with 95% CI (37.1, 42.7). Out of total, 33% (95% CI 30.5–40.7) of participants were reported verbal form of sexual abuse (verbal harassment), 40% (95% CI 38.5–46.7) of them reported unwelcomed touch/body contact, and 27% (95% CI 24.3, 33.7) reported rape. 34% of sexual abuse was took place in the hotels, 19% in the perpetrator’s home, 21% in the survivors’ homes, and the rest in the field/ outside home.

The majority 55.0% of the rape victims didn’t report the case to anybody and only 21.0% disclosed their case to someone else, 10.3% reported to their friends, 3.7% reported to legal bodies, and 10% of them were reported to their parents. The main reasons for not reporting the incidence were 30.3% because of fear of perpetrators, 18.8% because of fear of their families, 30.7% because of fear of stigma, and the remaining 20.2% of them didn’t know what to do.

Psycho social, conflict related, behavioural, and clinical related factors

Regarding psychosocial factors, 167(40%) of participants had moderate social support and 186(44.7%) had family history of violence. Out of total 226(54.2%) of respondents were from internally displaced family and 84(20.1%) of respondents had history of current khat chewing. Concerning clinical characteristics, 79(18.9%) of participants had history of mental illness (Table 2).


Explanatory variables
Frequency (n) Percentage (%)
Social support    
Good 101 24.2
Moderate 167 40
Poor 149 35.8
History of childhood abuse    
Yes 145 34.8
No 272 65.2
Insufficient adherence to the code    
No 204 48.9
Yes 213 51.1
Family history of violence    
Yes 211 50.6
No 206 49.4
Lack of parental control    
  Yes 175 42.9
  No  242 57.1
Living with    
Alone 97 23.3
Both Parents 198 47.5
Single parents 87 20.9
Friends/relatives 35 8.3
 Internally relocated  family    
Yes 226 54.2
 No 191 45.8
Destruction of resources    
Yes 183 43.9
No 234 56.1
Prior history of mental illness    
Yes 79 18.9
 No 338 81.1
Medical illness    
Yes 96 23
No 321 77
Family history of mental illness    
Yes 88 21.1
No 329 78.9
Sexually abusive peer    
Yes 105 25.2
No 312 74.8
No household conversation    
Yes 234 56.1
No 183 44.9
Alcohol current use    
Yes 76 18.2
No  341 81.8
Khat current use    
Yes 84 20.1
No 333 79.9
Ciggarate current use    
Yes 25 5.9
No  392 94.1

Table 2.Psycho social, behavioral, Sexual and clinical related factors among female students in conflict affected setting, Ethiopia, 2022(n=417).

Outcome/health consequences of sexual abuse

Reproductive health consequences

Among the total of 166 sexual abuse survivors 31(18.7%) developed abnormal virginal discharge, 26(15.7) experienced unwanted pregnancies and 16(9.6%) underwent an abortion (Table 3).


Variables
Frequency(n) Percentage (%)
Psychological consequences    
Alcohol dependence 24 14.5
Post-traumatic stress disorder 47 28.3
Psychological distress 63 38
Suicidal attempt 17 10.2
Homicidal ideas 15 9
Poor educational achievement 76 45.8
Gynecological complaint    
Abnormal vaginal discharge 31 18.7
Chronic lower abdominal pain 8 4.8
Abnormal vaginal bleeding  29 17.5
Unwanted pregnancy  26 15.7
Sexual dysfunction 11 6.6
Abortion 13 7.8
HIV serological status positive  9 5.4
Others * 16 9.6

Table3. Outcome of sexual violence among female students in conflict affected setting, Ethiopia, 2022(n=166).

Psychological consequences

Out of a total 166 sexual abuse survivors, regarding mental health/ psychological consequences of sexual abuse like psychological distress, post-traumatic stress disorder, alcohol dependency, suicide, and homicide were reported about 38%, 28.3%, 14.5%, 10.2%, and 9% respectively, and 46% had poor educational achievement.

