Associated factors of sexual and gender based violence among female high school students in Debre Markos Town, North West Ethiopia: an institutionally based cross-sectional study

Background: Sexual and gender based violence (SGBV) continues to be a concern of health, sexual and reproductive rights, sustainable peace and development issue that cuts across boundaries, cultural backgrounds and socio-economic groups to touch individuals of every sort around the world. SGBV remains one of the greatest inequalities of our time that takes life, violates the right they are entitled with, and seriously endangers women and girl’s mental and physical wellbeing, as well as sexual and economical security. This study aimed to assess the prevalence and associated factors of sexual and gender based violence among female high school students in Debre Markos Town, North West Ethiopia:. Methods: An institutionally based-cross-sectional study was conducted among 309 randomly selected female high school students in Debre Markos Town. Data was collected using self- administered questionnaire. Data was analyzed using multivariate logistic regression with odds ratio and 95% condence interval to identify factors associated with sexual and gender based violence. Statistical signicance was declared at p-value < 0.05. Results: The lifetime prevalence of GBV, sexual violence, and physical violence were found to be 47.0, 23.3, and 39.5%, respectively. The prevalence of sexual violence in the current academic year was 13.2%. Ever drink alcohol (AOR = 0.39; 95% CI: 0.18–0.86), have friends using substances (AOR = 0.26; 95% CI: 0.09–0.82), Grade level (AOR = 3.15; 95% CI: 1.32–7.48), witnessing parental conict (AOR = 0.29; 95% CI: 0.17–0.52), ever discuss gender related issues (AOR = 2.23; 95% CI: 1.31–3.78) and living condition of students (AOR = 3.53; 95% CI: 1.55–8.07) were signicantly associated with gender-based violence. Conclusion: The prevalence of sexual and gender-based-violence was high. This needs further intervention like awareness creation at school and community settings should be strengthened.


