Gender-based violence is becoming an increasing during conflict, with negative short and long-term consequences for the victims, their families, and communities. Since the eruption of war in November 2020 in Tigray, many women reported sexual violence. Thus, this study aimed to explore the physical, sexual and mental health consequences of gender-based violence among female survivors in severely war-affected areas of the Tigray region of Ethiopia.

This study employed mixed methods including quantitative and qualitative studies during the war in Tigray, Ethiopia. A total of 528 sexually abused women and girls were included in the quantitative study from a community-based survey conducted in August 2021. Moreover, six in-depth interviews with rape survivors were conducted to share their experiences. A standardized interviewer-administered questionnaire was used for the community survey and a semi-structured checklist recorded by audio was used for qualitative study. Descriptive statistics and the Pearson chi-square test were used to assess the relationship between health consequences, different socio-demographics, and types of sexual violence. Thematic analysis was performed after the recorded audios were transcribed.

Of the survivors, 435 (82.4%) had been raped and 404 (76.5%) had experienced a triple trauma burden of sexual, physical, and psychological violence. Most survivors had experienced consequences ranging from mild (34.5%) to severe injuries (42.1%), mental health and behavioral problems (75.6%) like posttraumatic stress disorder (12.1%), stress (63.5%), anxiety (38.6%), depression (27.5%), sleeping disturbance (35.2%), nightmare (29.0), flashbacks and social isolation. More than one-fifth (21.8%) of rape survivors experienced sexual and reproductive health problems such as exposure to STIs, unwanted pregnancy, abortion, and HIV. Survivors encountered the worst rape scenarios such as gang rape by troops and combatants.

Survivors experienced severe forms of physical injuries, posttraumatic stress disorder, and sexual and reproductive health problems. Humanitarian agencies and civic organizations need to provide immediate medical and psychological support to victims to reduce further health consequences and harm.

Recently, gender-based violence is increasing from time to time, especially in developing countries with a direct or indirect link to a conflict. Women and girls are disproportionately targeted in conflict and require higher levels of protection. They are at increased risk for sexual violence during conflicts and are forced to exchange sex for safe passage, food, shelter, or other resources and protection [1,2,3].

According to the ecological model of violence in conflict settings, there are various layers of factors that contribute to violence, especially against women. The different elements, such as global, societal, institutional, community, interpersonal, and individual, interact and influence each other, creating a complex environment where violence is more likely to occur and persist during and after conflict. Conflict settings introduce unique drivers of violence that exacerbate the vulnerability of women. Economic collapse, displacement, and the breakdown of family support systems are major contributors. Women may face increased poverty as conflict destroys resources, leads to hyperinflation, or causes the collapse of labor markets, making it harder for them to escape abusive situations. Displacement often results in a lack of access to basic needs and services, making women even more vulnerable to exploitation and violence. Additionally, in conflict zones, women may be targeted for sexual violence as a form of control, punishment, or revenge, adding another layer to the cycle of violence [4, 5].

Gender-based violence has varieties of negative short-term and/or long-term health, social, and economic consequences for the victims, their families, and communities at large. Victims face psychosocial consequences, including posttraumatic reactions, suicidal behavior, isolation, damaged reputation, and spiritual harmony. These consequences may affect multiple aspects of the victim’s life, physical well-being, and psychological well-being which in turn impacts their socio-economic opportunities [6, 7].

Globally, war-related sexual violence has become an increasing trait of conflict and security challenges. Rape is deployed deliberately and systematically as a weapon to achieve military or political goals to terrorize the population, break up families, and destroy communities [8,9,10,11,12,13,14]. In addition, essential social services, such as medical facilities, on which women heavily depend for their well-being, are greatly disrupted by armed conflicts [15]. This is an additional burden on subordinate populations like women and children in developing countries.

