Prevalence, pattern, and predictors of formal help-seeking for intimate partner violence against women: findings from India's cross-sectional National Family Health Surveys-3 (2005-2006) and 4 (2015-2016).

BACKGROUND: Help-seeking for intimate partner violence (IPV) requires women to disclose their experiences. For policymakers, low help-seeking threatens the United Nations Sustainable Development Goals (SDGs) of gender equality, good health, and wellbeing. In India, the Prevention of Domestic Violence Against Women Act (PWDVA 2005) was implemented in 2006. Using two rounds of the India National Family Health Survey (NFHS), one before and one after implementation, we examined the prevalence, pattern, and sociodemographic and socioeconomic factors associated with formal help-seeking for IPV. METHODS: We used univariable and multivariable logistic regression models to assess the prevalence of help-seeking for IPV in the past 12 months and examined associations with different forms of IPV and sociodemographic factors. RESULTS: The proportion of ever-married women aged 15-49 years who reported physical, sexual, or emotional IPV in the last 12 months increased from 23% in NFHS-3 (2005-2006) to 25% in NFHS-4 (2015-2016). In both surveys, few women sought help. Informal sources of help were preferred over formal sources, which declined from NFHS-3 to NFHS-4 (any help: 24.5 to 13.8%; informal help: 24.1 to 13.4%; and formal help: 1.2 to 1.1%). Women from lower castes and women with children were less likely to seek formal help. Over the two surveys, the odds of formal help-seeking for sexual IPV in the past 12 months remained similar (NFHS-3 aOR 1.9, 95% CI 1.4, 2.5. NFHS-4 aOR 1.9, 95% CI 1.4, 2.6). The odds were slightly higher for emotional IPV (NFHS-3 aOR 2.5, 95% CI 1.8, 3.3. NFHS-4 aOR 2.7, 95% CI 2.0, 3.7) and spousal control (NFHS-3 aOR 2.0, 95% CI 1.4, 3.0. NFHS-4 aOR 2.3, 95% CI: 1.4, 3.7). CONCLUSIONS: Low disclosure and help-seeking impact a country's social, cultural, economic, and political progress. The PWDVA did not appear to result in increases in help-seeking among women in India who experienced IPV. Further work is needed to understand barriers to help-seeking in the presence of public policy efforts to support women affected by IPV. These may include poor implementation and enforcement of Policy, as well as normalization and justification of gender-based violence. We recommend a deeper understanding of help-seeking across all systems to establish a barometer of help-seeking. An increase in formal or informal help-seeking is an indicator of reduced tolerance of IPV and the enabling environment of the PWDVA 2005 for tracking progress toward the SDGs of gender equality and the eradication of all forms of gender-based violence and discrimination.

Intimate partner violence against women with disability and associated mental health concerns: a cross-sectional survey in Mumbai, India.

OBJECTIVES: The risk of intimate partner violence (IPV) against women with disability is believed to be high. We aimed to compare the prevalence of past-year IPV against women with and without functional difficulties in urban informal settlements, to review its social determinants and to explore its association with mental health. DESIGN: Cross-sectional survey. SETTING: Fifty clusters within four informal settlements. PARTICIPANTS: 5122 women aged 18-49 years. PRIMARY AND SECONDARY OUTCOME MEASURES: We used the Washington Group Short Set of Questions to assess functional difficulties. IPV in the past year was described by binary composites of questions about physical, sexual and emotional violence. We screened for symptoms of depression using the Patient Health Questionnaire-9 and of anxiety using the Generalised Anxiety Disorder-7. Multivariable logistic regression models examined associations between functional difficulties, IPV and mental health. RESULTS: 10% of participants who screened positive for functional disability had greater odds of experiencing physical or sexual IPV (adjusted OR (AOR) 1.68, 95% CI 1.23 to 2.29) and emotional IPV (1.52, 95% CI 1.16 to 2.00) than women who screened negative. Women who screened positive for functional disability had greater odds than women who screened negative of symptoms suggesting moderate or severe anxiety (AOR 2.50, 95% CI 1.78 to 3.49), depression (2.91, 95% CI 2.13 to 3.99) and suicidal thinking (AOR 1.94, 95% CI 1.50 to 2.50). CONCLUSIONS: The burden of IPV fell disproportionately on women with functional difficulties, who were also more likely to screen positive for common mental disorder. Public health initiatives need to respond at local and national levels to address the overlapping and mutually reinforcing determinants of violence, while existing policy needs to be better utilised to ensure protection for the most vulnerable.

Domestic Coercive Control and Common Mental Disorders Among Women in Informal Settlements in Mumbai, India: A Cross-Sectional Survey.