Background
By de nition, any act of violence that results in, or is likely to result in physical, sexual, and psychological abuse regardless of the place it occurs denotes Gender based violence (GBV). Worldwide, GBV remains a hidden pandemic with the deepest expression of human rights abuse. It continues to be a concern of health, sexual and reproductive rights, sustainable peace and development issue that cuts across boundaries, cultural backgrounds and socio-economic groups to touch individuals of every sort around the world [1].
Being a good example of violence against women and girls (VAWG), gender based violence (GBV) is a typical and often invisible re ection of unequal gender relations in society. It is also a violation of human rights and an enemy of gender equality [2][3][4]. The cause of this violence is embedded in enriched harmful gender norms, attitudes, gender-based inequalities and discrimination. The status that girls and women have in the community together with the societal norm which supports men's superiority over women urges girls to tolerate and accept any forms of violence practice. On top of very undesirable sexual and reproductive health outcomes, such kind of violence and related pressure makes a woman to give less value for herself, societal image she expects, eventually lead her to feel a woman with no contribution and something to say [3,5].
In 2013, 1 in every 3 women had been beaten, faced forced sex or abused in different way mainly by a person they knows [6], while additional evidence in 2014 revealed that 1 in 5 women is sexually abused as a child [7]. In light of its public health importance, GBV remains one of the greatest inequalities of our time that takes life, violates the right they are entitled with, and seriously endangers women and girl's mental and physical wellbeing, as well as sexual and economical security. In this way, it denies their pursuit of enjoying fundamental freedoms for equality, humanistic respect and self-worth [8].
Through non consented and coerced sex as well as sexual assault, women's particularly adolescent girls face the risk of unwanted pregnancy and become vulnerable for sexually transmitted infections like HIV/AIDS. Furthermore, women and adolescent girls are at considerable risk of unforgotten psychological impacts including depression, intense stress, lowered self-worth, post-traumatic disorders, sleep disturbance and di culty in concentration, loneliness, and withdrawal [9]. Subsequently, the added health and psychosocial effect of the violence would negatively impact girl's educational performance and meaningful involvement in development. This is because the harm they face mentally make women and girls no to be creative in ideas and thereby limit their potential to devote their labor in development works [10].
In a traditional society who is tolerant of and has acceptance for harmful violence practice, efforts to prevent the situation takes time [11]. Accordingly, varied forms of gender based violence events occur in different settings, situations and population segments with a considerable undetermined impact on the health of adolescent girls. Adolescent girls in SSA suffered a lot from the unplanned and non-consented sexual exposure they have made. This forced nature of sexual relation puts adolescent girls' at marked risk of sexual start at earlier age, sexual act against will, engagement in transactional sexual relations, and non-use of condoms [12,13].
In Ethiopia, gender based violence has been a growing concern for a long time. It has mostly affected women and girls making it very di cult for them to participate in developmental activities at family, school and community levels. GBV is becoming one of the most triggering issues in the face of the spread of HIV infections throughout the country on one hand and the physical, social and psychopathological impact on the other. The many aspects of girls' and women's life in Ethiopia are characterized by low status. Since their teenage years, an imposition of tiresome and tedious workload, family arranged and early marriage in the absence of informed choice leave girls and women with a little chance for making and acting on their own decisions [14].
Girls and women in the country are challenged with persistent and varied harmful traditional practices (HTPs), another dangerous abuse. Above 60% women of all ages were undergone to female genital cutting (FGC) with a signi cant health, social and psychological risks. For instance, nearly seventy percent of massive life-threatening bleeding after delivery in women is secondary to FGC and the same problem contributes for more than fty percent of death among their babies. Despite the associated long lasting impact, unknown justi able causes, unexamined societal reasons and higher prevalence, the practice shifts its nature, tend to be persistent and eradication seems di cult [15,16]. Another important HTP existed in such conservative hierarchical society of Ethiopia is early marriage. It affects the physical and mental health of women and in question to stay in school and future economic generation dream. The practice has made girls to be a parent at teenage years through bearing a number of children with short period of time while they are unprepared mentally, economically and how to run a family [17].
Precise estimates on the burden of VAWG are di cult to come across in Ethiopia. Yet, the existed anecdotal and fragmented pieces of information from media reports point to an alarming picture of the increase in vulnerability of young girls and women in the country. In Ethiopia, earlier studies revealed that the lifetime prevalence of violence among women was 50-60% and the most common type of violence reported was sexual violence with the primary perpetrators were intimate partners and close family members [18]. The magnitude of sexual, physical, and psychological violence reported among women at some point in their lives was 59%, 46% and 71% respectively [19]. Based on another study conducted in central Ethiopia, seventy four percent of female high school students reported sexual harassment and around eighty ve percent of rape survivors were less than 18 years of age. Of the girls raped, twenty four percent had symptom suggestive of STI and nearly twenty percent were pregnant [20].
There are different factors at the individual, household, community and society level that signi cantly in uence the greatest rates of sexual and gender based violence among adolescent's girls. Societal level factors such as harmful gender norms and attitudes that acknowledge male dominance, unreasonable social norms, low societal sanction against perpetrators and others like poverty, increased criminal acts and con ict situations in society are among the important risk factors [21,22]. In Ethiopia, among the many contributors of GBV are: culture, harmful traditional practices, poverty, and low level of community awareness [23][24][25].
Given that GBV is linked to gender-based power inequalities, violation of human rights, poverty, poor sexual and reproductive outcomes mainly spread of HIV, the best step in responding and preventing GBV is an attempt to ensure gender equality and transform discriminatory gender norms. In addition, enforcement in the area of legal and policy platforms has a role since actions to ll the existed gap in what the law says and the practice in ground. Further, timely responding for violence survivors, in a way that ful lls the rights they entitled with including personal security and access to services, like basic needs and healthcare services, is again crucial [26,27]. Nevertheless, in the current times even a gap in understanding and practices, and poor SGBV report mechanisms. Also, the legal enforcement system is insu cient, irregular and non-uniform coupled with deep rooted cultural acceptance and useless traditional view given for the practice were additional reinforcing factors for GBV existence and its persistency [28].
To the best of our knowledge, evidences related to school related gender based violence especially in high school settings in Ethiopia is scarce. Further, some of the factors suggested to be associated with GBV are not explicitly adjusted in different previous studies. In light of this, it is relevant to investigate and document the prevalence and multifaceted factors linked to gender based violence. Therefore, this study aimed to determine the prevalence and identify factors associated with gender-based violence among female students in Debre Markos, Ethiopia.