Africa endures some of the worst cases of war-related sexual violence, with the situation in many parts of the continent characterized by indiscriminate sexual violence and mainly perpetrated by armed groups who use it to humiliate, intimidate, and dominate women, girls, and entire communities [16,17,18,19,20]. In recent years, security issues and conflict have presented common challenges for community members in Ethiopia. For example, one of the regions in Ethiopia, the Tigray regional state in Northern Ethiopia, has faced a disturbing armed conflict from November 04, 2020, to November 02, 2022, until the Pretoria peace agreement [21, 22]. As many reports indicated, many women and girls have been raped and sexually abused [23,24,25,26,27]. Around 43% of women and girls experienced one form of gender-based violence during the conflict [28]. The reports on the number of sexual violence vary from report to report. In July 2021, the United Nations Population Fund (UNFPA) estimated more than 26,000 women/girls need treatment services for sexual and gender-based violence in the Tigray war [25]. While the Tigray Health Bureau estimated more than 120,000 women and girls have been raped from November 2020 to June 2021 [26]. In general, this indicates there are a higher number of women and girls who have been sexually abused during the war in Tigray, Ethiopia.

As there is limited empirical data and reliable information, many gaps exist in our understanding of women and girls experiencing sexual violence, and this study aimed to assess the health consequences of gender-based violence among women and girls during conflict in the Tigray region of Ethiopia. The findings of this study could be used in preventing and reducing gender-based violence, raising the level of awareness among decision-makers, and setting priorities for rehabilitation measures during conflict periods.

Mixed-methods (quantitative and qualitative) studies were conducted among victims of sexual violence during the war period in the Tigray region of Ethiopia. A community survey was conducted in six zones of Tigray from August to September 2021. To support the quantitative study, six in-depth interviews with rape survivors were conducted among survivors who visited the health service. The Tigray region has suffered the worst warfare for the last two years, with a conflict waged between the federal government together with its ally (foreign forces and other regional forces) and the government of the Tigray regional state [22]. This conflict has led to the mass traumatization of the population, including the abuse of human rights, the massacring of innocent civilians, the mass raping of women and girls [28], the destruction of health facilities, and the forced displacement of over 1.2 million people into internally displaced person camps [21]. Following pressure from the international community, the federal government and the Tigray regional state government agreed to a truce in March 2022, which brought relative peace to the region. However, on August 24, 2022, the war unexpectedly resumed, intensifying the conflict and complicating the situation further. Finally, following repeated calls from the international community, the war was resolved peacefully through dialogue with the Pretoria agreement on November 3, 2022. This paper studied the particular health consequences of war-related sexual violence among women and girls from six war-affected zones of the Tigray region to emphasize the burden and consequences of the problems.

A community-based cross-sectional study with mixed methods was employed. In the quantitative part, a total of 528 sexually abused women and girls were interviewed from 5,171 sampled households in the 52 randomly sampled districts of the region.

To select 528 samples of survivors, first, a regional-based survey was conducted using multi-stage cluster sampling methods where the first stage was selecting districts and the second stage was selecting households having women of reproductive age groups. From the total 93 districts in the Tigray region, 84 districts were included in the random selection after excluding 09 districts due to security reasons, and then 52 districts were randomly selected. From the selected districts, 306 clusters (Tabias: smaller administrative unit) were selected randomly by taking at least four clusters per selected district. Further, 44 clusters were excluded due to security issues at the field level. A total of 5,240 households were selected from the remaining 262 clusters by considering 20 households per cluster. Finally, 5,171 HHs were included after excluding households for unavailability and incomplete data. From the 5,171 HHs, a total of 2,521 women/girls with experiences of any form of violence were selected from the survey. Further, 528 women/girls who experienced sexual violence were included for this study. After identifying survivors, detailed information about consequences was further collected. The detailed sampling procedure is found in (Fig. 1). Additionally, a qualitative study was done separately to get detailed information about the severity and lived experience of survivors. In the qualitative, a phenomenological study (lived experience about the phenomenon) was conducted with rape survivors. Six participants were recruited for the in-depth interviews. The rape survivors for the qualitative study were taken from the center where survivors were admitted to the safe house for care and treatment in the regional capital of Mekelle.

