Sexual Coercion and Associated Factors among Female Students of Madawalabu University , Southeast Ethiopia

Introduction. Violence against women, in its various forms, is an important social and public health problem in different communities around the world. Although violence against women is against the inalienable human right and resulted in physical, sexual, and psychological harm or suffering to women, little has been documented regarding its factors and distribution among youth population such as university students. Therefore, the objective of this study was to assess factors associated with sexual coercion among female students at Madawalabu University.Methods. This was a cross-sectional institution based study conducted on 411 female students which were selected by systematic random sampling from the list of female students. Data were collected in April 2012 using structured-interview administered questionnaire. Descriptive, binary, andmultivariable logistic regression analysis were carried out using SPSS version 16. Result. In this study, the mean (±SD) age at first sex was 18.19 (+1.83) years. Lifetime and coercion in last twelve months were 163 (41.1%) and 101 (25.4%), respectively. Twenty-one (5.9%) of the respondents were raped. Being influenced/forced into unwanted sexual act 74 (18.6%) and having their genitalia/breast unwillingly touched 44 (11.1%) were reported as the commonestmechanisms of coercion. Age at first sex (17–19 years) (AOR=0.241, 95%CI: 0.074, 0.765) and occasional alcohol use (AOR = 4.161, 95% CI: 1.386, 12.658) were significantly associated with coercion in the last twelve months. Conclusion. The overall lifetime sexual coercion was found to be 41.1%. In this study 6.8% of female students were raped and majority have had trial of rape. But 93.75% did not report to any legal body. With the existing prevalence and identified factors, the university should work towards minimizing the risk of sexual coercion through intensifying life skill peer education and assertiveness trainings.


Introduction
Gender based violence (GBV) is a pervasive problem for most women all over the world [1][2][3].Violence against women, in its various forms, is endemic in all communities and countries around the world.It affects all race, age, religious, and national boundaries [1].According to the United Nations Declaration, violence against women includes any act of gender based violence that results in physical, sexual, and psychological harm or suffering to women, including threats or such acts as coercion or durable deprivation of liberty, whether occurring in public or private life [4].
Over the past 25 years, there is recognition of gender based violence under reporting.In addition, there are high prevalence and increased acknowledgment that it can affect women at any stage of their lives and can occur in various forms that may involve physical, psychological sexual, and/or economic abuse.Violence against women is a crucial violation of human right to liberty and freedom from fear, and now it is recognized as a priority public health and human rights issue [5].Abuse by intimate male partners and coerced sex were the most common forms of violence against women, whether it takes place in childhood, adolescence, or adulthood [6].This problem is more severe among young adolescents and could affect their health in different aspects including physical, mental, and social wellbeing of the victim.
Intimate partner violence and sexual violence are serious and widespread problems worldwide.In addition to violations of human rights, violence profoundly damages the physical, sexual, reproductive, emotional, mental, and social wellbeing of individuals and families [7].Sexual violence thus appears to be a major challenge of school life for many adolescent females in Ethiopia and elsewhere [8].
Sexual violence is the act of forcing (or attempting to force) a female through physical body harm or any means to engage in a sexual behavior against her will.Sexual coercion exists along a continuum, from forcible rape to nonphysical forms of pressure that compels girls and women to engage in sex against their will.In some forms of coercion a woman lacks choice and faces several physical or social consequences if she resists sexual advances.Around the world, at least one woman in every three has been beaten, coerced into sex, or otherwise abused in her lifetime [6].Much sexual coercion takes place against children or adolescents in both industrial and developing countries whereby between onethird and two-thirds of women that are sexual assault victims are young [9].The experience of sexual coercion leads to a greater likelihood of risky sexual behavior such as early sexual debut, many sexual partners, and inconsistent condom use.Alcohol increases the likelihood of sexual assault occurring among acquaintances during social interactions.These pathways include beliefs about alcohol, deficits in higher order cognitive processing, and motor impairment induced by alcohol and peer group norms that encourage heavy drinking leading to forced sex.Studies on sexual coercion in higher learning institutions/universities in Ethiopia are limited and the problem was not well studied.
The level of sexual coercion and its factors among female students were not studied in Madawalabu University.Therefore, this study tried to assess sexual coercion among female students and associated factors as a crucial step to improve sexual health of female students in Madawalabu University.The finding from this study can be used as a baseline for further studies and as an input for policy makers and program designers.Thus the general objective of this study was to determine the prevalence and consequences and assess factors associated with it among female Madawalabu University students in southeast Ethiopia.

