Prevalence and Associated Factors of Sexual Violence among High School Female Students in Dilla Town, Gedeo Zone SNNPR, Ethiopia

Sexual violence is any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work [1]. The term violence against women includes forms of violence such as sexual partner violence and non-sexual partner violence [2]. It was found that 0.3% to 12% of women respondents reported being forced to have sex or to perform a sexual act that they did not want to by non-partners since the age of 15 years [3]. In rural Tanzania, 47% of ever-partnered women have ever experienced physical violence by an intimate partner, while 31% have ever experienced sexual violence. In rural Ethiopia, 49% of ever-partnered women have ever experienced physical violence by an intimate partner, rising to 59% ever experiencing sexual violence [4]. Violence against girls takes many forms including rape, sexual harassment, intimidation, teasing and threats [5,6]. Rape now carries the additional danger of HIV infection. Girls are the first to be taken out of school as families are affected by HIV/AIDS [6]. Abstract


Introduction
Sexual violence is any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person's sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work [1]. The term violence against women includes forms of violence such as sexual partner violence and non-sexual partner violence [2]. It was found that 0.3% to 12% of women respondents reported being forced to have sex or to perform a sexual act that they did not want to by non-partners since the age of 15 years [3].
In rural Tanzania, 47% of ever-partnered women have ever experienced physical violence by an intimate partner, while 31% have ever experienced sexual violence. In rural Ethiopia, 49% of ever-partnered women have ever experienced physical violence by an intimate partner, rising to 59% ever experiencing sexual violence [4]. Violence against girls takes many forms including rape, sexual harassment, intimidation, teasing and threats [5,6]. Rape now carries the additional danger of HIV infection. Girls are the first to be taken out of school as families are affected by HIV/AIDS [6].
Women are significantly more likely than men to be perpetrated of dating violence during young adulthood (38% vs. 19%). Based on the World Health Organization's report, the rate of violence against women is as following, Eastern Mediterranean countries (37%), and African countries (36.3%) American countries (29.8%), European countries (25.4%), Western Pacific (24.6%) and other countries with high salaries (23.2%) [2,7]. Level of education, economic freedom of women, men communication with their wives, the male dominated society, the physically stronger nature of men, presence of alcohol or drug use, unsatisfactory income level, and witnessing domestic violence to their mothers during childhood [8,9].
Sexual violence is an extreme restriction of the sexual and reproductive autonomy of women [10]. Although it is largely hidden by the victims, it is estimated that 12 million people around the world face sexual violence every year. Young people are the most frequent victims of sexual violence; it is generally thought that 12% to 25% of girls and 8% to 10% of boys fewer than 18 years of age will suffer sexual violence [11]. Therefore, assessing and showing the significance of violence against girls at school institutions might be important to enforce policy makers and different stakeholders to integrate this problem.

Study Design, Area and Period
Institution based cross-sectional was conducted on high schools students in SNNP regional state, Dilla town from April to March 2015 G.C. Dilla town is the center of the Gedeo zone. The town is located 359 kilo meter distance far from Addis Ababa in the southern part of Ethiopia. Dilla has an estimated total population of 209,000, of whom 107,000 were males and 102,000 were females. There are three public high schools and three private high schools in the town in 2015. Trade is the main source of income of the residents.

Sampling Size Determination and Procedure
It was determined by Level of significance (0.05), Power (0.50) with z= 95% confidence internal and by considering assumptions of (p= proportion of prevalence) sexual violence among high school students in Ethiopia was 25% from the study done in Harare region [7], Then by adding 10% of non respondents and adjusting of the sample size since (n < 10,000), thus total sample size for this study is 280. A series of sampling methods was used to achieve actual study subjects. The stratified sampling proportional to size allocation method used based on their grade (9 th -12 th ). Finally a simple random sampling technique was applied to select actual participants by using their alphabetical registration numbers/roster as sampling frame. Finally the study subject was selected using proportional allocation in each class.

