Intimate Partner Violence among Ever-married Women Treated for Depression at a Rural Health Center in Bengaluru Urban District.

BACKGROUND: Intimate partner violence (IPV) is a risk factor for depression among women. Spousal alcoholism and marital quality are associated with both depression and spousal abuse Knowledge about the factors contributing to IPV in depression will enable us to have interventions to address IPV in tandem with treating depression.
OBJECTIVES: (1) To estimate the prevalence of IPV in women treated for depression in a rural community health-care facility in Bengaluru Urban District. (2) To assess the association between IPV and various other factors in women treated for depression in a rural community health care facility.
METHODOLOGY: A cross-sectional study was conducted among ever-married women above 18 years, registered under mental health program in the mental health clinic in Mugalur, Karnataka, and currently on treatment for depression. The women who consented were interviewed using structured questionnaires - WHOQOL-BREF, standard of living index, Hamilton Depression Rating Scale, Index of Spouse Abuse, family interview for genetic studies for reported alcohol use, and marital quality scale.
RESULTS: The mean age of the study participants was 49.7 ± 13.2 years. The prevalence of physical IPV and non-physical IPV was found to be 18% and 7%, respectively. Marital quality was significantly lower among women who experienced IPV. Women with husbands who ever used alcohol were found to have six times more risk of experiencing physical IPV, odd ratio 6.193 (1.595, 24.047).
CONCLUSION: Health education, involvement of self-help groups, and awareness programs are required to alleviate IPV. Copyright:

INTRODUCTION

The global prevalence of physical and/or sexual intimate partner violence (IPV) among all ever-partnered women was 30.0% in 2013.[1] Various studies have shown that IPV is a risk factor for depression among women. Women who have experienced IPV in their lifetime have a higher prevalence of depression, suicidal thoughts, and attempts.[234] Physical or emotional abuse affects adversely on women's quality of life, and ultimately, the quality of life of the whole family.

Two important factors, among many others associated with depression, are spousal alcoholism and marital quality. Spousal alcoholism has been found to be an important factor contributing to spousal abuse.[5] It often decreases marital satisfaction and may result in an additional stress on the spouse.[6]

Very few studies have been done on women with depression regarding the prevalence of IPV. Although it has been affirmed that spousal abuse is a risk factor for depression in the general population, it is important to know the magnitude in a particularly vulnerable group of women already having comorbidity such as depression.

Also, knowing about the factors contributing to IPV in depression will enable us to have interventions to address IPV in tandem with treating depression.

Objectives

To estimate the prevalence of IPV in women treated for depression in a rural community health-care facility in Bengaluru Urban District

To assess the association between IPV and various other factors in women treated for depression in a rural community health-care facility.

METHODOLOGY

This cross-sectional descriptive study was aimed to study IPV and the associated factors among the ever-married women aged 18 years or more treated for depression in a rural area. The study was carried out in Karnataka, a southern state in India where the population accounts for 5% of the total Indian population. More than half of the population (61.3%) reside in a rural area.[7]

The sample size was calculated based on the estimates of IPV prevalence in a rural panchayat in Trivandrum, Kerala, where the IPV was estimated to be 31.7% in ever-married depressed women (community based study-unpublished data).[8] Based on this estimate and considering a confidence level of 95% and relative precision of 20%, the sample size for this study was computed to be 92 ever-married women, this figure was rounded off to include 100 ever-married women.

After obtaining their informed consent, the women were interviewed at their homes. Data were collected through interviewing women using six structured questionnaires:

WHOQOL-BREF for quality of life

Standard of living index for the standard of living and socioeconomic classification

Hamilton Depression Rating Scale for screening and grading of depression in the participants

Index of Spouse Abuse (ISA) for physical and non-physical IPV

Family interview for genetic studies for reported alcohol use

Marital quality scale for marital quality and satisfaction.

