Prevalence of violence and associated factors among youth in Northwest Ethiopia: Community-based cross-sectional study.

BACKGROUND: Violence as a known serious public health problem affects people in all stages of life, from childhood to the elderly. In society, one of the most visible forms of violence is young people violence, whereas they, adolescents and young adults, are the main victims of such violence. There was limited information on the burden of violence and factors among this age group. Therefore, this study aimed to determine the prevalence of violence and its associated factors among youth in Northwest, Ethiopia.
METHODS: A community-based cross-sectional study design was conducted to estimate the magnitude of violence among youth in Northwest, Ethiopia. Data were taken from the mega project entitled assessment of common health problem and risky health behavior among youth. Youth violence was the dependent variable whereas the socio-demographic variables and substance use were the independent-variables. The bivariate logistic regression model was employed to identify associated factors. An adjusted odds ratio with a 95% confidence interval was used to determine factors associated with violence.
RESULTS: From the total 1765 representatives of the youth population,1597 (90.5%) youth participated in the study. Overall, the prevalence of violence among youth aged 15-24 years for the last 12 months was 21.5%. In the multivariable logistic regression model, factors significantly associated with violence were being married and divorced (AOR = 1.77, 95%CI: 1.13, 2.79) and (AOR = 5.67, 95%CI: 2.93, 10.99), respectively, living with mother's only (AOR = 1.85,95%CI: 1.28, 2.66) and father's only (AOR = 2.45, 95% CI: 1.30, 4.63), and substance use (AOR = 2.38,95% CI: 1.56, 3.66).
CONCLUSIONS: The prevalence of violence among youth was high compared to other studies. Special emphasis Should be given for youth violence in order to manage the victims as well as for preventing and controlling the identified factors through strengthening policies and strategies.

Background

The World report on violence defines violence as, "the intentional use of physical force or power, threatened or actual, against another person or a group or community that either result in or has a high likelihood of resulting in injury death, psychological harm, mal- development or deprivation" [1, 2]. Violence as a known serious public health problem affects people in all stages of life [3]. In society, one of the most visible forms of violence is young people violence, whereas they, adolescents and young adults, are the main victims of such violence [4]. It is estimated that each year, 200,000 homicides occur in this age group in the world [2]. Nearly all of these deaths occur in low and middle-income countries and the majority of victims (83%) are males [2]. Violence is among the top five leading causes of death for young people [5] and the elimination of violence is foreseen in the United Nations Agenda Sustainable Development Goals by 2030 [3, 6]. Youth violence includes physical, psychological and sexual abuse, neglect, commercial or other exploitation of children (e.g labor exploitation, forced marriage, forced criminality, domestic servitude, child soldiers) “resulting in actual or potential harm to the child’ health, survival, development or dignity in the context of establishing a relationship, responsibility, trust or power” [7, 8].

Youth violence often occurs alongside other types of violence. For instance, maltreated children are themselves at increased risk in later life of either perpetrating or becoming the victims of multiple types of violence–including suicide, sexual violence, youth violence, and intimate partner violence. The same set of factors–such as harmful levels of alcohol use, family isolation and social exclusion, high unemployment, and economic inequalities–have been shown to underlie different types of violence [9]. Victims are not the only heirs of youth violence, but also deeply harm their families, friends, and communities. A great increase in the costs of health and welfare criminal justice services decreases the value of property in areas where it occurs, disrupts a range of essential services, reduces productivity, and generally undermines the fabric of society are imposed consequences of youth violence [2].

A study done in Serbia violence among youth was 13.4% [10], and China 13.2% [11]. The prevalence of violence in EDHS report was 27% [12]. A systematic review done in low and middle-income regions reported that, the lowest physical fighting between twenty studied countries was for females in Myanmar (8%), whereas, the highest rates are reported for boys in Samoa (73%) [2].

In Ethiopia, nearly 16% of male college students reported physically abusing [13]. Worldwide, around 15 million adolescent girls aged 15 to 19 have experienced forced sex in their lifetime; 9 million of these girls were victimized within the past year [14]. The reported prevalence of sexual violence among young people in dating relationships varies from 1.2%–32.9% for females in North America and Europe [15]. According to demographic and health survey data for selected low and middle-income countries, the percentage of girls aged 15–19 years who have ever experienced forced sexual intercourse ranges from zero among adolescent girls in Kyrgyzstan, to 22% among girls in the same age range in Cameroon. Among girls and women aged 15–49 years, the percentage reporting forced sexual initiation ranges from 1% in Timor-Leste to 29% in Nepal [16], in Uganda, 35% [17] and EDHS report, seven percent of women age15-49 reported that they have experienced sexual violence in the past 12 months, five percent of women had experienced sexual violence by age 18, including 2% who had experienced sexual violence by age 15 [12].

A study in Serbia showed that (in the family and on the street) 2.8% and 5.3% were victims of psychological violence, respectively [10]. The experience of any emotional violence in among ever-married women age 15–49 years was 20.2% [12].