Data collection instruments and collection technique
The self-administered questionnaires was prepared in English and then translated into Amharic and back to English to ensure its consistence of translation by experts. The questionnaire was developed by adapting other questionnaires previous similar studies materials and review of relevant literature.

Data quality control issues
Data quality control issues was insured by conducting the pretest prior to the actual study period on 5% of the students from the total sample study subjects on the other high school students in Yirgachefe town. It was also insured by giving training for the facilitators as well as strict and regular supervision at the period of data collection.

Data processing and Analysis procedures
First the data was checked for completeness and consistency. Then it was coded and entered in the computer using EPi data software. Then, data was analyzed by using SPSS version 21.0. Descriptive statistic was used to explain the study participants in relation to study variables. A Bivariate analysis was performed to determine the effect each of factors on the outcome variable. Only factors with p.value <0.2 on Bivariate analyses were kept for multivariate analyses and a p value of < 0.05 on multivariate analyses was considered as statistically significant.

Ethical consideration
Ethical clearance or approval was obtained from school of graduate studies of Addis Ababa University and then by Institutional reviews board of the University. Permission was obtained from schools directors. Informed consent would obtain from each participant. Privacy and confidentiality of the information was keep and assuring in secretly by excluding names for identification in the questionnaire. The study variable would have the right to refuse and withdrawal from this study at any time. Individuals must understand the nature of the study and possible implications. The rights of individuals must be protected. Coercion and deception must be avoided at all.

Socio-Demographic Characteristics
A total of 280 female students participated in the study with 97% response rate. Based on the sample size determined, among the total respondent students 104 (38.1 %) from 9 th grade, 72 (26.4 %) from 10 th grade, 55(20.1%) from 11 th grade and 42(15.4 %) from 12 th grade have participated in the study (Table  1). The minimum age of the respondents was 14 years and the maximum was 21years and the mean age of the respondent's was 16 years. Among the total respondents, the predominant religion was protestant 116(42.5%) and also the predominant ethnic group was gedeo 114(41.8%) of the respondents. Majority 266 (97.4%) of the respondent were never married. 263(96.3%) of the respondent usual place of residence was in Dilla town. Regarding current living condition, 219 (80.2%) were reported to live together with both parents and 5 (1.8%) of the respondent were living alone (Table 1).

Family History of the Respondents
From 273 of the respondents 115(42.1%) of their father educational level were certificate and above. But majorities of the respondents father educational level was only grade 12 th completed, from this parents 33(12.1%) was illiterate. Majority 116(42.6%) of the respondents mother educational level was up to 8th grade completed, 64(23.4%) had certificate and above and 43(15.8%) of the respondents mother was they cannot read and write (Table 2). From 273 of the respondents majority 201 (73.6%) of the students both parents had live together, 28(10.3%) of the respondents parent were divorced, 34(12.5%) of the respondents only mother alive 10(3.7%) of the respondents were father only alive. More than half 147 (53.8%) of the respondents family income was between 1000 and 2500birr in month and 86(31.5%) of the respondents family income were less than one thousands birr in month. However from those study participants majority 186(68.1%) of the respondents had get enough pocket money from their family, 87(31.9) of the respondents had not get enough pocket money from their family. Regarding to family relationship 41 (15%) of the respondents watch their mother beaten by her husband and majority 232(85%) of the respondent's mother had not beaten by her husband (Table 2).