A list of ever-married women, who were registered under the Rural Community Mental Health Program (Maanasi Project) and had visited the mental health clinic at least once in the past 1 year (prior to the commencement of the study) for treatment of depression, was prepared. The study participants were randomly selected from this list using currency method. If two or more ever married women were found in the same household, one subject was included by random allotment using the lottery method. Ever-married women are persons who have been married at least once in their life although their current marital status may not be “married” (women who are separated, widowed, or divorced).

Women who have been on treatment for depression under the rural community-based mental health program based at institution's rural health training center and have come at least once to the clinic in the past 1 year were considered “women currently on treatment.”

IPV was measured by a score above the cutoff score with ISA questionnaire which contained two subsets of questionnaires, namely ISA-P for physical spousal abuse and ISA-NP for non-physical spousal abuse. A study done to find the reliability and validity showed that a cutoff score of 10 for ISA-P and 25 for ISA-NP gives the maximum reliability.

The continuous variables were described in terms of mean with standard deviation and median with interquartile range, as appropriate. Categorical variables were described by proportions. To test the significance between two proportions, Chi-square test and independent sample t-test were used. Binary logistic regression was used to estimate the odds ratio of predictor variables and find adjusted associations.

RESULTS

The study participants were ever-married women treated for depression (n = 100). The mean age of the study participants was 49.7 ± 13.2 years. Among the study participants, 75 (75%) of the women were currently married, the median age at marriage was 17 (15, 18) years. The mean age of the husbands was 53.4 ± 12.9 years. About one-third, 35% of the husbands had ever used alcohol, and among them, 74.3% had alcohol abuse and 37.1% were alcohol dependent [Table 1].

Table 1

Sociodemographic characteristics of the study participants (n=100)

Variable	Category	n (%)
Age (mean=49.7±13.2 years)	≤44	39 (39.0)
	45-64	48 (48.0)
	≥65	13 (13.0)
Education	No formal education	64 (64.0)
	Primary school	11 (11.0)
	Middle school	12 (12.0)
	High school	11 (11.0)
	PUC-diploma	2 (2.0)
Employment	Not working	82 (82.0)
	Household and domestic	5 (5.0)
	Unskilled	4 (4.0)
	Semi-skilled	1 (1.0)
	Semi professional	2 (2.0)
	Shop/farm owner	6 (6.0)
Socioeconomic status (SLI)	Low	6 (6.0)
	Middle	38 (38.0)
	High	56 (56.0)

SLI: Standard of living index, PUC: Pre- University Certification

The prevalence of physical IPV in ever-married women treated for depression was found to be 18% and that of non-physical abuse was 7%. Women belonging to higher socioeconomic status had a protective effect compared to women of middle and low socioeconomic class. There was no association between other sociodemographic factors of the women, such as age, education level or occupation of the women, and IPV in our study. In our study participants, physical and psychological domains of the quality of life were more affected than environmental and social relationship domains [Table 2].

Table 2

Association of quality of life of the study participants and intimate partner violence (n=100)

Variables	Physical health		Psychological		Social relationships		Environmental
	Median (IQR)	P	Median (IQR)	P	Median (IQR)	P	Median (IQR)	P
Physical intimate partner violence
Present	11.7 (10.8-13.3)	0.78	12.6 (11.2-14.0)	0.39	14.0 (12.0-16.0)	0.95	13.0 (12.0-15.0)	0.16
Absent	12.0 (10.3-13.7)		12.7 (11.3-14.7)		14.0 (12.0-16.0)		14.0 (12.5-15.0)
Non-physical intimate partner violence
Present	11.4 (10.8-12.0)	0.27	12.0 (10.7-12.7)	0.07	13.3 (9.3-13.3)	0.04*	13.0 (10.5-13.0)	0.01*
Absent	12.0 (10.8-13.7)		12.7 (10.3-14.3)		14.7 (12.0-16.0)		14.0 (12.0-15.0)

P values are based on Mann-Whitney U-test, *Statistically significant at α=5%

Marital quality was significantly lower among women who experienced IPV compared to those who did not. Women with husbands who ever used alcohol were found to have six times more risk of experiencing physical IPV when compared to women whose husbands never used alcohol, odd ratio 6.193 (1.595, 24.047) [Table 3]. However, factors such as age, standard of living, and marital quality did not show any significant association.