Study Setting and Sample.
Institution based cross-sectional quantitative study was conducted in April 2012 in order to assess sexual coercion and its associated factors.The study was conducted in Madawalabu University that is located in Bale Zone, Oromia National Regional State, 430 km from the capital of the country, Addis Ababa, in the southeast direction.Madawalabu University is one of the public higher learning institutions established in Ethiopia in 2007.The university currently has two campuses (Goba and Robe).In the two campuses there were 3,211 regular students of which 2,484 males and 727 females were in the second year and above.The source population for the study was all female students registered in the 2nd year and above in the academic year of 2011/12.The study excluded all newly registered students that came from preparatory programs.
The study used a single population proportion to determine the sample size.The study considered a 41.8% proportion of sexual coercion that was used from a study conducted in Addis Ababa University female students [10] at 95% certainty and margin of error 0.05.Contingency of 10% was added to increase power and compensate for possible nonresponse.And the final sample size is 411 female students.The study follows the university's nine schools, one institute, and one college.Sample size for each school was distributed according to proportion of population female students.Sampling frame was prepared by taking a list of all second year and above students from the university registrar and alumni directorate office, and systematic random sampling was employed in each school to obtain a proportionally allocated number of participants from each school/college.

Measurement.
For meeting the objectives of the study the following variables were included.Dependent variable is sexual coercion including rape, assault, and harassment.The independent variables for the study wereage, previous residence, religion, ethnicity, year of study, parent marital status, student's marital status, family background including family income and money sent (provided by family member), previous sexual activity, history of coercion, and student habits (khat chewing, alcohol use, and/or smoking).
A structured questionnaire was prepared first in English and translated to Amharic and finally back-translated to English in order to ensure its consistency for selfadministration.The questionnaire was pretested in one of the departments of the university, which was not included in the study.Appropriate modification was made based on the findings of the pretest.
Data was collected by five diploma holder nurses who were trained for one day on the data collection process and the instrument for data collection.The principal investigators and two supervisors were assigned to lead the data collection, to check for completeness and consistency of a questionnaire, and to assist data collectors.Before data collection started, directors and student deans of the respective campuses and schools were approached using a letter written by the academic vice president.List of female students and selection of eligible students and questionnaire administration halls/rooms were arranged and prepared in these schools and colleges.The selected students were made to seat separately and the purpose of the study was well explained.Following a self-administered response to the questions, completed questionnaire was collected in a collection box.

Data Analysis.
Data were checked for completeness, sorted, entered, cleaned, and processed by Statistical Packages for Social Science (SPSS) version 16.Analysis of association for selected exposure variables was done with the outcome variables.Logistic regression was performed using SPSS version 16.The results were presented using figures, frequencies, proportions, odds ratio, and confidence interval.
In order to see the association between lifetime sexual coercion and explanatory variable, binary logistic regression was carried out.Those variables found to be statistically significant within the binary logistic regression model based on the COR and their  value ( < 0.05) were entered into the multivariable logistic regression model to come up with final predictors of lifetime sexual coercion with their respective adjusted odds ratios.
In the interest of common understanding the operational definitions of the following words and phrases are given.
Attempted rape: it is defined as a trial to have sexual intercourse without consent of the girl but without penetration of the vagina or anus or mouth.
Consequences of sexual coercion: they include social, physical, economical, educational, and psychological status of the victim women or girl after coercion.
Economic implication: sometimes parents are forced to take their daughter out of school because they are afraid of rape or girls drop out of school after being raped or abducted which results in improper education and unemployment or poverty.
Performed rape: it is defined as any nonconsensual penetration of the vagina or anus or mouth.It is done physically or by threatening of body harm, or when the victim is incapable of giving consent.
Physical consequences: raped victims reported problems of lacerations, pregnancy/abortion, and sexually transmitted diseases (STDs) and other injuries.
Rape: it is the act of forcing a female student through violent threats and deception to engage in sexual behaviors with penetration of the vagina.
Sexual coercion: it is the act of forcing (or attempting to force) a female student through physical body harm or any means to engage in a sexual behavior against her will.
Sexual harassment: it is unwanted sexual behavior such as physical contact or verbal comments, jokes, questions, and suggestions.