Factors Associated with Sexual Violence against Female Students
In the study alcohol drinking, chat chewing and use illicit drug is the main factors that exposed students to sexual violence. From 273 study participants 198(72.5%) of the respondents were not drink alcohol, 75(27.5%) of the respondents drinking alcohol. From the respondents who had drinking alcohol majority 29(38.7%) of them drink alcohol at least once or twice a week, 23(30.7%) drink occasionally less than once in a month, 21(28%) of the respondents drink alcohol two up to three times in a month and 2(2.7%) of the respondents drink alcohol every day (Table 3).
Chat chewing was one of the factors associated with sexual violence in this study, from 273 study participants 34(12.5) of the respondents use chat and majority 239(87.5%) of the respondents were not use chat. From the respondents who was using chat 2(2.7%) of the respondents using chat daily, 17(50%) of the respondents uses chat at least once or twice a week, 10(29.4%) of the respondents uses chat one up to three times in a month and 5(14.7%) of the respondents use chat occasionally less than once in a month (Table 3).
Substance use, from 273 study participants 21(7.7%) of the respondents had use drug or substance, majority 252(92.3%) of the respondents had not uses drug or substances. From the respondents who had uses drug or substances, 1(4.8%) of the respondents uses drug or substances daily, 2(9.5%) of the respondents uses drug or substances at least once or twice a week, the majority 12(57.1%) of the respondents uses drugs or substances one up to three times in a month and 6(28.6%) of the respondents uses drug or substances occasionally less than once in a month (Table 3).

Sexual History of the Respondent
From the 273 total study participant majority 219(80.2%) of the respondents had no regular boyfriend currently, 54(19.8%) of the respondents had regular boyfriend currently. In addition from 273 study participants 64(23.4%) of the respondents had sexual relation, and the rest 209(76.6%) of the respondents had no sexual relation (Table 4). From those who had sexual relationship the highest number 21(33.8%) of the respondents condition of start sexual intercourse was by peer pressure, the second highest number 18(27.7%) of the respondents condition of starting sexual relation was by personal interest, 11(16.9%), 5(7.7%), 5(7.7%) and 4(6.2%) by marriage, for passing examination/for mark, by forcing against me, or financial purpose was the reason or condition of starting sexual relation respectively. In addition from those respondents who had sexual relation most 44(67.7%) of them had sexual relation before the age of 17, 20(30.8%) of the respondents had sexual relation between the age of 17 and 19, only 1(1.5%) had sexual relation above the age of 19.there for almost all of the respondents who had sexual relation they start sexual relation before the 19 years (Table 4).
Concerning to sexual harassment from the total study participants 61(22.3%) of the respondent had faced unwanted sexual act like talking unnecessary words and the majority 212(77.7%) of the respondents had not faced unwanted sexual act. Moreover from total study participants 65(23.8%) of the respondents had facing unwanted kiss, 208(76.2%) of the respondents had not facing unwanted kiss. On the other hand from 273 study participants 50(18.3%) of the respondents had facing unwelcome touching of body parts likes breast, hair and majority 223(81.7%) of the respondents had not facing unwelcome touching of body parts (Table 4). Regarding to forced sexual attempt from 273 study participants 46(16.8%) of the respondents had encountered forced sexual attempt but they escaped from that sexual violence by different means; 12(36.4%) of the respondents escaped by shouting resulting to arriving somebody, 8(24.1%) of the respondents were escaped from that sexual attempt by hiding them self from that person/attackers, 6(18.2%) of the respondents were escaping from that sexual attempt by taking a defensive measure and fighting against the attacker, 7(21.2%) of the respondents was escaped by giving false promise word from sexual attempt and the majority 227(83.2%) of the respondents were had not facing forced sexual attempt (Table 4).
Surprisingly from 273 study participants 36(13.2%) of the respondents had encountered sexual violence, most of the victim students 16(50%) of the respondents was victimized in hotel, 6(18.8%) of the respondents was victimized in their home, 6(18.8%) of the respondents was victimized in school and the rest 4(12.5%) of the respondents was victimized in perpetuators home and also 237(86.8%) of the respondents were had not encountered forced sexual intercourse, in addition to that from the respondents who was encountered sexual violence majority 31(86%) of the respondents violence is made by frightened by using different sharp material (Table 4).
Concerning to the time of sexual violence from those who encountered sexual violence more than half 19(59.4%) of the respondents were victimized in day time and 13(40.6%) of the respondents were victimized in night time. In addition from the respondents who had sexual violence majority 17(50%) of the respondents had faced two times in their life time. Moreover most 9(28.1%) of the students encountered sexual violence by unknown person and majority 22(68.8%) of the students sexual violence was done by older men compared the female students age (Table 4).