The associations of socio-demographic and other factors with violence; being raised in poverty has been found to contribute a greater likelihood of involvement in violence, and poverty both in the community and at the level of individual households has been shown to predict violence [2, 18]. A study conducted in Serbia, predictors of violence victimization were male gender, lack of close friends and urban settlements [10]. The youngest women (age15-19), women with no children, and never-married women are less likely to have experienced violence [12]. Young men are at far greater risk than females for becoming perpetrators and victims of youth violence [19]. Those who are involved in youth violence show lower educational performance and are more at risk of school dropout [20]. At the individual level, young people who start drinking early and drink frequently are at increased risk of perpetrating or being a victim of youth violence [21]. DHS in Ethiopia, all forms of spousal violence are higher among divorced/separated/widowed women, women with no education, with the level of husband’s/partners alcohol consumption and urban-rural residence [12].

There are no or limited studies conducted to assess violence against young people and its determinants in the study area as well as in Ethiopia. Even some studies conducted previously focused only on the reproductive health problems of young people; yet, which does not address violence against young people in both sex groups. Hence, the present study was designed to determine the prevalence of violence and related factors among youth in Northwest Ethiopia.

Thus, the findings of this study contribute to public health researchers and policy makers to promote further research and develop or modify strategies designed to reduce violence.

Materials and methods

Study design, setting and period

A community-based cross-sectional study design was conducted to estimate the magnitude of violence and associated factors among young people aged 15–24 years. This study was done in Central, West and North Gondar Zones. A total of 24 woredas and one city Administration present in the three zones: Central Gondar Zone have 13 woredas, North Gondar Zone 7 woredas, and West Gondar Zone 4 woredas. The total number of kebeles in the three zones is 546 having a total population of 3,654,920 populations, from this 1,847,631 was males and 1,807,289 females [22]. The study was done from September 2018 to June 2020.

Sample size and sampling techniques

The source population of the study was young people aged 15–24 years living both in rural and urban settings in Central, West and North Gondar Zone whereas youth in the selected kebeles of in these rural and urban settings were the study population. The sample size of the study was calculated by considering the prevalence of a study conducted in Ethiopia 27.0% [12], significance level = 95%, margin of error = 3%, and design effect = 2. The total sample size was 1681. By considering the non-response rate of 5%, the final sample size was 1765.

A multistage cluster sampling method was employed to get the study participants.

This study was done in Central, West and North Gondar Zone. A total 24 woredas present in the three zones: Central Gondar Zone have 13 woredas, North Gondar Zone 7 woredas and West Gondar Zone 4 woredas.

Firstly, two woredas from the Central Gondar Zone, one woreda from each North Gondar Zone and West Gondar Zone were selected by simple random sampling. Secondly, three kebeles were selected from the selected woredas. From each kebele, three clusters (Ketena/Gote) were randomly selected. The non-proportional or equal location was considered to get households in each cluster and eligible study participants were interviewed.

Study variables

Youth violence is defined by the World Health Organization ’’the intentional use of physical force or power, threatened or actual, against youth, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation” Any of the specified acts of physical, sexual, or emotional violence in the past 12 months preceding the survey [1, 12].

Emotional violence is say or does something to humiliate you in front of others; threaten to hurt or harm you or someone close to you; insult you or make you feel bad about yourself [12]. Physical violence is push you, shake you, or throw something at you; slap you; twist your arm or pull your hair; punch you with his/her fist or with something that could hurt you; kick you, drag you, or beat you up; try to choke you or burn you on purpose; or threaten or attack you with a knife, gun, or any other weapon [12].

Sexual violence is defined as physical force you to have sexual intercourse with him even when you did not want to; physically force you to perform any other sexual acts you did not want to; force you with threats or in any other way to perform sexual acts you did not want to [12].

The survey questions to address the above variables: Have you experienced violence in the past 12 months? Have you experienced violence like hit /slapped or thrown something by someone in the past 12 months? Have you experienced violence like scared/intimidated by somebody in the past 12 months? Have you exposed to sexual violence for the last 12 months?

Data collection procedure

Data were collected from the mega project entitled assessments of common health problem and risky health behaviour among youth aged 15–24 years in Central, North and West Gondar Zone. Twenty-four data collectors, who were nurses and midwives working in the public health institutions in the selected woredas especially those who were working in a youth-friendly clinic, and six supervisors (one supervisor per woreda) who were at least degree holders involved during data collection. To assure data quality, training was given for data collectors and supervisors on the objective of the study, consent and confidentiality, and data collection technique. After getting the consent, the data were collected from study participants through pre- tested interviewer-administered questionnaire, and both supervisors and investigators were checked for completeness before data entry.

Data processing and analysis

An Epi Info version 7 was used for data entry and transferred to STATA 14 for data management and final analysis. First, descriptive analysis was done to determine the problem of violence among young people. Second, binary logistic regression was used to do both bivariable and multivariable analyses to see the association between covariates and violence. Odds ratio with 95% CI and P-value <0.05 was used to determine the presence and the strength of the association between dependent and independent variables.

