Magnitude And Associated Factors of Child Sexual Abuse: A Mixed Method Study Among Pediatric Patients at Hawassa University Comprehensive Specialized Hospital, Ethiopia, 2023

Introduction: CSA is the least documented form of violence in many developing countries including Ethiopia, and only 1 in 10 incidents have been reported. Most of the studies conducted previously were investigate the problem with quantitative study only and study was not conducted in the study area to determine the magnitude of child sexual abuse. The objective of the study is to review child sexual abuse cases presented to one stop center of Hawassa University Comprehensive Specialized Hospital, 2023.

Method: Cross-sectional study design supplemented by Explorative qualitative study design was employed from February 15, 2022- March 31, 2023. For quantitative study we employed systematic random sampling technique and the sample was calculated by using single population proportion formula the final sample size will be 424. For qualitative study one-on-one in-depth interviews were conducted to collect data from participants by using open-ended interview guide questions. Purposive sampling technique was used in order to select key informant interview which had rich information.

Result: During the three years period a total of 680 children were seen at stop center of Hawassa University Comprehensive Specialized Hospital out of them 424 (63.8 %) were cases of child sexual abuse. Majority (70%) were form urban areas. Male survivors of child sexual abuse have constituted only 7 (1.6%). about three fourth (74.7%) were in the age category of 11-16 years. Regarding the type of sexual assault, three fourth (75.5%) were victims of rape and around 20 % were attempt. Age, educational status, living with a care giver, type of injury was found to be predicting factors.

Conclusion and Recommendation: The magnitude of child sexual abuse is high. Behavioral and sexual education is very essential and. measures should be taken to encourage abused children to report to legal bodies. There is a need of more research to understand the whole dynamics of child sexual abuse.

Sexual violence refers to a wide range of behaviors, such as attempting or completing intercourse, unwanted sexual contacts, and sexual insinuations made by any individual, regardless of their relationship with the victim [1]. In turn, child sexual abuse (CSA) can be defined as contacts and sexual interactions between a minor and an adult or between minors if there is a 5-year age difference between them or if the child/adolescent perpetrator is in a situation of power or control over the victim, even if there is no age difference [2].

Child sexual abuse (CSA) is a widespread public health issue that can have a wide range of detrimental effects on the victim throughout the course of their life. The Centers for Disease Control and Prevention (CDC) describe CSA as any completed or attempted sexual act, sexual contact with, or sexual exploitation of a child [3]. Violence against children continues to grow as a salient issue in national and international public health and public policy discussions. However, epidemiology to accurately describe the problem and track trends continues to be challenging [4].

CSA prevalence ranged from 0% to 53% among females and 0% to 60% among males [5]. According to recent evidence, between 10 and 12% of children will experience sexual abuse before turning 18 years old. Studies have indicated that CSA is more common in the years of preadolescence, between the ages of 8 and 13, although there is no clear consensus regarding the victims [6-8]. 

Globally, one in three adolescent girls’ reports had their first sexual experience as a result of coercion [9]. CSA is the least documented form of violence in many developing countries including Ethiopia, and only 1 in 10 incidents have been reported. Factors such as inconsistencies in the definitions of sexual abuse, fear and social stigma against rape survivors, committed in complete secrecy, and social and cultural norms are contributed to underreporting [10, 11].

Multiple factors contribute to health professionals' failure to detect child sexual abuse. It is difficult to accept the social and cultural taboos surrounding the idea of adults sexually abusing children. Additionally, the knowledge required to correctly identify child sexual abuse is limited and talking about sexual issues can also cause psychological and societal anxiety. Furthermore, in traditional communities, there is widespread and individual denial of any kind of child sexual abuse. Another reason for the avoidance of the subject is the relative ignorance on the prevalence of child sexual abuse [12, 13].

A cross-sectional study conducted in Addis Ababa identified child sexual abuse prevalence rate of 38.5 % among the general public, out of which 29% were committed by victims’ family members and 68% of them were victimized by adults the children knew [14]. In a similar study, in south west Ethiopia, samples of Hospital reports show that 61.7% of alleged sexual abuse cases were targeted against children [15]. Nevertheless, there aren't many studies being done, there aren't many people reporting the occurrence, and there aren't many health resources available, therefore it's impossible to offer an exact estimate of child sexual abuse in poor nations like sub-Saharan Africa [16].