Schematic representation of sampling procedure used to select survivors of sexual violence in Tigray war, 2021

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The standardized interviewer-administered questionnaire was prepared by adopting from the WHO multi-country study, and the tool was translated into the local language (Tigrigna) and then back to English to check for consistency (Additional file 1). The questionnaire sections include socio-demographic characteristics, physical, psychological, and sexual violence forms, consequences (physical, psychological, sexual, and reproductive health), and coping mechanisms. Before the actual data collection, the tool was pretested and modified accordingly to minimize possible error. Data were collected by female health extension workers at a community level. Training on the purpose of the study, techniques of data collection, and ethical issues was given to data collectors and supervisors. In the qualitative study, a case study using in-depth interviews was conducted to complement with the quantitative data. A checklist was prepared to guide interviews with survivors. The in-depth interviews using tape recording were conducted among six volunteer rape victims receiving medical care in a safe house in Ayder Comprehensive Specialized Hospital, Mekelle, Tigray. Data were collected by female investigators and clinicians who work at the center caring for rape survivors.

Data were entered and cleaned using Epi-data version 4.6 and then exported into STATA version 14 for analysis. Descriptive statistics were used for graphing and tabulation (computation of frequencies and percentages) of selected variables. For the qualitative data, thematic analysis was employed, focusing on the way the theme is treated and the frequency of its occurrence. The collected data were coded and organized using quotes from subjects focusing on major issues and critical events relevant to the research questions. Thus, triangulation of the evidence strengthens the validity and reliability of the study findings.

Sexual violence: Was measured if women/girls experienced at least one of the following: any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic a person’s sexuality, using coercion, threats of harm, or physical force, by any person [1, 29].

Completed Rape: defined as non-consensual penetration or sexual intercourse even if slight of the vagina, anus, or mouth with a penis or other body part, and also includes penetration of the vagina or anus with an object [30].

Attempted Rape: It was measured if survivors experienced uses of force, threat of force, and/or coercion effort to rape them which do not result in penetration of vagina, anus, or mouth are considered attempted rape [31].

Physical violence: It is an act of physical violence/abuse that is not sexual in nature. It was measured if women/girls experienced at least one of the following: slapping, hitting, choking, shoving, cutting, burning, use of any weapons or shooting, acid attacks, or any other act that results in pain, discomfort, or injury.

Psychological violence: The mental or emotional pain or injury that caused by at least one of the following: threats of physical or sexual violence, intimidation, harassment, humiliation, forced isolation, stalking, unwanted attention, remarks, gestures, or written words of a sexual and/or menacing nature, destruction of cherished things.

Posttraumatic Stress Disorder (PTSD): Measured based on the definition of primary care, posttraumatic stress disorder (PC-PTSD) screening scale [32]. Which measured using 4-items: (Nightmare: had nightmares about it or thought about it; Avoidance: Avoidance of reminders of the event, Social Isolation: felt numb or detached from others; and Excessive worry: hyper-vigilance presents for at least one month). The primary care, posttraumatic stress disorder (PC-PTSD) screening scale, considered"positive"if a survivor’s answers"yes"to any 3 items of the 4-items [32].

Physical trauma: it was measured if women/girls experienced one of the following: scratch, abrasion or bruises; cuts, punctures or bites; burns; penetrating injury or deep cuts; sprains or dislocations; broken eardrum or/and eye injuries; fractures or broken bones; broken teeth, internal injuries, and it was coded as 1 “Yes” and 2 “no”.

Mild physical trauma: categorized if survivor experienced one of the two types of traumas (scratch, abrasion or bruises; or cuts, punctures/bites);

Severe physical trauma: categorized if survivor experienced one of the seven traumas (sprains or dislocations; burns; penetrating injury or deep cuts; fractures or broken bones; broken eardrum or/and eye injuries; broken teeth, internal injuries).

Mental health and behavioral problem: measured if a women or girls experienced at least one of the following 12 items which was assessed based on self-report on the presence of emotional and mental health problems after sexual abuse includes: night mare, avoidance of events, excessive worry, social isolation, depression, suicidal ideation or attempt, fear, stress, anxiety, flash backs, experiencing of events, sleeping disturbance. Coded as “Yes” = 1 and “no” = 0.

Sexual and reproductive health problems: it was measured among the rape survivors. Coded as 1″yes” if survivors experienced at least one of the five items (experiencing STIs, HIV, Hepatitis B, unwanted pregnancy or had abortion) due to the rape; coded 0 “no” if not experienced any of the five items on sexual and reproductive health problems.