Ethics approval and consent to participate

Ethical clearance was obtained from the Institutional Review Board of University of Gondar. Permission letter to conduct the study was obtained from Central, West and North Gondar Zone Health department. Assent and verbal informed consent were obtained from potential study participants. Verbal consent for age 18 and above, and verbal assent for minors was obtained from their families or guardians after detailed explanation on the purpose, risks, and benefits of the study including the selection of the study participants is randomly and they have the right not to participate or withdraw from the study at any time. To ensure confidentiality, their name and other personal identification were not registered in the format. Finally, the participation of the study participants was confirmed by receiving their responses of agreement and have made tick to each consent form by the data collectors.

Results

Socio-demographic characteristics of Youth in Northwest, Ethiopia

From the total 1765 representative sample of the youth population, 1597 (90.5%) young people participated in the study. From the total respondents, 50.7% was found in Central Gondar, 68.1% of the participant’s age in the study was below 20 years, the mean and median age of the participants were 19.19 and 19 respectively, with an SD± 2.85. More than half of the respondents 51.2% were females. The majority of respondents was in rural settlements 53.5% and had primary education 46.6%. The majority of their parents (mother and father) were (88.6%) and (80.2%) alive, respectively. The educational status of their parent’s not educated, mother’s (77.5%) and father’s (37.7%) (Table 1).

Table 1

Socio-demographic characteristics of youth and youth parent’s Northwest Ethiopia.

Variable name	Frequency	Percentage
Zone
Central Gondar	810	50.7
North	523	32.8
West Gondar	264	16.5
Age
<20	1087	68.1
20 and above	510	31.9
Sex
Male	780	48.8
Female	817	51.2
Residence
Rural	854	53.5
Urban	743	46.5
Religion
Orthodox	1483	92.9
Muslim	104	6.5
Others	10	0.6
Marital status
Single	1721	79.6
Married	283	17.7
Divorced	43	2.7
Educational level
Unable to read and write	114	7.1
Primary education	739	46.3
Secondary education	550	34.4
Higher	194	12.2
Currently attending school
No	611	38.3
Yes	986	61.7
Occupation
Unemployed	1356	84.9
Employed	241	15.1
Living arrangement
Mother and father	758	47.5
Mother only	184	11.5
Father only	45	2.8
Husband/wife	222	13.9
Relative/sister or brother	105	6.6
Others	70	4.4
Alone	213	13.3
Mother alive
No	182	11.4
Yes	1415	88.6
Mothers education	1415
Cannot read and write	997	70.8
Read and write	223	15.8
Primary education	116	8.2
Secondary education	53	3.7
College and above	26	1.8
Mothers occupation
Housewife	1237	77.5
Merchant	94	5.9
Government employee	35	2.2
Private employee	9	0.6
Daily laborer	26	1.6
Others	14	0.9
Father alive
No	316	19.8
Yes	1281	80.2
Fathers education
Cannot read and write	483	37.7
Primary education	657	51.3
Secondary education	99	7.7
Higher education	41	3.2
Father’s occupation
Merchant	245	15.3
Government employee	98	6.1
Private employee	35	2.2
Daily laborer	30	1.9
Farmer	858	53.7
Others	15	0.9
Number of families
<5	1018	63.7
5–9	557	34.9
10 and above	22	1.4
Wealth index
First(lowest)	319	20
Second	320	20
Third	319	20
Fourth	320	20
Highest	319	20

The prevalence of violence among youth 15 to 24 years old in the past 12months

Overall, the prevalence of violence among youth for the last 12 months was 21.5%. Youth hit /slapped or thrown something (physical violence), scared/intimidated (psychological violence), and exposed to sexual violence for the last 12 months were 8.3%, 13.6%, and 3.4%, respectively (Table 2).

Table 2

Percentage of youth violence and their personal behavior Northwest, Ethiopia.

Variable	Frequency	Percentage
One people scare or intimidate you for the last 12 months
No	1380	86.4
Yes	217	13.6
Intimidate for the last 3 months
No	86	39.6
Yes	131	60.4
Threatened to hurt you for the last 12 months
No	1471	92.1
Yes	126	7.9
Threatened to hurt you for the last 3 months
No	40	31.7
Yes	86	68.3
Hit/slapped you or thrown something to you for the last12 months/physical violence
No	1465	91.7
Yes	132	8.3
Hit/slapped you or thrown something to you the last 3months
No	43	32.6
Yes	89	67.4
Forced or pressured you to have sexual intercourse for the last 12 months/sexual violence
No	1543	96.6
Yes	54	3.4
Forced or pressured you to have sexual intercourse for the last 3 months
No	32	59.3
Yes	22	40.7
Violence within the last 12 months
No	1254	78.5
Yes	343	21.5
Violence within the last 3months
No	1371	85.8
Yes	226	14.2
Ever use substance
No	1489	93.2
Yes	108	6.8

Factors associated with youth violence

In the bivariate logistic regression analysis, a statistically significant association (p<0.05) was observed between youth violence and the independent variables. All independent variables listed in the socio-demographic table and other potential variable from the survey (substance use) were tested in the bi-variable analysis. Those variables sex, marital status, educational level, currently attending with school, living arrangement, wealth index, and substance use have a p-value of < 0.2 were taken in to the multivariable logistic regression’ model.