Factors Associated With Sexual Violence
The likelihood of experiencing sexual violence in their life time was higher among those students who uses drugs or substances than students who didn't have using drugs or substances, (OR=5.103, 95% CI; 1.174, 22.188), (Table 5). In this study using drugs or substances had significant association with sexual violence (p-0.030) ( Table 5). Among the female students, the odds of life time experiencing sexual violence was higher among those students who had using chats than those who had not using chat (OR=15.099, 95% CI; 3.735, 61.038), (Table 5).
Using chat was one of the major significant variables that related with life time sexual violence. Therefore using chat was the main associated factors of sexual violence (p-0.000) ( Table 5). The likelihood of experiencing sexual violence in their life time was higher among those students who had a habit of taking alcohol than those who didn't have a habit of alcohol intake. (OR= 1.579, 95% CI; 0.450, 5.541)( Table 5). And the chance of experiencing life time rape was higher among those who were having a low income family than those who had medium and higher income of family (AOR-0.912, 95% CI=0.227, 3.667) ( Table 5). From the respondents who had not getting enough amount of pocket money was more exposed than those who had getting enough amount of money (AOR= 1.303, 95% CI, 0.430, 3.953) ( Table 5).

Sexual factors associated with sexual violence
According to the result of this study from the respondents who had regular boyfriend currently (AOR-1.009, 95% CI 0.212, 4.806) was highly exposed to sexual violence than those who had no regular boyfriend currently. In addition in this study from the respondents who had sexual intercourse was significant association with sexual violence (p=0.010) and the odds of the respondents (AOR-5.760, 95% CI -1.517, 21.871) this value indicates that from the students who had sexual intercourse has around six times risk of exposure to sexual violence than those who had not sexual intercourse. Tables 5 & 6 the odds of female students who had encountered unwanted sexual act was (AOR 1.860, 95% CI 0.319, 10.856) this result indicates that the students who had face unwanted sexual act was two time exposure risk than those who had not face unwanted sexual act. From the respondents who had encountered unwelcome touching of their body part had sixteen times risk to sexual violence than those who had not facing unwelcome touching of body part and in addition to that unwelcome touching of body part was significant association with sexual violence(p=0.004).Moreover in this study facing sexual attempt was significant association with sexual violence with a p-value of (p-0.009) and the odds of the respondents who had facing forced sexual attempt was (AOR-9.426, 95% CI(1.757, 50.568) this indicates that nine times risk than those who had not facing forced sexual attempt. Below the Figure 1 shows that the mechanisms of female students how was escaped from sexual violence attempt, majority of 36.36% of the respondents escaping by shouting, 24.24%, 18.18%, and 21.21% of the respondents was escaped by hiding, by fighting and by giving a false hope respectively. Figure 1: Indicates the distribution of female high school student's mechanism of escape from sexual violence attempt.