Study setting and population
An institutionally based-cross-sectional study was employed among high school female students in Debre Markos, Ethiopia. Debre Markos is the administrative capital city of East Gojam zone in Ethiopia, which is found at 299 KM of North of Addis Ababa, the capital city of Ethiopia and 255 KM East of Bahirdar, the capital city of Amhara region. Based on the 2007 national census reports, it has the estimated population number of 62,497. There are four high schools in the town [29]. The study was conducted between May 2018 and June 2018.
Sampling size determination and sampling procedure A sample size of 309 female high school students was calculated using a single population proportion formula with a 95% con dence level, 5% margin of error, and prevalence of GBV/ sexual harassment among female high school students in Addis Ababa as 75.9% (39) and by considering a non-response rate of 10%. Strati ed random sampling technique was used to select the study participants. First, female students were strati ed by grade level as grade nine and grade ten. Proportion to population size sampling was used to allocate the students to their respective grade level. Then, systematic sampling technique was applied to select students using students' roster (name list) as a sampling frame. The total students (age > 15 years) in each grade were divided by the allocated sample size for each grade to nd the interval (K) and the 1st female student in each class was selected randomly using the lottery method Data collection instruments Data were collected using structured, pre-tested and self-administrated questionnaire which was adapted from previous published studies [30][31][32]. Four well trained grade twelve completed students who know the local language and culture were participated in the data collection activity. They helped in seating students in the classrooms designated for completing the survey and provided explanation on the study procedures and tools. They were also ensured complete privacy during completing questionnaire. The questionaries' was developed in the English language and then translated to Amharic language and back to the English language to ensure convenient information was obtained. A pre-test study before the actual data collection was done at Dibiza high school students and some modi cation in the questionnaire was made based on the feedback taken from the pretest.

Data processing and analyses
Data were double entered and cleaned in EPI data software version 3.1 to cross check the data for completeness before analysis. The entered data were exported and analyzed with SPSS version 22.
Descriptive statistics, tables, graphs, means, and frequency distribution was used to present the information. Bivariate and multivariate logistic regression with odds ratio along with the 95% con dence interval were used to ascertain the association between associated factors and the dependent variable. Pvalue < 0.05 was considered for statistical signi cant.

Results
Socio-demographic characteristics of high school female students A total of 296 out of 309 students were participated in the study giving a response rate of 95.8%. The mean age (+SD) of the study participants was 16.89 ± 1.4 years. Of 296 students included in the study, Most (92.2%) were Orthodox religion followers. Among the respondents; 196 (66.2%) were grown in an urban setting, 248(83.8%) were living with their parents, 61.1% had tight family control and 98 (33.1%) had a pocket money (Table 1). The lifetime history of chewing chat, smoking cigarette/tobacco, and drinking alcohol was reported by 45.45%, 4.5%, 13.9% of the respondents respectively and 22 (7.4%) respondents reported that they have a close friend who used substances.

Sexual experiences
Of the total 296 students, 11 (3.7%) had started sexual intercourse and 8 (72.2%) reported that they practiced sexual intercourse without their will. The mean age (+SD) for having the rst sexual intercourse were found to be 16.4± 2.1 years and above 90% of respondents had one sexual partner. About 66 (22.3%) of respondents reported that they have witnessed violence as a child. More than half (50.3%) of respondents said that there is no free discussion with their family members on reproductive health and other gender related issues.
The prevalence of GBV  The lifetime prevalence of sexual violence among female students was found to be 23.3%, while forced sexual violence before joining high school, since joining high school and the current academic year was reported 6 (2%), 12(4.1%) and 9(3%) respectively. Similarly, 9 (3%), 7(2.4%) and 6(2%) of respondents had faced unwelcomed touch before joining high school, since joining high school and the current academic year. Prevalence of sexual violence in the current academic year was 13.2%.