The odds of being married and 2.11 divorced (AOR = 1.77, 95%CI:1.13, 2 79) and (AOR = 5.67, 95%CI:2.93, 10.99), respectively associated with violence among youth compared to unmarried or single. Living with mother only (AOR = 1.85, 95%CI: 1.28, 2.66), father’s only (AOR = 2.45, 95%CI: 1.30, 4.63) and husband/wife (AOR = 0.44, 95%CI:0.25, 0.76) were associated with violence compared to living with both parents.

In this study substance use is 2.2 times more likely associated with youth violence compared to non-substance use (AOR = 2.38, 95% CI: 1.56, 3.66) (Table 3).

Table 3

Factors associated with violence among youth in Northwest, Ethiopia.

Variable name	Violence for the past12months		COR/CI	AOR	P-value
	No	Yes
Sex
Male	601	179	1.19 (0.13, 1.51)
Female	653	164	1	1
Marital status
Single	1010	261	1	1
Married	224	59	1.02 (0.74, 1.40)	1.77(1.13, 2.79)	0.012*
Divorced	20	23	4.45 (2.41, 8.23)	5.67(2.93, 10.99)	0.0001***
Educational level
Not educated	95	19	0.59 (0.33, 1.07)
Primary education	571	168	0.87 (0.60, 1.26)
Secondary education	443	107	0.72 (0.49, 1.05)
Higher education	145	49	1	1
Currently attending school
No	469	142	1.18 (0.93, 1.51)
Yes	785	201	1	1
With whom you live
Mother and father	610	148	1	1
Mother only	126	58	1.89 (1.33, 2.78)	1.85 (1.28, 2.66)	0.001***
Father only	28	17	2.50 (1.33, 4.69)	2.45 (1.30, 4.63)	0.006**
Husband/wife	188	34	0.76 (0.49, 1.12)	0.44 (0.25, 0.76)	0.004**
Relative/sister/brother	79	26	1.36 (0.84, 2.19)	1.35 (0.83, 2.19)	0.223
Others	61	9	0.61(0.29, 1.25)	0.49 (0.23, 1.05)	0.065
Alone	162	51	1.29 (0.90, 1.86)	0.91 (0.62, 1.35)	0.652
Wealth index
First(lowest)	255	64	0.75 (0.52, 1.09)
Second	255	65	0.76 (0.53, 1.10)
Third	245	74	0.90 (0.63, 1.30)
Fourth	260	60	0.69 (0.47, 1.01)
Highest	239	80	1	1
Substance use
No	1186	303	1	1
Yes	68	40	2.30 (1.53, 3.47)	2.38 (1.56, 3.66)	0.0001***

P value < 0.05, p value <0.01 and p value ≤ 0.001.

Discussion

Violence is the leading cause of morbidity as well as mortality among young or youth populations. In this study, the prevalence of violence among youth was 21.5%. This finding was in line with the study conducted in Ethiopia, 27% [12], but it was higher than a study conducted in Serbia 13.4% [10], China 13.2% [11] and in Ethiopia 16% [13]. The higher finding in our study might be most of the youth were unemployed and living in lower socioeconomic status that imposed them on substance use, commits crime and violence.

In this study, the prevalence of physical violence among youth in the past 12 months was 8.3%. It was comparable with a study done in Serbia7.3% [10], Myanmar (8%) [2], and in Malaysia, 11.8% [23], but lower than a review done in twenty countries (in low and middle-income regions) [2] and a study in Isfahan, Iran among boys and girls in middle school, 42.4% and 18.1% in high school, respectively [24] and in Uganda 59% [17]. This variation was due to differences in population characteristics and settings. The review of the above studies was done on the riskiest regions (in low and middle- income) and targets (school students). Large segments of adolescents or youth found in the school compound were much more likely to encounter violence from their peers.

In this study, the prevalence of sexual violence among youth was 3.4%. This finding was consistent with a study done in Uganda 5.6% [25] and Ethiopia 7% [12]. But lower than a review done in Nepal 29% and Cameroon 22% [16] and Uganda 35% [17]. This difference might be due to the study setting and period. Currently, the violators of sexual violence and their legal punishment were exhibited through the media that might impede others to commit sexual violence.