Coercive control behaviors central to the abuse of power appear more frequent than other types of domestic violence, but little is known about its frequency, features, and consequences for women in India. We aimed to examine the prevalence of domestic coercive control and its association with physical, sexual, and emotional domestic violence in the preceding year and symptoms of depression, anxiety, and suicidal thinking. In a cross-sectional survey, we interviewed 4,906 ever-married women aged 18-49 years living in urban informal settlements in Mumbai, India. We developed a 24-item scale of coercive control, assessed physical, sexual, and emotional violence using existing questions, and screened for symptoms of depression with the Patient Health Questionnaire (PHQ9), anxiety with the Generalized Anxiety Disorder (GAD7) questionnaire, and suicidal thinking with questions developed by the World Health Organization. Estimates involved univariable and multivariable logistic regression models and the prediction of marginal effects. The prevalence of domestic coercive control was 71%. In total, 23% of women reported domestic violence in the past 12 months (emotional 19%, physical 13%, sexual 4%). Adjusted models suggested that women exposed to controlling behavior had greater odds of surviving emotional (aOR 2.1; 95% CI 1.7, 2.7), physical (1.4; 1.0, 1.9), and sexual (1.8; 1.1, 3.0) domestic violence in the past 12 months; and higher odds of a positive screen for moderate or severe depression (1.7; 1.3, 2.2), anxiety (2.1; 1.3, 3.1), and suicidal thinking (1.7; 1.2, 2.3), and increased with each additional indicator of coercive control behavior. When women reported 24 indicators of coercive control, the adjusted predicted proportion with moderate or severe depressive symptoms was 60%, anxiety 42%, and suicidal thinking 17%. Inclusion of coercive control in programs to support domestic violence, would broaden our understanding of domestic abuse to resemble most victims experience and improve interventions.

Predictors of spousal coercive control and its association with intimate partner violence evidence from National Family Health Survey-4 (2015-2016) India.

BACKGROUND: The feminist theory posits that spousal coercive control is not random but a purposeful and systematic men's strategy to control and dominate their female partners. The frequency of coercive control is more than emotional, physical, and sexual intimate partner violence (IPV). Coercive control is usually mistaken with psychological abuse when it is not and has recently gained independent attention within the spectrum of IPV. The role of socioeconomic factors in determining coercive control and associations between coercive control and form of IPV is less researched. OBJECTIVE: We aimed to examine sociodemographic and socioeconomic predictors of spousal coercive control and its association with IPV (past 12-months). METHODS: We analysed data of 66,013 ever-married women aged 15-49 from the National Family Health Survey (NFHS)-4 (2015-2016). Estimates involved bivariate and multivariate logistic regression models, and marginal effects prediction. RESULTS: The prevalence of spousal coercive control is more commonly reported by 48% of women than the prevalence of IPV 25% (emotional 11%, physical 22%, and sexual 5%) in the past 12 months. Adjusted odds ratio indicate that women having three and more children (aOR 1.1, 95% CI: 1.0-1.2), women work status (1.1; 1.1-1.2), husband's secondary (1.1; 1.1-1.2) or higher education (1.1; 1.1-1.2), and husband alcohol consumption (1.7; 1.6-1.7) increase the odds of coercive control. In the fully adjusted model coercive control independently increased the likelihood of experiencing emotional (aOR 2.8.; 95% CI: 2.6, 3.1), physical (2.2; 2.1, 2.3), and sexual (2.5; 2.3, 2.8) IPV in the past 12 months; and with an increase in each additional indicator of coercive control acts, the likelihood of physical, sexual, and emotional IPV further increases. When women reported six indicators of coercive control, the predicted proportion of women experiencing emotional 53%, physical 45%, and sexual IPV was 25% in the fully adjusted model. CONCLUSION: Coercive control limits women's social support and contacts contributing to low self-esteem, self-efficacy, and poor mental health. The purpose of this study is to highlight that understudied coercive control is more common than other forms of IPV and is a potential risk factor for physical, sexual, and emotional IPV independently. The inclusion of coercive control in interventions is crucial to prevent form of IPV. Survivals long-term safety and independence can be secured if the current protection law against domestic violence is extended to encompass coercive control.

Economic abuse and its associations with symptoms of common mental disorders among women in a cross-sectional survey in informal settlements in Mumbai, India.