Discussion
The study assessed as the life time prevalence rate of sexual violence among female high school students was 13.2% when compared to studied conducted in Harare shows that Sexual violence among in school adolescents were 25% [7,12] and a study conducted in Bahir Dar town among private college female students revealed that the prevalence of sexual violence among female college students was 37.3% [13]. And also in this study had a lower prevalence rate than the study of Harare and Bahir Dar town. In addition to that a cross sectional study conducted in Iran indicates that the prevalence of sexual violence against women was found to be around 63.8%. Regarding two factors associated with sexual violence in this study using chat is one of the important contributing factors for sexual violence of school students in Dilla town (p=0.000) ( Table 5) and in the other hand using drugs or substances like shisha had significant association with sexual violence with (p=0.030). When I compared with other past study on sexual violence, a study conducted in Harare revealed that students used addictive drugs like alcohol (18%), chat and shish (7.2%) as very important contributing factors for sexual violence's [7,12]. Also this study finding supports my study findings.
Furthermore a study done in eastern Ethiopia with a multivariate analyses revealed that high-rejection sensitivity, having multiple sexual partners, the frequent watching of pornography, and use of alcohol or other soft drugs (chat or shisha) are factors associated with higher levels of sexual violence victimization. On the other hand a study conducted in china indicates that, students who had sexual intercourse, drug use (odds ratios [OR, 2.44), attempted suicide (OR, 2.30), physical abuse (OR, 1.74), binge drinking (OR, 1.62), verbal abuse (OR, 1.29), experience of being drunk (OR, 0.68), and smoking of cigarettes (OR, 0.52) were related to a history of sexual coercion [14][15][16][17][18][19].
In addition a study in Brazil indicates that the prevalence of violence against women was 27.5%. The associated factors for sexual violence were low level of schooling (OR = 2.34), a history of domestic violence (OR = 2.21) the woman being mentally disturbed (OR = 2.35), and the partner's consumption of alcohol (OR = 1.77) (16). This finding is also having some similarity with the study explored. Findings of this study revealed that family income was one of the associated factors of sexual violence among female high school students (AOR =0.912, 95% CI 0.227, 3.667) those students who had low amount of income of family was had more experienced sexual violence than those who had medium and higher income family. A study conducted in Nigeria indicates that most of violence was associated with economical reason; the prevalence of violence against women (VAW) six months preceding the survey was 52.5%. Sexual violence was the commonest type (41.9%) of violence experienced, followed by economic (37.7%), physical violence (35.7%) and psychological (31.9%) [19].
According to this findings from the respondents who had sexual intercourse was significant association with students exposure to sexual violence (AOR=5.670, 95% CI 1.517, 21.871, p-0.010) five times more likely exposure to sexual violence than not had sexual intercourse. The same study conducted in Nigeria indicates that sexual violence was significantly more experienced (AOR 2.23; 95% CI 1. 15-4.36) by older female sex workers (FSWs) than their younger counterparts, by permanent brothel residents (AOR 2.08; 95% CI 1.22-3.55) and among those who had been in the sex industry for more than five years [17]. Also this findings helps to conclude that females who had on sexual relation more likely vulnerable to sexual violence than those who had not sexual relation.
The result of these findings indicates that from the respondents who had unwelcome touching of body part was more likely vulnerable to sexual violence than those who had not unwelcome touching of body part. Other study conducted in Harare indicates that females dressing style, their act, peer pressure, revenge and males emotionality identified as contributing factors for sexual violence [7,12].
According to this study from the respondents who had boyfriend/partner was more likely vulnerable to sexual violence than those who had not have boyfriends or partners(AOR=1.009, 955 CI 0.212, 4.806, p=0.991) may the violence made by their partner. Also this findings had supported by a study conducted by WHO multi countries study against women the prevalence of partner violence nearly one half (49%) of ever-partnered women experienced physical violence by a partner at some point in their lives, and 29% during the past 12 months. 59% of ever-partnered women experienced sexual violence at some point, and 44% during the past 12 months. Combining the data for physical and sexual violence, 71% of ever-partnered women experienced one or the other form of violence, or both, over their lifetime [12].

Conclusion
Prevalence of sexual violence still is high among female high school students in Dilla town. Life time experience of sexual violence was significantly associated with the income of their family, using of drug or substances and habit of taking alcohol and chat.

Authors' contribution
Desalegn Tarekegn conceived and designed the study and collected data in the field, performed analysis, interpretation of data, and draft the manuscript. Mr. BalchaBerhanu and Mr yigrem Ali involved in the design, analysis, and interpretation of data and the critical review of the manuscript. All authors approved and read the final manuscript.