A total of 528 sexually abused survivors were identified and extracted from the community survey during wartime in Tigray to participate in the quantitative study. The survivors’ ages ranged from 10 to 68 years old. Thirty (5.7%) of the survivors were underage (< 18 years). Nearly one in four 125(23.7%) of the respondents were between the ages of 18 and 24 years. The majority of victims, 500 (94.7%) were in their reproductive age group (15–49 years) and from rural residence, 273 (51.7%). Most of the victims 234 (44.3%) had no formal education. Nearly two-thirds of victims 309 (58.5%) lived in rental or family houses, and 21 (4%) lived in internally displaced persons (IDP) camps. One half of 264 (50%) of the respondents were married (Table 1).

Participants for the qualitative study include six (n = 6) female rape survivors admitted in safe house program and completed in-depth interviews. The women’s age ranged from 17 to 30 years. The average length of record for each IDI was 16 min.

The study finding indicated that about three in four 404 (76.5%) of the victims had combined sexual, physical, and psychological violence (triple trauma burden) during wartime in Tigray. Among the 528 sexual violence victims, 435 (82.4%) were raped and 93 (17.6%) experienced other forms of sexual assault. Nearly two-thirds 349 (66.1%) of the victims were physically forced to have unwanted sexual intercourse, and 319 (60.4%) were threatened with harm to make the victim have vaginal or anal sex.

The survivors in the qualitative study reported that most encountered the worst rape during the wartime. They were raped on their way when they moved to their routine daily activity, displaced from one place to another place, and even when they sat at their homes by multiple perpetrators or gang-raped. When every perpetrator raped them, they were intimidated on purpose, belittled or humiliated, and even had sex in front of their children or family member. Moreover, the participants reported that they were detained against their will on average for about six days, ranging from 1 to 14 days.

…Three external forces raped me on December 13, 2020. While raping me, I was a virgin. My right hand and my leg got fractured while they were raping me. Eventually, they snapped at me and dropped me on the ground. (IDI displaced student, 17 years old)

Among the 528 victims, 483 (91.5%) experienced physical violence in addition to sexual violence. Three in five, 322 (60.9%), of the victims were physically kicked, dragged, or beaten up by the perpetrators, and 269 (50.9%) were punched with a fist or with something else. Among the physically abused victims, 358 (74.4%) reported sustaining two or more forms of physical violence.

The study participants in the qualitative also explained the different forms of physical violence encountered by the perpetrators. These physical violence forms included hitting with a fist or with something else that could hurt the victim, pricking with a knife, beating up or slapping the face, burning the reproductive organ, dropping the victim, pushing the victim and her child, hitting the victim’s teeth, breaking the hands and legs, taking money using force, and taking the child using force.

When I was going to my work on February 03, 2021, military personnel who had patrol ordered us to lift stones from the road. However, they ordered me to enter the cabin and took me with them into their camp. Then, turn by turn, then beaten and raped me (cry). As a result of this, I have been exposed to a disease (30 years, IDI, teacher, married).

Though empirical data on psychological trauma is intricate to obtain, 431 (81.6%) of the 528 sexual violence victims reported experiencing psychological violence. Such as three in four (400, 75.7%) of the victims were insulted or made to feel bad about themselves during the sexual violence. Besides, 308 (58.3%) of the victims were belittled or humiliated in front of other people. Among the psychological violence victims, 403 (93.5%) reported experiencing two or more forms of psychological violence. Furthermore, 37.6% of the psychological violence victims sustained all five forms of psychological violence. Among the sexual violence victims, 175 (33.1%) reported that the perpetrators were laughing at them, 205 (38.8%) reported that they were mocking them, and 272 (51.5%) reported that they were throwing abusive words (Table 2).

Participants in the qualitative study mentioned that perpetrators detained against their will, belittled or humiliated the victim in front of other people, intimidated the victim on purpose, disdained and degraded the victim, and insulted or made to feel bad.

Among the sexual violence victims, 30 (5.7%) were underage girls (< 18 years of age), out of whom 27(5.1%) were raped. Nearly one in four 125 (23.7%) of the victims were in their late teens or early twenties, and 110 (20.8%) were rape. More than three in four 411 (77.8%) in their reproductive age group experienced rape, which led to the high probability of unwanted pregnancy (Fig. 2).

