Childhood Sexual Abuse Against Girls in Sub-Saharan Africa : Individual and Contextual Risk Factors

Sammanfattning: Background and objectives: Childhood sexual abuse (CSA) is a substantial public health and human rights problem, as well as a growing concern in sub-Saharan Africa (SSA). It has both short and long term effects on girls: physical and psychological, including negative sexual outcomes. Up to one-third of adolescent girls report their first sexual experience as being forced. Despite growing evidence supporting a link between contextual factors and violence, no studies have investigated the connection between CSA and contextual factors. It is therefore important to identify the extent of CSA and understand factors associated with it in SSA in order to develop interventions aimed to address the scale of the problem.Aim: The overall aim of this thesis is to assess the individual and contextual factors associated with CSA. In addition, the thesis aims to quantify the magnitude of CSA and describe the factors associated with CSA among women from SSA (Study I). This thesis also examines the independent contribution of individual and community socio-economic status on CSA (Study II). Moreover, it scrutinises the effect of social disorganisation on CSA (Study III) and explores the relationship between CSA and sexual risk behaviours as well as potential mediators (Study IV).Methods: This thesis used the Demographic and Health Survey (DHS) datasets conducted between 2006 and 2008 from six SSA countries. The thesis used multiple logistic regression models to describe and explore factors associated with CSA among 69,977 women (Study I).  It used multivariable multilevel logistic regression analysis to explore the effect of contextual level variables (neighbourhood socio-economic status) on CSA among 6,351 girls (Study II). Neighbourhood socio-economic status was operationalized with a principal component analysis using the proportion of respondents who were unemployed, illiterates, living below poverty level and rural residents. Study III applied multivariable multilevel logistic regression analysis on 6,351 girls and considered five measures of social disorganisation at the community level: neighbourhood poverty, female-headed households, residential mobility, place of residence, population density, and ethnic diversity. In study IV, 12,800 women from the Nigerian DHS were used. Structural equation modelling was applied using a two-step approach. The first step used a confirmatory factor analysis to develop an acceptable measurement model while the second step involved modifying the measurement model to represent the postulated causal model framework.Results: In study I, the reported prevalence of CSA ranged from 0.3% in Liberia to 4.3% in Zambia when the prevalence was based on all respondents aged between 15 and 49 years and who were present during the survey. None of the socio-economic factors were associated with CSA. In study II, where the data was restricted to permanent residents aged between 15 and 18 years, the prevalence ranged between 1.04% in Liberia to 5.8% in Zambia. At the individual level, there was no significant association between CSA and wealth status while at the community level, there was no significant association between CSA and socio-economic position. However, 22% of the variation in CSA was attributed to the community level factors. In study III, there was significant variation in the odds of reporting CSA across the communities, with community level factors accounting for 18% of the variation. In addition, respondents from communities with a high family disruption rate were 57% more likely to have reported sexual abuse in childhood. Study IV showed that there was a significant association between CSA and sexual risk behaviours and the association was mediated by alcohol and cigarette use.Conclusions: The study provides evidence that adolescents in the same community were subjected to common contextual influences. It also highlighted the significance of mediators in the relationship between CSA and sexual risk behaviours. It is therefore important that effective preventive strategies are developed and implemented that will cut across all socio-economic spheres in a context that both permits and encourages disclosure as well as identifying predisposing circumstances for recurrence.