Sexual victimization has a variety of immediate and/or long-term repercussions on children. The most prevalent psychological effect of child sexual abuse is post-traumatic stress disorder (PTSD), while many victims also experience sadness, anxiety, promiscuity, general behavioral issues, low self-esteem, and disruptive behavior disorders [7]. Additionally, children's social and occupational functioning may become impaired as they grow into adults. This includes withdrawal and isolation, phobias, hostility, subpar work output, and troubled interpersonal interactions [17]. More than this, engaging in unsafe sex, having many sexual partners, earlier sexual initiation, unplanned pregnancy and higher risk of infection with STDs including HIV/AIDS are also common consequence of child sexual abuse[18]. In conclusion, despite the fact that child sexual abuse is a worldwide problem, socio-cultural factors make it difficult to determine the scope, causes, and effects of incidents in developing nations like Ethiopia. Most of the studies conducted previously were investigate the problem with quantitative study only and study was not conducted in the study area to determine the magnitude of child sexual abuse. Thus, the objectives of the study are to review child sexual abuse cases presented to one stop center of Hawassa University Comprehensive Specialized Hospital and to identify their life experience.

Study design, period and setting

Cross-sectional study design supplemented by Explorative qualitative study design was employed from February 15, 2022- March 31, 2023. The study was conducted in Hawassa University Comprehensive Specialized Hospital, found 273 km away from Addis Ababa, the capital city of Ethiopia. Hawassa is located in Sidama National Regional state 278 kilometers south of Addis Ababa.

Study population and sampling 

The source population for the study was all children (less than 17 years) who came to HUCSH for treatment of gender-based violence will be eligible for study and all children (less than 17 years) who came to HUCSH for treatment of gender-based violence and meet inclusion and exclusion criteria of the study were the study population. For quantitative study we employed systematic random sampling technique and the sample was calculated by using single population proportion formula with the following assumptions: 50% prevalence of child sexual abuse (no study exists for retrospective study with adequate sample size), 95% confidence interval, and 5% margin of error, considering non-response rate 10% the final sample size was 424. 

All cases came to gender-based violence treatment center in the previous three years (2012 -2014 EC) were included. Those children who have incomplete data in their card were substituted with other card with the nearest card number during data collection. 

Qualitative study 

Even if the final sample size depends on saturation and redundancy of data, we have conducted 8 interviews (3 Key In-depth Interview and 5 in-depth interviews). Participants of key informants were Hawassa city police commission, city administrative head, women and child affair and selected non-governmental organization who work on child sexual abuse (if they available).   

Sampling procedure

For qualitative study, we took all information of sexual abuse victims from the medical records of the patients from the center and we called them to ask their consent. If they become volunteer, we arranged an appointment and go to interview place, which is convenient and selected by the participants.  One-on-one in-depth interviews were conducted to collect data from participants by using open-ended interview guide questions. Purposive sampling technique was used in order to select key informant interview which had rich information. 

Inclusion and Exclusion Criteria

Inclusion Criteria

Children (less than 17 years) who came to treatment center will be included to this study.

Exclusion criteria

Those patients who have incomplete document were excluded from this study.

Data collection tool and procedure

A pre-tested structured interviewer administered questionnaire which has adopted from different literatures was used to collect the data and all information was collected by reviewing their medical records using KOBO collect application. 

For qualitative, a face-to-face in-depth interviewing technique was conducted to collect data from participants. All interviews were audio-recorded by using a digital voice recorder on a smartphone. 

A total of 6 fist and second-degree holder health professionals was recruited to collect data (4 for quantitative study and 2 for qualitative study design). We used one interviewer for each In-depth interview (IDI). Each of the participants was asked their lived experience, consequence, and supervision was done by principal investigator and co-PI.

Measurement and operational definition 

Sexual abuse

The infliction of sexual contact upon a person by forcible compulsion; the engaging in sexual contact with a person who is below a specified age or who is incapable of giving consent because of age or mental or physical incapacity.

Rape: is the intentional and unlawful sexual intercourse by a male over 14 years of age, with a woman without her consent.

The dependent variable was voluntary counseling and testing service utilization (yes/ no). The independent variables included were socio demographic variables such as age, sex, marital status, place origin (urban or rural), year of study, college of study, religion, knowledge related factors such as knowledge about HIV, source of information and behavioral factors like having sexual partner.

Data processing and analysis

Quantitative study

The collected data was downloaded from the server and exported to SPSS version 25 for further analysis. Descriptive statistics and inferential statistics were done to answer predetermined research question. Final significance was set at p-value less than 0.05. 

Qualitative study

Atlas ti. Version 9 software has used for analysis. The recorded audio was first transcribed verbatim. The transcribed data for each respondent was made into a word document; documents for all respondents has imported into the software as ‘cases. Thematic analysis approach was used for analyzing data. A careful line-by-line reading of each document was done to identify major topics within the data; the topics was then labeled and entered into the ‘variables’ section of the software. The responses were coded and included under each relevant topic or ‘variable’ for further analysis.

During data analysis, themes have identified and those themes were grouped under the appropriate topic or ‘variable’; similar topics or themes were merged, and some new topics or themes have also created during data analysis as new themes emerged.