Discussion
The study assessed prevalence of gender based violence and associated factors among female high school students in Debre Markos town. The life time and current prevalence of gender based violence among high school female students in the current study area was found to be 47% and 23.6% respectively. The prevalence of life time physical and sexual violence was 39.5% and 23.3%. In addition, the prevalence of current year physical and sexual violence was found to be 13.2% and 17.6%. Other similar study conducted among female high school students in Butajira, Southern Ethiopia showed that the prevalence of life time physical and sexual violence was 15.5 and 35.5, and that of current year physical and sexual violence was found to be 35.2% and 19.1% [33]. Possible reason for such differences among the two studies could be due to the difference in socio demographic characteristics and the difference in time.
The current year prevalence of completed rape was 3% and that of attempted was 4% while the case of sexual harassment being 9.8%. In the above study completed and attempted rape were 2.5% and 10.7% respectively with sexual harassment of 15.4%. The ndings in both studies were comparable. Similarly a study on prevalence and factors related to sexual violence among high school students of Addis Ababa and Western Shewa, completed and attempted rape was 5.1% and 10.1% [20]. These ndings were also comparable with the current study ndings.
Major complications of physical violence were disgusting people 31.6%, temporary physical injury 13.7%, poor school achievement 11.1%, and school failure 0.9%. Family members 36.8% and students 27.4% were the common sources of physical violence among the respondents. Similar study among female students of Menkorer high school in Debre Markos town, Northwest Ethiopia showed common consequences of physical violence among participants were disgusting people, 40%, poor school achievement 29.3%, and school failure 14.6%. The most common individuals who committed physical violence were family members, 47.6%, followed by students 34.5% [31]. Findings of the current study were lower than the previous nding. This difference could be due to the differences in educational level and number of high schools included in the study. The current study includes all high schools in the town with educational levels of 9 up to 12, whereas the previous study includes only one high school with educational levels of 9 to 10.
Gender based violence (physical and/or sexual violence) was analyzed for possible association with the independent variables. Accordingly; drinking alcohol, having peers who used substances, living condition, educational status, witnessing marital con ict as a child and ever discus gender related and other reproductive health issues with family members were found to have an association with GBV. Findings like drinking alcohol, having peers who used substances and educational status were supported by study ndings from WHO world report on violence and health [3]. From factors associated with GBV: students who never drinking alcohol, did not had peers using substances and never witnessed marital con ict had a decreased risk by 39%, 26% and 29% respectively. Possible reason for this could be due violent behavior of students on the category of those who had peers using substances, impaired judgment of students who drink alcohol and behavioral impact of being witnessing marital con ict while child.
On the other hand students who never discuss gender related issues and not live close enough to their families were more likely to face GBV 2.23 times and 3.53 times respectively. The reason could be lack of awareness on consequences of gender related health issues and lack of family protection. Regarding educational status, students with 12th grade had 3.15 times more likely hood of GBV compared to those with 9th grade. Similarly those students in the educational level of 10th and 11th had 2.33 times and 1.49 times more likely hood of GBV. The possible reason could be due to being matured in age and sexuality makes the students to experience violent behavior.
The current ndings of alcohol drinking, having peers who ever used substances, living far from parents/guardian and ever discuss gender related and other reproductive health issues were documented in other similar study ndings in Ethiopia [20]. On other similar study conducted ve years back in the same area, never drinking alcohol had a decreased risk by 38% and witnessing violence as a child increase the risk 2.07 times [33]. In the current study never drinking alcohol decrease the likely hood of experiencing GBV by 45% and never witness violence as a child by 34% in this academic year. Possible reason for such a discrepancy could be due to time difference and subsequent intervention measures that could be taken throughout this time gap.

Conclusion
According to this study nding, Gender based violence is still a problem of female high school students.
But magnitude of the problem is decreasing compared to the previous similar studies.
The life time and current prevalence of gender based violence was found to be 47% and 23.6% respectively. Similarly the prevalence of life time physical and sexual violence was 39.5% and 23.3%. In addition, the prevalence of current year physical and sexual violence was found to be 13.2% and 17.6%. Major factors associated with Gender based violence in the study were ever drinking alcohol, having peers who used substances and educational level of students. The common consequences of physical violence were disgusting people, temporary physical injury poor school achievement and school failure.
Students have also reported several physical, psychological and social consequences of sexual violence and majority (92%) of the respondents did not share to somebody ales even when faced completed rape.
Awareness creation on Gender related issues and risk sexual behavior at school and community levels should be done for both students and parents. School teachers, parents and other stake holders in the legal system should identify and take corrective measures up on students who use substances. The importance of adolescent -parent communication on Gender related and other reproductive health issues should be advocated further on public medias. Further studies supplemented with focus group discussion recommended for better understanding of factors associated with GBV. After the objective of the study was explained, verbal consent was obtained from the school administration and both verbal and written consent was obtained from each participant. Moreover, privacy and con dentiality of information was strictly guaranteed by all data collectors and investigators. For students whose age was < 18 years, a written informed consent was obtained from their parents and/or guardians and an assent was obtained from each students.

Funding
No fund is obtained for this study

Authors' Contribution
All authors, Wassachew Ashebir and Abiot Ayichew conceptualized the research question, monitored and managed eldwork, analyzed and interpreted the ndings, and written the paper.