Results
Three hundred ninety-seven (96.6%) respondents completed the questionnaire administered.About two-thirds of the respondents, 242 (61%), were in the age group of 20-24 years and the mean age of the study subjects was 21.08 ± 1.40 SD; the majority, 358 (90.2%), of the respondents were not married.Two hundred twenty-four (56.4%) were Oromo ethnic group.More than half of the respondents, 255 (64.2%), were Orthodox; two hundred ninety-six (74.6%) were from urban areas and the majority of the respondents, 383 (96.5%), lived in the campus (Table 1).
The mean of the last semester cumulative GPA of the respondents was 2.78 ± 0.50 SD.One hundred thirteen (28.5%) of respondents' fathers' education levels were college/university.And eighty-two (20.7%) of mothers of study subjects were able to read and write.Two hundred sixty (65.8%) of respondents' mothers and fathers lived together and 12 (3.0%)did not have both mother and father.Threefourths, 297 (75.2%), of the respondents were living with their family (mother and father) before joining university (Table 2).
The mean age at first sex was 18.19 years ± 1.83 SD.One hundred ninety (47.9%) of the respondents had constant sexual partner.And 96 (24.2%) responded that they had had sex.Sixty-one (64.9%) of those sexually active had started sex in their late adolescent (17-19 years).About two-thirds, 62 (64.6%), of the respondents who were sexually active had started sex before joining university.Seventeen (50%) of the respondents who started sex after joining university started sex in the second year of their study.About one-third (36.8%) of the sexually active respondents started sex within marriage and 27 (28.4%)started sex by their interest (Table 3).
Thirty-six (9.1%) of the respondents were using any of the substances always.Among the substances used were alcohol 23 (5.8%), khat 11 (2.8%), hashish 6 (1.5%), cigarettes (2.3%), and others 13 (3.3%).Eighty-eight (22.2%) of the respondents were using different substances sometimes.The substances Lifetime coercion for the study subjects was 163 (41.1%).The mechanisms of forcing were by influencing them in unwanted sexual acts 121 (30.5%), having their genitalia/breast unwillingly touched 86 (21.7%), having faced trial of rape 20 (5.0%), being forced into sex 13 (3.3%), and using force for sex by frightening 8 (2.6%).In the past twelve months 101 (25.4%) of the respondents were coerced.The mechanisms of coercion were being influenced to unwanted sexual act 74 (18.6%), having their genitalia/breast unwillingly touched 44 (11.1%), having faced trial of rape 10 (2.5%), and being forced into sexual act 8 (2.0%).As a result of coercion the study subjects experienced frequent headache, poor appetite, sleeplessness, fear, selfblaming, blaming others, loss of self-value, the thought of coercion as end of life, the thought of death as being better than being coerced, and other consequences.
From the total study subjects 27 (6.8%)had faced rape and nearly half (48.1%) of the rape was committed in the perpetrators' home.The time of rape was in the afternoon 12 (44.4%),evening 11 (40.7%), and early morning 4 (14.8%).Surprisingly, only 2 (6.25) of the victims of rape reported the event to legal bodies (Table 4).Boyfriends account for the highest percentage of perpetrators followed by brother's friend and neighbors (Figure 1).Following rape attack eight (28.6%)became pregnant; four (14.3%) faced abortion; six (21.4%) faced genital trauma; six (21.4%) experienced unusual vaginal discharge; four (14.3%) developed genital swelling; and four (14.3%) suffered from other problems.
For 14 (51.9%) of rape victims the way of forcing was beating them (physical force).Moreover, nine (32.1%) were raped after they were given alcohol.Fifty-six (49.1%) of the mechanisms used to escape rape were by cheating with false promise.Seventeen (47.2%) of the victims of rape did not report the event to anyone.Fear of families was the main reason for not disclosing rape 12 (48.0%),followed by not knowing what to do 7 (28.0%)(Table 5).
In order to see the association between lifetime sexual coercion and explanatory variable, binary logistic regression was carried out.Those variables found to be statistically significant within the binary logistic regression model based on the COR and their  value ( < 0.05) were entered into the multivariable logistic regression model to come up with final predictors of lifetime sexual coercion with their respective adjusted odds ratios.