Table 3

Association of physical violence experiences (Index of Spouse Abuse-P) by the study participants with various factors (n=100)

Variables	OR	95% CI for OR		P
		Lower limit	Upper limit
Age (years)
≤44	4.138	0.476	35.985	0.198
45-64	2.049	0.229	18.340	0.521
≥65	-	-	-	-
Wife’s employment
Employed	2.038	0.458	9.063	0.350
Unemployed	-	-	-	-
Standard of living
Low	5.409	0.582	50.237	0.138
Middle	1.271	0.332	4.856	0.726
High	-	-	-	-
Depression grade
Mild	2.023	0.219	18.910	0.537
In clinical remission	-	-	-	-
Marital quality
Poor marital quality	987.4	0.000	-	0.999
Good marital quality	-	-	-	-
Alcohol use
Present	6.193	1.595	24.047	0.008*
Absent	-	-	-	-

* Statistically significant at α =5%. OR: Odd ratio, CI: Confidence interval

DISCUSSION

In our study, the prevalence of physical IPV in ever-married women treated for depression was found to be 18% and that of non-physical abuse was 7%. This is slightly less, but comparable to the prevalence in Karnataka given in National Family Health Survey (NFHS-4), where 20.4% of ever-married women experienced spousal abuse in the rural area.[9] According to a study conducted among educated women in a southern city of Karnataka, the prevalence of IPV was found to be 40.5%. This variation can be attributed to the difference in subject characteristics and the study tool used.[10] Physical IPV among married couples in a rural area of Thane, Maharashtra, was reported to be 35.9% and non-physical violence was reported to be 31.7%.[11] The difference can be attributed to the fact that the age group of the two studies was different. The risk of IPV, both physical and non-physical, was inversely associated with socioeconomic status. This is consistent with a study conducted by Koenig in Uttar Pradesh, where the risk of physical violence was significantly lower among households at higher socioeconomic levels.[12] Women's poor socioeconomic background had emerged as a strong predictor of domestic violence in India according to a study conducted by Kustov.[13]

In our study participants, the quality of life in all four domains was less in those who experienced IPV, although the result was not significant. The physical and psychological domains of the quality of life were more affected than environmental and social relationship domains. This may be due to coexisting depression and associated somatic symptoms.

Women whose husbands had ever used alcohol experienced were more at risk of IPV compared to women whose husbands did not use alcohol. In our study, women whose husbands ever used alcohol were at a greater risk of physical IPV (P = 0.0001) compared to women whose husbands never used alcohol. Our study result is comparable to a study conducted by Begum et al. in the urban slums of Maharashtra, where women whose husband used alcohol were at a higher risk compared to women whose husbands did not use alcohol.[14] Our study found a significant association between marital quality and IPV, although IPV was more common in women with poor marital quality. This is similar to a study conducted in Nigeria, which showed that participants with low marital satisfaction experienced a higher level of domestic violence, while participants with high marital satisfaction experienced a lower level of domestic violence.[15] A hospital-based study in Iran showed a negative correlation between marital satisfaction and domestic violence among pregnant women. That is, higher the marital satisfaction, lower the domestic violence among them.[16]

CONCLUSION

In this study, the prevalence of physical IPV (ISA-P) in ever-married women treated for depression was found to be 18% and that of nonphysical IPV (ISA-NP) was 7%. In our study participants, physical and psychological domains of quality of life were more affected than environmental and social relationship domains. IPV was found to be associated with spousal alcohol abuse and poor marital quality.

Social desirability bias is one of the limitations of the study. Furthermore, the participants would be embarrassed to talk about a sensitive issue such as partner violence. Another limitation was that our study was cross sectional in nature; hence, the causal association of various factors could not be found. Education and counseling for the victims and their family members are needed as a short-term measure. Long-term measures include health education, involvement of self-help groups, and more awareness programs regarding IPV.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.