Factors associated with sexual violence

Family history of violence, a family that has been internally relocated, insufficient adherence to the code, no household conversation on health - related issues, and residing alone were significantly associated with sexual violence among respondents in multivariate logistic regression, with a p-value of 0.05.

The odds of having sexual violence among female students who Family history of violence were 3 times higher when compared to counterpart (AOR=3.01, 95% CI=2.66, 6.12). When compared to their counterparts, those who were residing alone were 3.57 times more likely to have sexual violence (AOR=3.57, 95% CI 2.06 to 6.19). When compared to counterparts, those who had no household conversation on health - related issues were 2.23 times more likely to have sexual violence (AOR=2.23, 95 % CI 1.29 to 3.87). The risk of sexual violence was 4.27 times higher in participants with insufficient adherence to the code practiced (AOR=4.27, 95 % CI 2.78 to 6.09). The odds of having sexual violence among participants from a family that has been internally relocated were 1.8times higher as compared to counterpart (AOR=1.8, 95% CI=1.97, 3.35) (Table 4).


Explanatory variables
Sexual abuse COR, (95% CI) AOR, (95%CI)
Yes No
Age
15-19 139 127 1.23(0.89, 7.61) 2.1(0.97, 4.01)
20 and above 71 80 1 1
Insufficient adherence to the code
No 42 162 1 1
Yes 113 100 5.13(3.95, 8.24) 4.27(2.78, 6.09)**
Internally relocated  family
Yes 76 150 2.11(1.95, 4.15)=1.5 1.8(1.97, 3.35)*
No 37 154 1 1
No household conversation on health
Yes
No 90 144 2.47(1.04, 4.63) 2.23(1.29, 3.87) **
37 146 1 1
Current alcohol use
Yes 18 58 1.22(0.88, 1.76) 0.68(0.44, 1.06)
No 69 272 1 1
Social support
Poor 60 41 2.05(1.02, 4.21) 2.17(0.84, 5.60)
Moderate 82 85 1.35(0.91, 2.07) 0.80(0.46, 1.41)
Strong 62 87 1 1
Living with
Alone 37 60 2.87(2.03, 5.31) 3.57(2.06, 6.19) **
With single parents 15 72 0.97(0.51, 1.86) 1.19(0.62, 2.26)
With friends/relatives 6 29 0.96(0.71, 2.19) 1.46(0.80, 2.68)
With both parents 35 163 1 1
Family history of violence
Yes 127 84 2.64( 1.75, 3.92) 3.01(2.66, 6.12)**
No 75 131 1 1

Table 4.  Bi-variable and multivariable binary logistic regression analysis showing association between factors and sexual violence among female students in conflict affected setting in south Ethiopia 2022(n=417).

Discussion

Sexual violence in the conflict affected setting is the major public health problem. In this study the proportion of female students who reported at least one form of sexual abuse was 166(39.7%) with 9 5% CI (37.1, 42.7). Out of total, 33% (95% CI 30.5-40.7) of participants were reported verbal form of sexual abuse (verbal harassment), 40% (95% CI 38.5-46.7) of them reported unwelcomed touch/body contact, and 27% (95% CI 24.3, 33.7) reported rape.

This findings is similar with study done in Nigeria,42.3%(36), Bahir Dar city, 37.3%(37), and Wolaita Sodo, 37.2 Similarly, the result in this study is higher than study conducted Addis Ababa 12.7% Haramaya 27.8% College women27%, Madawalabu 10.9%. Aletewondo, and Hawassa 14.3%. In contrarily, the result is lower than study conducted in Ethiopia 67.7%(36), higher education institutions of Ethiopia 49.4%(43), Northern Nigeria 58.8%(44), Gondar 35.1%(45), Bahir Dar 71.1%.(46), Debre Markos 57.3% Debrebrahan 54.9% and Awassa,59.9. The possible discrepancy could be socio cultural difference and study settings, previous study was conducted in out of conflict area, whereas, this study conducted in female students from conflict affected setting. Methodological differences like the study population difference (university female students, college female students and high school female students), regarding measurement, most of the previous studies used WHO gender based violence questionnaire, whereas in this study, Childhood Experience of Care and Abuse Questionnaire (CECA-Q) was used, and this could be another reason.