Discussion
This study identified sexual coercion and its associated factors.The lifetime prevalence of coercion in this study was found to be 41.1%.This finding was less than the finding in Uganda, 31.1% (94), but very much less than prevalence of sexual harassment in high schools of Addis Ababa [2].This difference could be due to the difference in the setting of the study area [11].
The study tried to show the forms of coercion as physical, sexual, and psychological.As a result of coercion the study subjects experienced frequent headache, poor appetite, sleeplessness, easy fear, self-blaming, blaming others, loss of self-value, the thought of coercion as end of life, equating of coercion to death, and other consequences.These were also the consequences identified in Addis Ababa University [10].The perpetrators of sexual coercion were relatives, husbands, teachers, strangers, boyfriends, and health professionals which is similar to the finding of Nigerian university [12].The coercion was perpetrated by both intimate and nonintimate persons using physical force, psychological influence, and intoxication by alcohol [3].
Intimate partner violence is worldwide [7] and the consequences of sexual violence are a serious problem worldwide whether it is caused by intimate partner or stranger [13].In this study 6.8% of the respondents reported they were raped which is higher than the finding in Nigerian university (3.2%) [12] and lower than the finding of Addis Ababa University (12.7%) [10].Only 3.2% had reported the rape event to legal bodies and 28.3% of the victims were raped more than two times.The prevalence of rape among Jijiga and Addis Ababa Universities students was 15.1% and 12.7%, respectively [10,14].In Addis Ababa University 6.4% of the victims had reported the event to legal body.In Nigeria University only 3.2% of rape victims had reported the event to police [15].After rape attack the victims faced unwanted pregnancy, abortion, genital trauma, unusual vaginal discharge, genital swelling, and other problems.These are also similar to the findings of other studies [10,12,15].
In this study, 24.2% of the respondents were sexually active but in Addis Ababa University and Jijiga University 25.8% and 35.9, respectively, were sexually active [10,14].This may indicate that in our study area students' sexual practice was less or they may not tell that they are sexually active.In this study, the age of initiating sex (sexual debut) was 18.19 years.In a study conducted in northeast Nigeria and Cameroon the mean age at first sex was 16.1 and 15.3 years, respectively [15,16], whereas in Addis Ababa and Jijiga Universities the mean age at first sex was 18.75 and 17.59 years, respectively [10,14].In a study on high school students in Addis Ababa, the mean age at first sex was 18.5 years [2].Studies conducted on sexual behavior of youth in Ethiopia revealed that the mean age at first sex in Dessie town was 17.18 years [17], in Nekemte town in western Ethiopia was 15.2 years [18], and in high schools in Harar (east Ethiopia) was 16 years [19].These differences could be due to difference in factors for starting sex early such as perception of the respondents about early sexual practice and knowledge of the effects of early sexual initiation.Early initiation of sexual practice could lead to early pregnancy, thereby predisposing the girl to unwanted pregnancy, its complication such as sexually transmitted infection including HIV/AIDS, and physical injuries such as laceration of the genital tract.
In this study 64.9% of the respondents have started sex in the late adolescent 17-19 years.More than one-third (35.4%) of the respondents started sex after joining university which is much higher than the proportion of students who started sex after joining university in Haramaya University (22.8%) [20].In this study 50.0% of those who started sex after joining university started sex in the first year of study.In a study conducted in Jijiga University 92.2% of sexually active students who had sex had started sex before joining university [14].In this study 65.2% of those sexually active had started sex willingly whereas 37.9% had started sex by the pressure from their peers and friends.This finding was inconsistent with the findings of Jijiga University [14].This is indicative of the need for providing intensive education for students joining university by designing different approaches like life skill and peer education training [21].And this could be due to lack of assertiveness and the fact that they are unable to negotiate safe sex and decide responsibly.
The other impressive finding of this study was 38.9% transactional sex, which is sex to any benefit from the partner at the time of initiating sex.The benefits mentioned in this study were friend promise (24.2%), gain of money (6.3%), and passing of examinations (8.4%).Transactional sex was a problem as it may open the gate to risky sexual relation.
From those who were sexually active only 36.8% started sex with marriage, while for 63.2% of them sexual activity was premarital.The high prevalence of premarital sex would likely increase the risk of sexually transmitted infections including HIV/AIDS and unwanted pregnancy.In Addis Ababa University the reasons mentioned for initiating sex before marriage were self-interest, peer influence, friend promise, getting money, being forced, and others [10].These were also the reasons mentioned for the initiation of sexual intercourse by adolescents in Nekemte town [18].Peer influences have significant effect on early initiation of sex which is risk behavior [6,8].
The study shows that 9.1% of the respondents use substance always whereas 22.2% use only sometimes.Alcohol and khat were the most widely used by the respondents.Using such substances was a risk for problems of unsafe sexual practices that predispose them to sexually transmitted infections including unwanted pregnancy, HIV/IDS, and other consequences of unsafe sex.These problems were also the problems faced by university students in China and Sweden [22,23].In Addis Ababa 22.0% use alcohol and 8.0% chew khat [10].In Jijiga University 29.5% use alcohol sometimes and 16.6% chew khat [10,14].Substance use including alcohol is a risk factor for risky sexual behavior [24,25].If the students and/or their partner/s were using alcohol it may result in altered behavior that leads to violence.
Following coercion the victims faced sexual and reproductive health problems such as unwanted pregnancy, abortion, genital trauma, genital swelling, and unusual vaginal discharge.This is similar to the finding of Addis Ababa and Jijiga Universities [10,14].These adolescents need help and support in order to protect them from such health risks of risky sexual relation [26].Such violence is a violation of sexual rights of a person and a human right violation at large.These consequences have an impact on the physical, mental, and psychosocial wellbeing of the victim.