The prevalence of scared/intimidated (psychological violence) in this study was 13.6%. It was higher than a study done in Serbia 2.8% [10], but this finding was lower than a study in Isfahan, Iran among boys 25% in middle school and 19.1% in high school, respectively [24] and similar study in the same country among adolescents and youth reported to be between 30% and 65.5%, respectively [26] and in Uganda 33.3% [17]. This difference could be a difference in the study area, setting, and participants; a large segment of adolescents or youth found in the school compound were much more likely to encounter violence from their peers, and the biological differences of the participants might explain some differences in levels of violence between boys and girls.

In the multivariate logistic regression proved that the odds of being married and divorced were 1.8 and 5.7 times more likely associated with violence among youth compared to unmarried or single, respectively. Never-married women are less likely to have experienced violence. This finding was inconsistent with a study done in Serbia [10] and DHS in Ethiopia [12]. The possible explanation for this difference could be married youth or divorced were unemployed and those who were married also economically dependent on their husband or husband’s parents that led them to conflict and exposed to violence.

Living with mother only or father alone was 2 to 2.5 times more likely associated with violence compared to living with both parents. This finding was consistent with a study done in Goa, India [27] and Arbaminch town, Gammo Goffa zone, Southern Ethiopia [28]. The possible explanation could be, parental monitoring and supportiveness minimize their chance of exposure to risks of substance use and violence.

In this study substance use was 2.4 times more likely associated with youth violence compared to non-substance use. The finding of this study corroborated with studies done in different countries [21, 27, 29, 30]. This is because alcohol use directly affects cognitive and physical functioning and can reduce self-control and the ability to process information and assess risks. It can increase impulsiveness and make particular drinkers more likely to engage in violent behavior. Several studies confirm that violent incidents often occur in situations of alcohol intoxication [29, 30].

Strength and limitations of this study

The strength of this study was community based study that could be more representative for the study area. The main limitations of this study relate to the cross-sectional design, which does not allow us to determine the direction of the causality of the detected associations. It doesn’t measure the amount and frequency of substance use among the respondents. There might be recall bias and social desirability bias since the data were collected by interviewer administered questionnaire.

Conclusions

The prevalence of violence among youth was high compared to other studies special emphasis should be given for youth violence in order to manage the victims as well as for preventing and controlling the identified factors through strengthening policies and strategies.

Implications of the study

The prevalence of violence in this study was high. The policy makers and programme planners will give attention to prevent and control violence and immediate interventions for the victims by integrating violence prevention with other sexual and reproductive health services, community involvement and behavioral change communication for youth including intersectoral collaborations.

(SAV)

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17 Aug 2021

PONE-D-20-39684

Prevalence of violence and associated factors among Youth in Northwest Ethiopia: Community-based Cross-sectional study

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

7. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

8. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review the manuscript titled “Prevalence of violence and associated factors among Youth in Northwest Ethiopia: Community-based Cross-sectional study”. This paper assessed the prevalence of violence and related factors among youth in Northwest Ethiopia. Overall, this manuscript is not well-written, with too broad introduction, unclear dependent and independent variables used for analysis, and unorganized results. Below are the detailed comments.

Abstract:

Page 2, line 33, the authors stated that “There was limited information on the burden of violence and factors among this age group”. This is not true. In fact, WHO has published many materials regarding youth violence, school-based violence, and prevention strategies focusing on the youth population. The CDC has also posted guidelines for youth violence prevention at individual, interpersonal, community, societal levels by reducing risk factors and promoting protective factors.

Page 2, lines 39-40, variables/risk factors used in the logistic model should be specified in the abstract. What was the dependent variable? What were the independent variables?

Page 3, lines 47-48, is it a new sentence for “Living with mother’s only... ”? This part should be checked for typo and reorganized for better understanding.

Introduction:

Page 3, line 63, need a citation for the sentence “It is estimated that each year, 200,000 homicides occur in this age group in the world.”

Pages 4-5, lines 82-108, the authors introduced many violence-related studies involving youth around the world. What was the core information the authors tried to deliver? As we all know, the prevalence of violence has been well studied; in some countries, surveillance data are available to monitor the trend and consequences of youth risk behaviors including violence. The authors may want to reorganize the literature and see how they can better serve their paper.

Page 6, lines 123-129, what are the gaps in the current literature? The authors need to briefly summarize the findings from pervious violence-related studies that included youth in Ethiopia, and then specify the gaps that this study may bridge. If very limited studies were found, studies in other countries with similar demographic characteristics or socio-economic status should be highlighted to provided information instead.

Methods:

Page 7, lines 147-149, the authors mentioned: “Firstly, two woredas from the central Gondar zone, one woreda from each North Gondar zone and west Gondar zone were selected. Secondly, three kebeles were selected from the selected woredas.” How were the woredas and kebeles selected? Details need to be provided.

Pages 7-8, lines 154-167, what were the variables/survey questions used in this study? Only definitions from WHO are insufficient for readers to learn this study. The authors may benefit from providing a detailed description of the survey, including how it was developed, included domains/topics, and questions/valid responses used in this study.

