A theory of change for community interventions to prevent domestic violence against women and girls in Mumbai, India.

Background: We describe the development of a theory of change for community mobilisation activities to prevent violence against women and girls. These activities are part of a broader program in urban India that works toward primary, secondary, and tertiary prevention of violence and includes crisis response and counselling and medical, police, and legal assistance. Methods: The theory of change was developed in five phases, via expert workshops, use of primary data, recurrent team meetings, adjustment at further meetings and workshops, and a review of published theories. Results: The theory summarises inputs for primary and secondary prevention, consequent changes (positive and negative), and outcomes. It is fully adapted to the program context, was designed through an extended consultative process, emphasises secondary prevention as a pathway to primary prevention, and integrates community activism with referral and counselling interventions. Conclusions: The theory specifies testable causal pathways to impact and will be evaluated in a controlled trial.

You can't burn the house down because of one bedbug: a qualitative study of changing gender norms in the prevention of violence against women and girls in an urban informal settlement in India.

Background: The contribution of structural inequalities and societal legitimisation to violence against women, which 30% of women in India survive each year, is widely accepted. There is a consensus that interventions should aim to change gender norms, particularly through community mobilisation. How this should be done is less clear. Methods: We did a qualitative study in a large informal settlement in Mumbai, an environment that characterises 41% of households. After reviewing the anonymised records of consultations with 1653 survivors of violence, we conducted 5 focus group discussions and 13 individual interviews with 71 women and men representing a range of age groups and communities. We based the interviews on fictitious biographical vignettes to elicit responses and develop an understanding of social norms. We wondered whether, in trying to change norms, we might exploit the disjunction between descriptive norms (beliefs about what others actually do) and injunctive norms (beliefs about what others think one ought to do), focusing program activities on evidence that descriptive norms are changing. Results: We found that descriptive and injunctive norms were relatively similar with regard to femininity, masculinity, the need for marriage and childbearing, resistance to separation and divorce, and disapproval of friendships between women and men. Some constraints on women's dress and mobility were relaxing, but there were more substantial differences between descriptive and injunctive norms around women's education, control of income and finances, and premarital sexual relationships. Conclusions: Programmatically, we hope to exploit these areas of mismatch in the context of injunctive norms generally inimical to violence against women. We propose that an under-appreciated strategy is expansion of the reference group: induction of relatively isolated women and men into broader social groups whose descriptive and injunctive norms do not tolerate violence.

Examining inequalities in uptake of maternal health care and choice of provider in underserved urban areas of Mumbai, India: a mixed methods study.

BACKGROUND: Discussions of maternity care in developing countries tend to emphasise service uptake and overlook choice of provider. Understanding how families choose among health providers is essential to addressing inequitable access to care. Our objectives were to quantify the determinants and choice of maternity care provider in Mumbai's informal urban settlements, and to explore the reasons underlying their choices. METHODS: The study was conducted in informal urban communities in eastern Mumbai. We developed regression models using data from a census of married women aged 15-49 to test for associations between maternal characteristics and uptake of care and choice of provider. We then conducted seven focus group discussions and 16 in-depth interviews with purposively selected participants, and used grounded theory methods to examine the reasons for their choices. RESULTS: Three thousand eight hundred forty-eight women who had given birth in the preceding 2 years were interviewed in the census. The odds of institutional prenatal and delivery care increased with education, economic status, and duration of residence in Mumbai, and decreased with parity. Tertiary public hospitals were the commonest site of care, but there was a preference for private hospitals with increasing socio-economic status. Women were more likely to use tertiary public hospitals for delivery if they had fewer children and were Hindu. The odds of delivery in the private sector increased with maternal education, wealth, age, recent arrival in Mumbai, and Muslim faith. Four processes were identified in choosing a health care provider: exploring the options, defining a sphere of access, negotiating autonomy, and protective reasoning. Women seeking a positive health experience and outcome adopted strategies to select the best or most suitable, accessible provider. CONCLUSIONS: In Mumbai's informal settlements, institutional maternity care is the norm, except among recent migrants. Poor perceptions of primary public health facilities often cause residents to bypass them in favour of tertiary hospitals or private sector facilities. Families follow a complex selection process, mediated by their ability to mobilise economic and social resources, and a concern for positive experiences of health care and outcomes. Health managers must ensure quality services, a functioning regulatory mechanism, and monitoring of provider behaviour.

Sweat, Skepticism, and Uncharted Territory: A Qualitative Study of Opinions on Data Sharing Among Public Health Researchers and Research Participants in Mumbai, India.

Efforts to internalize data sharing in research practice have been driven largely by developing international norms that have not incorporated opinions from researchers in low- and middle-income countries. We sought to identify the issues around ethical data sharing in the context of research involving women and children in urban India. We interviewed researchers, managers, and research participants associated with a Mumbai non-governmental organization, as well as researchers from other organizations and members of ethics committees. We conducted 22 individual semi-structured interviews and involved 44 research participants in focus group discussions. We used framework analysis to examine ideas about data and data sharing in general; its potential benefits or harms, barriers, obligations, and governance; and the requirements for consent. Both researchers and participants were generally in favor of data sharing, although limited experience amplified their reservations. We identified three themes: concerns that the work of data producers may not receive appropriate acknowledgment, skepticism about the process of sharing, and the fact that the terrain of data sharing was essentially uncharted and confusing. To increase data sharing in India, we need to provide guidelines, protocols, and examples of good practice in terms of consent, data preparation, screening of applications, and what individuals and organizations can expect in terms of validation, acknowledgment, and authorship.