Conclusion and Recommendation
In conclusion, the study has found that coercion is prevalent in the study area and has illustrated the contribution of several factors to sexual coercion.The educational approach to life skills and peer education for students could avert the problem.Therefore the university should strengthen the sexual and reproductive health services.Using substances including alcohol needs to be avoided in order to reduce the risk of sexual coercion and mitigate its impact.
Madawalabu University is expected to work towards minimizing the risk of sexual coercion and its consequences by implanting strategies like life skill, peer education, and assertive training and strengthening youth friendly services through different outlets.

Table 1 :
Sociodemographic characteristics of the respondents in Madawalabu University, southeast Ethiopia, April 2012.

Table 2 :
Family educational status, mother and father living situation, and students' living arrangement before joining university in Madawalabu University, southeast Ethiopia, April 2012.

Table 3 :
Sexual history and characterises of sexual initiation respondents in Madawalabu University, southeast Ethiopia, April 2012.

Table 4 :
Ever raped, where rape was committed, time of rape event, number of rape events, and reporting rape to legal body, Madawalabu University, May 2012.

Table 5 :
Ways of raping, mechanism used to escape, to whom rape was reported, and reason for not reporting rape, Madawalabu University, May 2012.

Table 6 :
Association of lifetime coercion and behavioral characteristics of respondents in Madawalabu University, southeast Ethiopia, May 2012.