Pages 8-9, lines 180-185, was it a complete dataset for analysis? Any missing data information?

Results:

Pages 9-13, table 1 and table 2 can be combined, as both addressed the participants’ demographic information.

Page 13, lines 201-205, it seems there were multiple violence variables. Which one was the dependent variable used for the logistic regression?

Page 15, line 201, what were the independent variables that tested in the regression? If all of them were listed in table 4, why they were selected? Are there any other variables in the survey that can be potentially taken into the model (e.g., mental health problems)?

Discussion:

This section repeated too much of the results (e.g., lines 227, 235, 248, 251...). Also, the authors may want to discuss the strengths of this study and implications for violence prevention.

Reviewer #2: This research article has chosen well objectives, study selection, study characteristic however there is limited information about assessing risk of bias. Authors have IRB authorizations and followed the scientific research.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

16 Oct 2021

To: Dear, Siew Ann Cheong, Ph.D

PLOS ONE

Subject: Submitting a revised version of manuscript and point by point response

PONE-D-20-39684

Prevalence of violence and associated factors among Youth in Northwest Ethiopia: Community-based Cross-sectional study

Point by point response

Response for Editor

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, Thank You Dear,

• Authors have made corrections on the manuscript by using the PLOS ONE’s style.

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information. • This is also corrected in the manuscript

3. Please update your submission to use the PLOS LaTeX template. • Authors, We have done correction based on this instruction

4. The University of Gondar had sponsored this study. However, it has no role in manuscript preparation and publication." At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

a) The University of Gondar supported the staffs financially to conduct this research.

b) The funder had no role in this research: had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

c) All authors are received their salaries from University of Gondar except Temiro Azanaw Mengistu and Yilikal Tiruneh Ayele.

5. Thank you for stating the following:

a. Review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. These amendments should be made in the online form.

b. Confirm in your cover letter that you agree with the following statement, and we will change the online submission form on your behalf:

“The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. • "The University of Gondar had sponsored this study. However, it has no role in manuscript preparation and publication."

a) Authors, we have made correction in the main document.

b) Corrected.

6. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found • The minimal data set underlying the results are found in the tables within the manuscript.

7. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID ID and that it is validated in Editorial Manager Thank You.

8. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section • It is moved to the appropriate place.

Reviewers' comments

Reviewer #1:

Abstract:

Page 2, line 33, the authors stated that “There was limited information on the burden of violence and factors among this age group”. This is not true • Thank you for providing an important comments and questions.

• Even if there were a lot of studies in different setting, those studies mainly concerned on institution based, the study participants were adolescent females or males only, researched a single problem (sexual or physical). Whereas, this study was community based including both sex group, assessed overall prevalence of violence in general and the three common forms of violence in particular.

Page 2, lines 39-40, variables/risk factors used in the logistic model should be specified in the abstract. What was the dependent variable? What were the independent variables?

Thank You!

• Youth violence was the dependent variable whereas socio-demographic variables(age, sex, marital status, religion, residence, occupation, educational level, currently attending school, with whom you live, wealth index) and substance use were the independent variables.

Page 3, lines 47-48, is it a new sentence for “Living with mother’s only... ”? This part should be checked for typo and reorganized for better understanding. • It has no any error. When the data collector asked an individual’s living arrangement. The response of the participant was living with mother’s only meaning the respondent was living only with his or her mother.

Introduction:

Page 3, line 63, need a citation for the sentence “It is estimated that each year, 200,000 homicides occur in this age group in the world.”. Thank you,

• Authors accepted the comments and corrected it accordingly.

Pages 4-5, lines 82-108, the authors introduced many violence-related studies involving youth around the world. What was the core information the authors tried to deliver? As we all know, the prevalence of violence has been well studied; in some countries, surveillance data are available to monitor the trend and consequences of youth risk behaviors including violence. The authors may want to reorganize the literature and see how they can better serve their paper. • The core information was to know how much the magnitude of youth violence in different countries and settings in general and types of violence in particular and also to look-over a limited studies on youth violence in Ethiopia. These reviews used for the authors to compare their own research findings accordingly.

Page 6, lines 123-129, what are the gaps in the current literature? The authors need to briefly summarize the findings from pervious violence-related studies that included youth in Ethiopia, and then specify the gaps that this study may bridge. If very limited studies were found, studies in other countries with similar demographic characteristics or socio-economic status should be highlighted to provided information instead.

• The gaps in these limited literatures were the studies mainly concentrated among women age 15 to 49 or only on males, and institutional based. Whereas, this study concerned on both sex, among youth and community based and also assessed the three forms of violence simultaneously.

• Studies in other countries with similar demographic characteristics or socio-economic status might have different socio-cultural and behavioral characteristics. There might be also a variation on the associated factors. So, Identifying the prevalence and associated factors of youth violence was helpful to design an intervention in the study area.