BACKGROUND: Domestic violence takes a range of interconnected forms, of which economic abuse is common, but less studied than others. We examine the prevalence of economic abuse, its determinants, and its association with symptoms of depression, anxiety, and suicidal ideation. METHODS: Our cross-sectional survey in informal settlement areas in Mumbai, India, asked women aged 18-49 years 15 questions about acquisition, use, and maintenance of economic resources, demographic and socioeconomic factors, and physical, sexual, and emotional violence. We administered the Patient Health Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7) scales and asked about suicidal thinking. Determinants of economic abuse and its associations with positive screens for depression and anxiety were explored in univariable and multivariable logistic regression models. RESULTS: Of 4906 ever-married women respondents, 23% reported at least one form of economic abuse by either an intimate partner or another family member. The commonest were denial of property rights (10%), not being trusted with money (8%), and coercive appropriation of belongings (7%). Economic abuse was more commonly reported by widowed, separated, or divorced women than by married women (aOR 12.4; 95% CI 6.4, 24.1), and when their partners used alcohol or drugs (aOR 1.4; 95% CI 1.2-1.7). Women had greater odds of reporting economic abuse if they had suffered emotional (aOR 6.3; 95% CI 5.0-7.9), physical (aOR 1.9; 95% CI 1.4-2.6), or sexual violence (aOR 5.4; 95% CI 3.6-8.1) in the preceding 12 months. Economic abuse was independently associated with positive screens for moderate-severe depression (aOR 2.6; 95% CI 2.0-3.4), anxiety (aOR 2.7; 95% CI 1.9-3.8), and suicidal ideation (aOR 2.2; 95% CI 1.5-3.1). The odds of anxiety and depression increased with each additional form of economic abuse. DISCUSSION: To our knowledge, this is the first community-based study in India of the prevalence of economic abuse and its associations with symptoms of common mental disorders. It provides empirical support for the idea that economic abuse is at least as harmful to women's mental health as physical violence. Surveys should include questions on economic abuse and prevention and intervention strategies need to help survivors to understand its forms.

Prevalence of domestic violence against women in informal settlements in Mumbai, India: a cross-sectional survey.

OBJECTIVES: Domestic violence against women harms individuals, families, communities and society. Perpetrated by intimate partners or other family members, its overlapping forms include physical, sexual and emotional violence, control and neglect. We aimed to describe the prevalence of these forms of violence and their perpetrators in informal settlements in Mumbai. DESIGN: Cross-sectional survey. SETTING: Two large urban informal settlement areas. PARTICIPANTS: 5122 women aged 18-49 years. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence and perpetrators in the last year of physical, sexual and emotional domestic violence, coercive control and neglect. For each of these forms of violence, responses to questions about individual acts and composite estimates. RESULTS: In the last year, 644 (13%) women had experienced physical domestic violence, 188 (4%) sexual violence and 963 (19%) emotional violence. Of ever-married women, 13% had experienced physical or sexual intimate partner violence in the last year. Most physical (87%) and sexual violence (99%) was done by partners, but emotional violence equally involved marital family members. All three forms of violence were more common if women were younger, in the lowest socioeconomic asset quintile or reported disability. 1816 women (35%) had experienced at least one instance of coercive control and 33% said that they were afraid of people in their home. 10% reported domestic neglect of their food, sleep, health or children's health. CONCLUSIONS: Domestic violence against women remains common in urban informal settlements. Physical and sexual violence were perpetrated mainly by intimate partners, but emotional violence was attributed equally to partners and marital family. More than one-third of women described controlling behaviours perpetrated by both intimate partners and marital family members. We emphasise the need to include the spectrum of perpetrators and forms of domestic violence-particularly emotional violence and coercive control-in data gathering. TRIAL REGISTRATION NUMBER: ISRCTN84502355; Pre-results.

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India.

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.919; root mean square error of approximation, 0.036; weighted root mean square residual, 1.949). Comparison of multi-group models across gender, education, caste, and marital status showed little evidence against measurement invariance. Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts.

Contraceptive Use and Unintended Pregnancies Among HIV-Infected Women in Mumbai.

BACKGROUND: Access to reproductive health services in Human Immunodeficiency Virus (HIV) programs can greatly enhance program's potential to limit the spread of disease, reduce unintended pregnancies and safeguard the health of infected people. OBJECTIVES: To assess (i) knowledge, attitude, and use regarding contraceptives; safe sex and dual protection; (ii) fertility desires and unintended pregnancies post HIV and (iii) symptoms of reproductive tract infection/sexually transmitted infection (RTI/STI) among women infected with HIV. MATERIALS AND METHODS: A cross-sectional study among 300 currently married HIV-positive women who had not undergone permanent sterilization with no immediate desire for pregnancy. Study site was Integrated Counseling and Testing Centers (ICTC) in tertiary hospitals of Mumbai and women were interviewed using a semistructured questionnaire. RESULTS: In spite of good awareness about modern methods, 42.7 felt that contraceptives other than condoms were harmful to use due to their HIV status. Knowledge on dual protection was limited to condom (75%). Condom use increased from 5.7% pre-HIV to 71.7% post-HIV, with 89.6% reporting regular use. Future fertility desire was expressed by 8.7% women. Induced abortions post-HIV was reported by16.6% women, as pregnancies were unintended. About 69% wished to use dual contraceptive methods for effective protection if it was not harmful to be used by people living with HIV (PLHIV). CONCLUSION: Data reveals a need to promote modern contraceptive methods along with regular condom use to prevent unintended pregnancies and improve health-seeking behavior for contraception. Health system models that converge or link HIV services with other reproductive health services need to be tested to provide comprehensive reproductive healthcare to infected women in India.