Data quality control

Before conducting both IDI and quantitative questionnaire, pretest has done at another similar center. Training has given for all data collectors using KOBO tool box before the beginning of data collection.

Ethical Clearance

The study gets ethical approval from Hawassa University College of medicine and health science institutional review board. Based on this and explaining the importance and intention of the study an official letter of co-operation was received from respective institutions. Finally, data were collected after assuring confidentiality (anonymity and not writing their address) and receiving consent from each participant. 

Socio demographic characteristics of children with sexual abuse, HUCSH

From the total respondent’s majority (70%) were from urban areas. Male survivors of child sexual abuse have constituted only 7 (1.6%). About three fourth (74.7%) were in the age category of 11-16 years. Regarding the perpetrators relation with the victim majority (80%) were abuse by strangers.

Table 1: Socio demographic characteristics of children with sexual abuse, HUCSH (n= 424)

Clinical related characteristics of children with sexual abuse

Majority (98.4%) of the survivors had no past history of sexual abuse. Regarding the type of sexual assault, three fourth (75.5%) were victims of rape and around 20 % were attempt. Nearly half (48.6%) of the genital injuries have hymeneal tear. Psychological support was provided for most of the survivors.

Table 2: Clinical related characteristics with child sexual abuse, HUCSH (n= 424)

Table 3: Laboratory investigations

What is child sexual abuse and its magnitude compared with previous years

All participants stated that child sexual abuse is a criminal act

A participant from medico legal service asserted “as a general sexual abuse means child’s either boy or girl whose age less than 18 years who exposed to criminal act like abduction, early marriage and sexual abuse including harassment and also linked with homo sexuality that we investigate generally.” Noting child sexual abuse is a punishable act, one of a participant from the legal system remarked, “child sexual abuse means when once child face any assault or attempt beyond his or her age for example rape, abduction including female genital mutilation we consider as abuse as police so we will conduct crime investigation.”

A chairperson from the medico legal service at Hawassa University has clearly stated the cases they have been managing “since the establishment of the medico legal center in HUCSH there are about 106 criminal records reported to us. From those reported cases about 31 crime record report had been sent to prosecutors and from those cases under investigation with prosecutors about 25 cases get final judgment. There are discontinued cases due to lack of adequate evidences that fulfill sexual abuses.”

Women from child protection unit also stressed the cases of child sexual abuse has been increasing “compared to sub city the cases of child sexual abuses are increasing especially in tabor sub city including abduction and child sexual abuse. the violence is more common in girls , …. One male case only in adis kifleketema sub city”

Prosecutor has supported her idea increased awareness of the community as a positive factor for better reporting of the cases “… I think the problem has increased in my opinion, and the reason for this is that the medical and legal services have been given at one center. Establishment of the treatment center at HUCSH has increased the access for information and awareness to report the cases; it will increase the knowledge of the community.”

The way to handle cases of child sexual abuse?

The teams working at the medico legal services in HUCSH have mentioned they give medical and legal services jointly. “We are working in collaboration with the health care providers to support the victims in many aspects “…. First, we will make them get medical treatment. If they do, we will sign the release, sign our ID and bring them to us. In the end, we will conduct the investigation and check the record together with the prosecutor for better documentation.” A man from the legal service emphasis they have been giving well organized services “…we are doing this together. We will put the victims of violence, children and women, in custody until the action is decided by law. They will be treated psychologically and we will help them financially. ” 

Attitude of the community about child sexual abuse

A woman from women and children office has noted the community have both supportive and against idea for child sexual abuse. “The society has a good attitude about this case. When the person has committed the attack they brought to court, some are very supportive; they are satisfied when the perpetrator gets punished.” Initially they bring the violated person to the court system but they would not proceed with the legal system or try to solve the problem by the cultural negotiation system. 

He has also mentioned contradicting idea with this point saying “…. but some argue about abduction, it has been a culture and when they argue, they argue that it had continued from the previous generations. However, we are advocating reducing the problem some people mentioned that abduction has come from the past and it still continues and they think it is having no problem. There are also those who say that many people are married by abduction. The society is familiar with abduction. From what we hear and see, some of the society reflects abduction as a normal tradition.”

Government concern to fight against child sexual abuse 

A health care provider at one stop center has emphasized there are different platform previously to advocate “to prevent crime, there is something called sub-city community policing, which means crime prevention. In the past, the seriousness of crime was discussed in meetings and different forum, but now I think it is not given much attention.”

There is also concern from another participant mentioned there are NGO which had been working to support the victim “…. there are two rehabilitation centers for those who have been victim of violence in Hawassa city. The survivors will give psychological support. They will be supported morally and financially from various humanitarian organization called AWSAD and Talitan.”