Methods:

Page 7, lines 147-149, the authors mentioned: “Firstly, two woredas from the central Gondar zone, one woreda from each North Gondar zone and west Gondar zone were selected. Secondly, three kebeles were selected from the selected woredas.” How were the woredas and kebeles selected? Details need to be provided. • Centeral Gondar having 13 woredas (north Gondar zone having 7 woredas and west Gondar zone having 4 woredas).

�  “Firstly, two woredas from the central Gondar zone, one woreda from each North Gondar zone and west Gondar zone were selected by using simple random sampling tecnique.

�  Secondly, from the total number of kebeles (546 kebeles) in the three zones: three kebeles were selected from each selected woredas by simple randomly sampling.

Pages 7-8, lines 154-167, what were the variables/survey questions used in this study? Only definitions from WHO are insufficient for readers to learn this study. The authors may benefit from providing a detailed description of the survey, including how it was developed, included domains/topics, and questions/valid responses used in this study.

The survey questions were

• Have you experienced violence in the past 12 months?

• Have you experienced violence like hit /slapped or thrown something by someone in the past 12 months?

• Have you experienced violence like scared/intimidated by somebody in the past 12 months?

• Have you exposed to sexual violence for the last 12 months?

Pages 8-9, lines 180-185, was it a complete dataset for analysis? Any missing data information? • Yes, No any missing data information

Results:

Pages 9-13, table 1 and table 2 can be combined, as both addressed the participants’ demographic information Thank You,

• Table 1 and table 2 are merged into one table.

Page 13, lines 201-205, it seems there were multiple violence variables. Which one was the dependent variable used for the logistic regression?

• The dependent variable used for the logistic regression was “prevalence of violence”

Page 15, line 201, what were the independent variables that tested in the regression? If all of them were listed in table 4, why they were selected? Are there any other variables in the survey that can be potentially taken into the model (e.g., mental health problems)? • No, all variables listed in the socio-demographic table were tested in the bi-variable analysis. Those variables have a p-value of < 0.2 were taken in to the multivariable logistic regression model. Those variables are listed in the table 4(3) and other potential variable like substance use was considered from the survey.

Discussion:

This section repeated too much of the results (e.g., lines 227, 235, 248, 251...). Also, the authors may want to discuss the strengths of this study and implications for violence prevention • It has no any repetition; the authors wanted to describe how much the prevalence of different forms of youth violence (physical, sexual or emotional) and compared them with other studies.

Reviewer #2

There is limited information about assessing risk of bias Thank you very much!

• In addition to recall bias, social desirability bias might be occurred during data collection since the data collectors were used interviewer administered questionnaires.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

25 Nov 2021

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Siew Ann Cheong, Ph.D.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review the revised manuscript titled “Prevalence of violence and associated factors among Youth in Northwest Ethiopia: Community-based Cross-sectional study”. Without using track changes in the main text or pointing out the changes in the responses to comments, it was very challenging to tell the difference between the original submission and the revised one. I did a side-by-side check and found there were very limited changes in the introduction, methods, results, and discussion sections. Most of my previous concerns/suggestions remained unsolved.

Reviewer #2: The author/authors have responded to all the comments and provided information regarding their research .

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Ashraf Mozayani

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

5 Jan 2022

Point by point response

Response for Editor

Please ensure that your manuscript meets PLOS ONE's style requirements, Dear Editor, we have tried to address the PLOS ONE’s requirements.

Reviewer #1:

Abstract:

Page 2, line 33, the authors stated that “There was limited information on the burden of violence and factors among this age group”. This is not true. Dear reviewer #1, Author’s have accepted your complaint, however, we couldn’t understand which areas/questions were not well addressed.

Anyway, we have made modification on some questions as much as possible.

• Authors reviewed a lot of studies however, those studies mainly concerned on institution based, the study participants were adolescent females or males only, researched a single problem (sexual or physical) and didn’t show burden of violence among this specific age group. Whereas, this study was community based including both sex group, assessed overall prevalence of violence in general and the three common forms of violence in particular.

Page 2, lines 39-40, variables/risk factors used in the logistic model should be specified in the abstract. What was the dependent variable? What were the independent variables? Thank You!

• “Youth violence” was the dependent variable whereas all socio-demographic variables listed in table1 and substance use were the independent variables.

Page 3, lines 47-48, is it a new sentence for “Living with mother’s only... ”? This part should be checked for typo and reorganized for better understanding. • Living with mother’s only indicates adolescents/youth were living only with the support of his or her mother. When the data collectors asked them about currently living arrangement of the participants, a numbers of the participant’s responses were living with mother only or father only or living with both mother and father or others options found in the table.

Introduction:

Page 3, line 63, need a citation for the sentence “It is estimated that each year, 200,000 homicides occur in this age group in the world.”. Thank you,

• Authors accepted the comment and corrected it accordingly.