Age of survivors by the type of sexual violence during the wartime in Tigray, 2021

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Physical health consequences on the victims range from mild to severe injuries. Two in five of the victims, 222 (42.1%) suffered severe physical injuries, including internal injuries, burns, sprains, and bone fractures. Besides, 182 (34.5%) suffered mild physical injuries, including abrasions, cuts and punctures (Table 3).

Participants in the qualitative study mentioned the following physical health consequences. For example, the victims reported fractures of hands and legs when they were raped, broken bones, sprains or dislocation of the backbone, burns of the reproductive organ, internal injuries like sound in the reproductive organ, paralysis of the hands, scratches, abrasions, bruises, and many of them experienced physical disfigurements.

My reproductive organ has sounded since I was raped by 8 perpetrators. I could not stand from my seat by myself. Yes, they beat me up with the heavy part of their weapon, and my hands became paralyzed. I could not do anything with my hands. Then, I came to the health facility and got treatment. Now, I am lucky I can talk. (24 years, IDI, bachelor degree holder, married, Mekelle zone)

Anxiety, sleep disturbance, nightmares, flashbacks, and social isolation were some of the most noticeable descriptions of mental health and behavioral problems experienced by the victims. Participants in the qualitative study mentioned the following mental health and behavioral problems. These were excessive worries when people had no sleep at night, never slept the whole night, feared, had flashbacks when remembering family and past life, experienced mental instability, compulsive thinking, a flow of blood from the nose and mouth when worried, disappointment, committed suicide attempts by cutting the body with a blade, isolated from people, re-experiencing the event, avoidance of people, unable to communicate with people, beaten up children with no reason, madness, crying the whole night, and shaking of the whole body when people talked about the issue of sexual violence (Table 3).

Just in the night, I did not sleep. I never slept. I just sat the whole night. If I disappoint, a gush of blood will flow through my nose and mouth. Last time, I experienced a car accident, and I was unconscious for 30 minutes. Whenever I disappointed, I cried and became angry. I was disappointed very much. I never had such a kind of behavior before. Whenever I remembered the incidence of rape, my mind told me to go away to a place or country where there is no person (to disappear). I worried very much, and I did not listen to anyone who talked to me. (17 years, IDI, elementary school student displaced from western Tigray).

One fourth, 95 (21.8%) of rape survivors experienced at least one of the sexual reproductive health problems, such as HIV infection (2.5%), other sexually transmitted diseases (13.1%), unwanted pregnancy (8.7%), and abortion (4.0%). Out of the 528 victims of sexual violence, only 88 (16.7%) sought and attempted to receive support from healthcare facility, and yet only 81 (15.3%) had received medical care and treatment. However, the remaining 447 (84.7%) sexual violence victims did not receive any medical support (Table 3).

Participants in the qualitative study mentioned the following sexual and reproductive health consequences: menstrual disorder (abnormality of menses, irregular bleeding, absence of a period for 4 months, heavy bleeding), burning sensation in the reproductive organ, discharge followed by itching and burning sensation, infection with disease, having foul-smelling discharge that cannot be treated, infected with HIV, unwanted pregnancy, abortion, and swelling in the reproductive organ associated with itching (Table 3).

My reproductive organ (vagina and perineum) was swelling and prolapsed outside. Bleeding was not stopped. It is better now. I was also infected with HIV before this event happened, I was negative (crying…for long time). (30 years, IDI, diploma holder teacher, married)

About 400 (75.8%) of the sexual abuse victims suffered from mental health and behavioral consequences. And posttraumatic stress disorder was one of the common problems observed. Based on the four items (nightmare, avoidance, excessive worry, Isolation), 64 (12.1%) victims experienced posttraumatic stress disorder (PTSD) (Table 3). Those women or girls whose age was less than 35 years, urban residence, able to read & write, employed/private business, living alone, never married or single, having no child, raped, and with physical trauma had experienced higher mental and behavioral consequences (Table 4).