The risk of sexual violence was 4.27 times higher in participants with insufficient adherence to the code practiced. The normalization of violence, combined with rampant impunity, creates a favourable scenario for continuous violations of women’s rights. The persistence and exacerbation of violence are also explained in the context of the war against drugs, which has led to an expansion and normalization of extreme violence in general. The weakness of the State and the underlying impunity fostered a scenario in which women suffered not only from highly unequal conditions at work but also became more likely to be victims of crimes and human rights violations while the perpetrators of those crimes faced limited consequences. Sufficient adherence to the code and rule of law enables conditions in which violence flourishes.

The odds of having sexual violence among participants from a family that has been internally relocated were 1.8times higher as compared to counterpart. Displacement is significantly connected with both the recent year and lifetime prevalence of sexual assault. Displaced women are 9-10% more likely than nondisplaced women to encounter sexual violence at some point in their lives, and 6-8% more likely to have experienced it in the previous year. Each displacement related risk factor increases a woman’s risk of lifetime sexual violence by 6%t even after adjusting for other risk factors.

When compared to counterparts, those who had family history of violence were 3 times more likely to have sexual violence. Observing domestic violence can lead children to develop an array of age-dependent negative effects.

Research in this are has focused on the cognitive, behavioural, and emotional effects of violence. Children who observed violence in the home and children who are abused may display many similar psychological effects. Child witnesses display inappropriate attitudes about violence as a means of resolving conflict and indicate a greater willingness to use violence themselves.

No household conversation on health - related issues with their family and or friends has increased sexual violence almost 2.23 times. This finding was a consistent study at Wolaita Sodo University that showed that discussions of sexual issues with her partner reduced 74% of the risks of sexual violence. One of the ways that teenagers might postpone their first sexual experience or prevent sexual and physical assault is by having a conversation with their parents about sexual and reproductive health issues. Teenagers should be taught about the human reproductive system, issues around sexual and reproductive health, and acceptable family responsibilities.

When compared to their counterparts, those who were residing alone were 3.57 times more likely to have sexual violence. These findings are in line with the studies done among high school students in Arbaminch town, Ethiopia, in Harar, and southeast Nigeria and Dire Dawa. The answer could be that parents are more concerned about their daughter than their friends and relatives, which can reduce the likelihood of sexual abuse occurring to children who live with them [14].

Conclusion

High rate of sexual violence was found among conflict affected female students. Family history of violence, a family that has been internally relocated, insufficient adherence to the code, no household conversation on health - related issues, and residing alone were significantly associated with sexual violence among respondents. Therefore, the ministry of health, ministry of education and humanitarian organizations should work collaboratively in providing consistent school based psychosocial support and appropriate intervention for conflict affected students. Comparative and longitudinal study was recommended to other researchers to see the long term effect of sexual violence of conflict in recent conflict of north Ethiopia.

The Study's Strengths and Limitations

For first, this is the first research of its kind in Ethiopia, involving female students from conflict-affected areas. Second, it included crucial elements that had previously been left out of earlier research. The study's use of an updated, standardized, and validated instrument to measure the outcome variable was one of its strengths. The fact that only female students from south Ethiopian regions afflicted by violence were included was one of the limitations.

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Citation: Madoro D, Cherinet A (2023) Sexual Violence, its Outcome and Associated Factors among Female from Conflict Affected Setting, Ethiopia. Health Sci J. Vol. 17 No. 6: 1028