Barriers to stop the cases of child sexual abuse 

A participant from the legal system has mentioned “in my opinion the assigned body is not accomplishing their responsibility properly and not engaged in educating the society. Another problem is that the assigning body should evaluate the progress. The work and the expert should be connected. Otherwise, it will be continue increasing. There is no adequate material support to report cases.” Other participant as also supported this idea “…. there is no special support for the professional. For the future, the government should pay the salary and additional incentive for the professional to do this job properly and access for training related with sexual violence should be improved.”

We extracted data from medical registers of three years from 2022-2022 GC. The total number of cases registered during the past three years was 680; the magnitude of child sexual abuse was 63.8%. This is much higher than the study conducted among children treated in Public Hospitals of Addis Ababa [19]. where magnitude of child sexual abuse was found 42.7%. This might be due to difference in the study design we extracted data from three years of medical records which might include a greater number of cases. From the total participants most of them (70%) have come from urban setting. This is in contrast with a study conducted among female high school student in Dire Dawa [20]. where the odds of experiencing sexual abuse among students of rural residence were 3.2 times higher than their urban counterparts (AOR 3.2; 95% CI 2.02–4.51). 

This might be due to female student who came from rural areas may not have access for media about sexual abuse to protect themselves. In addition, many students may move to urban cities to attend their high school education this might expose them for the new environment and they may start new relationship. In this study majority (98.4%) were female. This could be justified with females may be abused more often than males, even though both sexes are approached in equal frequency, because females have been socialized to be more compliant and responsive to the needs of others, while males are perpetrators more often than females because males have been socialized to be more aggressive, powerful, and dominant [21]. In addition, three fourth (74.7%) has fall in the age category of 11-16 when compared to those under five children and age between five to ten years old. Majority (79.3%) were get attacked by their caregivers. Regarding their clinical characteristics majority (98%) had no history of sexual abuse. Nearly half (48.6%) have hymeneal tear (99.8%) were negative for HIV test. 

This is consistent with a study in United State [22]. a predictive relationship between a history of child sexual abuse and subsequent HIV infection was observed among the large sample of HIV-uninfected male child. Findings indicate that HIV-uninfected children with child sexual abuse histories are at greater risk for HIV infection [23]. Four hundred fourteen (95%) were stable at charge. Psychological support was given for majority of the study participants .This  has supported by a study which has investigated the efficacy of the psychological treatment of children and adolescents that have suffered sexual abuse [24]. Significant differences among the various psychological treatment approaches were found for the global outcome measure, sexualized behaviors, and behavior problems. Moreover, trauma-focused cognitive-behavioral treatments combined with supportive therapy and a psychodynamic element showed the best results.

The magnitude of child sexual abuse among children at HUCSH was high. Behavioral and sexual education is very essential and. measures should be taken to encourage abused children to report to legal bodies.

Strategies that involve the community and that protect children against the threat need to be designed. Others such as caregivers, schools, police department, Youth and Women’s Affairs, and child advocacy organizations should be called up on to work together and design mechanisms of checking the expansion of this public health challenge. 

All children are at risk of sexual abuse irrespective of their age, gender, degree of relationship to the perpetrators. Females are more affected than males. Living with both parents was not found protective and children were abused in the environment considered safe. There is a need of more research to understand the whole dynamics of child sexual abuse

Strength and Limitation

The strength of this study is we collected data with KOBO tool box which add quality to our data. It has conducted qualitative interview to get more accurate and rich information. The study has employed cross sectional study design which could not infer the temporal association between the variables. It is facility-based study hence it could not be generalized for the community level. In addition, we extracted information from medical registers we could not get adequate information due to some variables is removed due to incomplete information in the register.

Consent for publication

Not applicable

Availability of data and materials

Data is not available for online access, however readers who wish to gain access to the data can write to the corresponding author Ayantu Melke.

Competing interest

The authors declare that they have no competing interests.

Funding

Hawassa University.

Authors’ Contributions

All authors significantly contributed to the work whether it is conception, study design, execution, and acquisition of data, analysis, and interpretation. They also all participated in the writing, editing, or critical evaluation of the publication. They have agreed to be responsible for all aspects of the work and have chosen the journal to which the article has been submitted.

Acknowledgement

First our deepest gratitude does to Hawassa University Research and Technology Transfer director, research and community service director for providing as this opportunity and giving research fund. We also acknowledge our supervisor Mr. Yusuf Haji (Assistant professor of Epidemiology) for his close follow up and supervision. Next, we would like to thank HUCSH manager for providing support letter, nurses, and coordinators working at one stop center of HU. Last but not the least we are so grateful for our data collectors and study participants for valuable contribution in this study.

Authors’ information

AM: Lecturer, School of Public Health, College of Medicine and Health Sciences, Hawassa University; MJ: Lecturer, School of Public Health, College of Medicine and Health Sciences, Hawassa University.