As coping mechanisms, many survivors sought refuge by hiding in caves or religious places (24.5%), in the mountains (18.5%), or in other secret locations (21.8%). A significant number also sought shelter with the Tigray Defense Force (TDF) army (24.1%), while others relocated within their own areas (7.8%). Survivors also reported on how communities and families protected children from violence during the conflict. According to the report, community and family members primarily encouraged young girls and boys to join the TDF army (85.2%), while smaller percentages hid them in secret places (6.9%) or in caves and religious locations (4.5%) (Table 5).

The study findings showed three-fourth of the survivors experienced a severe form of physical, medical, reproductive, and psychological trauma during the wartime in Tigray. This shows how wartime sexual violence has a negative effect on women, mainly due to mass or gang rape by the combatants. The absence of security and social breakdown makes women and children highly vulnerable during wartime and exposes them to different gender-based violence. The harm and consequences will be too high if women disclose freely. However, due to shame, fear of stigma or isolation, and low awareness, sexual violence is often underreported [20].

This study has revealed that different forms of sexual violence have been inflicted on women and girls. Two-thirds of the victims reported two or more forms of sexual violence, mainly rape, which signifies sexual violence has been an insidious and alarming feature of the war in Tigray. Consistently, previous reports in different conflict settings show that the pattern of sexual violence was systemic and widespread, with all the victims sustaining symmetric forms of assault [12, 13, 27]. The forms of sexual violence in the current study included sexual assault, such as touching on sexual parts, forced nudity, sexual exploitation, penetration of the vagina with an object, and forcible sexual intercourse, which were similar to those reported in the Sierra Leone civil war [17]. Similar to a cross-sectional study reported by Kinyanda et al., in the northern Uganda war [19], though sexual violence in Tigray has also affected extreme ages (very young and too old women), where reproductive age group girls and women were found to be most at risk for sexual violence during the current study.

In this study, two-fifths of the rape survivors suffered severe physical injuries as a result of the physical assault, including beating, dragging, shoving, slapping, choking, burning, hitting with a fist, defacement, and threatening to use or using a weapon. Consistently, this was reported in multiple war raid places in Africa and Ukraine [2, 10, 17, 19].

In the present study, four in five of the sexual violence victims reported experiencing psychological trauma, most of whom endured two or more forms of psychological trauma. Most survivors manifested anxiety, sleep disturbance, nightmares, flashbacks, depression, social isolation, and avoidance. About 12% of the victims suffered from PTSD, and 75% experienced at least one form of mental and behavioral health consequences. Similarly, studies by Kinyanda E [19], Tol WA [33], and Chivers-Wilson KA [34] reported that most of the victims of conflict-related sexual assault had endured severe psychological consequences. Both the general war trauma and conflict-related sexual violence can aggravate the mental health consequences among victims in this study. There are several factors for the high mental health problems related to conflict-related sexual assault. According to Campbell R, et al., the negative mental health consequences of sexual assault arise from various factors, not solely the victim's characteristics. Elements such as the nature of the assault, post-assault disclosures, help-seeking behaviors, sociocultural norms [35] and the general war set-up [4] all play a significant role in shaping how this trauma impacts women's psychological well-being. Survivors’ pre-assault mental health may also affect the recovery process, as Campbell R, et al. indicated, but in this study, prior mental health of the survivors was not studied. We recommend further study to assess prior victimizations or general war trauma effects in relation to preexisting mental health. Thus, survivors need to get immediate psychological care and medical support since this condition may harm young girls and women and influence their daily activities and social behaviors.

More than half of the victims reported that the perpetrators who were involved were multiple in number and frequently raped. It has been reported that the perpetrators subsequently mutilate survivors, psychologically abuse them by telling abusive words and rape them in front of their family members. This is supported by different reports in Tigray war where militants sexually and psychologically abused girls and women during the war period [27, 36]. Correspondingly, reports in other conflict zones have demonstrated the different forces utilize sexual assault as a weapon of war [14, 37]. This condition may result in sever forms of psychological problems unless treated early, since it has social and relationship impacts.