Pages 4-5, lines 82-108, the authors introduced many violence-related studies involving youth around the world. What was the core information the authors tried to deliver? As we all know, the prevalence of violence has been well studied; in some countries, surveillance data are available to monitor the trend and consequences of youth risk behaviors including violence. The authors may want to reorganize the literature and see how they can better serve their paper. • The core information that the authors tried to deliver was how much the prevalence of youth violence in different countries and settings in general and types of violence in particular. By reviewing different literature, authors identified limited studies on youth violence in Ethiopia, most of the studies were concerned on gender based or intimate partner violence among reproductive age women from 15 to 49 or sexual and reproductive health problems among youth.

Page 6, lines 123-129, what are the gaps in the current literature? The authors need to briefly summarize the findings from pervious violence-related studies that included youth in Ethiopia, and then specify the gaps that this study may bridge. If very limited studies were found, studies in other countries with similar demographic characteristics or socio-economic status should be highlighted to provided information instead.

• The gaps in these limited literatures were the studies mainly concentrated among women age 15 to 49 years. On the other hand, analysis from EDHS data that might underestimate the prevalence of violence, other studies were done only on males on a single type of violence or institutional based. Whereas, this study concerned youth violence on both sex groups, community based and also assessed the three forms of violence among youth simultaneously.

• Studies in other countries with similar demographic characteristics or socio-economic status might have different socio-cultural and behavioral characteristics. There might be also a variation on the associated factors due to that their results might not represent the results of studies in our country. Therefore, Identifying the prevalence and associated factors of youth violence will be helpful to design prevention and intervention strategies in the study area.

Methods:

Page 7, lines 147-149, the authors mentioned: “Firstly, two woredas from the central Gondar zone, one woreda from each North Gondar zone and west Gondar zone were selected. Secondly, three kebeles were selected from the selected woredas.” How were the woredas and kebeles selected? Details need to be provided. • This mega project study was done in centeral, west and north Gondar zone. A total 24 woredas present in the three zone: centaral Gondar zone have 13 woredas, north Gondar zone 7 woredas , and west Gondar zone 4 woredas.

�  “Firstly, two woredas from the central Gondar zone, one woreda from each north Gondar zone and west Gondar zone were selected by using simple random sampling technique.

�  Secondly, from the total number of kebeles (546 kebeles) in the three zones: three kebeles were selected from each selected woredas by simple randomly sampling.

Pages 7-8, lines 154-167, what were the variables/survey questions used in this study? Only definitions from WHO are insufficient for readers to learn this study. The authors may benefit from providing a detailed description of the survey, including how it was developed, included domains/topics, and questions/valid responses used in this study.

Thank You, we have addressed the survey questions in the document.

The survey questions were

• Have you experienced violence in the past 12 months?

• Have you experienced violence like hit /slapped or thrown something by someone in the past 12 months?

• Have you experienced violence like scared/intimidated by somebody in the past 12 months?

• Have you exposed to sexual violence for the last 12 months?

Pages 8-9, lines 180-185, was it a complete dataset for analysis? Any missing data information? • Yes

• No any missing data information was found in this study analysis.

Results:

Pages 9-13, table 1 and table 2 can be combined, as both addressed the participants’ demographic information Thank You,

• We have done it.

Page 13, lines 201-205, it seems there were multiple violence variables. Which one was the dependent variable used for the logistic regression?

• The dependent variable used for the logistic regression was “prevalence of youth violence”

Page 15, line 201, what were the independent variables that tested in the regression? If all of them were listed in table 4, why they were selected? Are there any other variables in the survey that can be potentially taken into the model (e.g., mental health problems)? • All independent variables listed in the socio-demographic table and other potential variable from the survey (substance use) were tested in the bi-variable analysis.

• Variables listed in table 4(3) (sex, marital status, educational level, currently attending with school, living arrangement, wealth index, and substance use) were selected after bivariable analysis results- variables have a p-value of < 0.2 were taken in to the multivariable logistic regression model.

• Potential variable selected in the survey was substance use.

Discussion:

This section repeated too much of the results (e.g., lines 227, 235, 248, 251...). Also, the authors may want to discuss the strengths of this study and implications for violence prevention. • Thank you. Authors have made correction on the main document.

• The strength and implication of this study is included in the main document.

Submitted filename: Revised Response to reviewers.docx

Click here for additional data file.

16 Feb 2022

Prevalence of violence and associated factors among Youth in Northwest Ethiopia:

Community-based Cross-sectional study

PONE-D-20-39684R2

Dear Dr. Yeshita,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Siew Ann Cheong, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #3: Yes

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6. Review Comments to the Author

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Reviewer #3: Very thorough feedback was give to the authors by each reviewers. Given the time and line by line response by the authors, there have been an excellent attempt to edit the manuscript accordingly. The responses are satisfactory and there there are no concerns or worry about methodology, writing, or findings at this time. Thank you for your efforts

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Reviewer #3: Yes: Carolyn Gentle-Genitty, PhD

4 Mar 2022

PONE-D-20-39684R2

Prevalence of violence and associated factors among Youth in Northwest Ethiopia: Community-based Cross-sectional study

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