In the present study, bacterial STDs, HIV, and hepatitis infections were reported in 13.1%, 2.5%, and 0.8%, respectively. Schwarcz et al. reported the prevalence of post-assault bacterial STDs ranges from 3 to 9% and viral agents of STD, including hepatitis and HIV, were very common [38]. This indicates there is a higher prevalence of STIs in the present study. In the present study, 8.7% of victims experienced unwanted pregnancy. This was in agreement with a report by Holmes et al. which depicted the rape-related pregnancy rate to be 5.0% [39]. As this finding indicated, the medical health consequences were too high compared to other studies in conflict areas. The different medical problems and pregnancy-related complications and poor outcomes, such as fistula, traumatic genital injury, unwanted pregnancy, abortion, and sexual transmitted infections were reported as consequences in the war-affected setting [16, 38, 39]. Moreover, four in five of the victims in the present study did not receive any medical support. This is supported by studies in war settings where most of the survivors do not get healthcare services or may be delayed [40]. This might be because most of the healthcare institutions during the war in Tigray were rendered non-functional during the war period [41, 42], undercounting or fear of being raped again [43].

Mental health and behavioral consequences on the victims showed the presence of significant associations with some types of sexual violence and socio-demographic characteristics of the victims. Survivors who were raped experienced more medical and psychological consequences than those who experienced sexual assault, including attempted rape. Survivors who experienced sexual violence by more than one perpetrator experienced more mental and psychological consequences. Those younger girls, from urban residences, unable to read and write, married or ever married, and had a child, experienced more mental and psychological problems.

The findings of this study were subjected to certain limitations. The information is based on self-reported data elicited through interviews, which could be subject to recall bias, and for several reasons, including shame, stigma, and low awareness, sexual violence might have been underreported. Most of the mental health and emotional change consequences were measured using single items (yes/no) as a self-report from victims. Due to the large number of items to measure each component of mental health and psychological problems including, posttraumatic stress disorder, depression, and stress the researcher could not measure the mental health and psychological problems using the standard guideline. The researcher used a self-report of girls and women to report depression, stress, and anxiety as a single question (yes/no) etc. We did not use different item scales to measure depression. Moreover, we did not use the Hopkins Symptom Checklist or the Harvard Trauma Questionnaire due to limited access during the war of the study period. However, the PTSD was measured and screened using the standard, which is a commonly used scale in primary health settings, which was developed by a known psychologist [32]. Moreover, this study used both quantitative and quantitative studies to supplement each other and used data from most of the war area in Tigray, which was the strength of the study. Therefore, the limitation and strength of the study should be considered in the interpretation of the findings.

IDI:

In-depth interview

GBV:

Gender-based violence

HIV:

Human Immuno-deficiency Syndrome

PTSD:

Posttraumatic stress disorder

STDs:

Sexual Transmitted Diseases

STIs:

Sexual Transmitted Infections

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GFA, AG, AM, YGR, TZ, HBT, and AH were involved in the inception of the concept and proposal development. GF, HHA, ABA, ADW, FT, GKL, and BD develop the methodology section. GF, AM, and GKL validate the data quality. FT, HHA, ADW, ABA, TH, TKW, YBT, BA, AHA, HT, AY, HG develop the methodology for qualitative data, analysis, and result section. GF, HHA, ADW, and ABA have drafted the manuscript. All authors review the manuscript.

Correspondence to Girmatsion Fisseha Abreha.

Ethical clearance was obtained from the Institutional Review Board of the College of Health Sciences, Mekelle University (Reference No: MU-IRB1905/2011). Permission letters were obtained from the Tigray Health Bureau and district health offices. Written informed consent was taken from adult women. Moreover, informed consent (assent) was obtained from a parent or legal guardian to interview underage women. Participants were informed about the purpose and use of the study and gave their consent without any pressure to speak or participate. Information confidentiality was maintained throughout. All methods were performed in accordance with the relevant guidelines and regulations. Additionally, a referral pathway was established for all survivors who were not receiving health services at the end of the interview. A primary objective was to guide them in connecting to these referral services and inform them about accessing health care. We set up a telephone service to facilitate their communication with health facilities through the One-stop Center, a separate project aimed at assisting survivors in the Tigray region. Moreover, a psychological support, including adequate time and reassurance was provided when survivors became emotional during the interviews. The study adhered to the Declaration of Helsinki.

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The authors declare no competing interests.

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