Domestic Violence and its Determinants among 15-49-Year-Old Women in a Rural Block in South India.

CONTEXT: Domestic violence in Indian setting has five major components: emotional abuse; physical violence; sexual violence; honor killing; dowry-related abuse; and death. AIMS: The aim of the study was to estimate the prevalence of domestic violence and 3 of its components - emotional abuse, physical violence, and sexual violence among women in the age group of 15-49 years in Kaniyambadi block, rural Vellore, Tamil Nadu and to determine the risk factors of domestic violence. SETTINGS AND
DESIGN: A community-based cross-sectional study among women between the ages 15 and 49 years at the rural setting of Kaniyambadi block, Tamil Nadu.
RESULTS: Prevalence of all forms of domestic violence among women was 77.5%, and forty percent women were classified as having ever been subjected to severe domestic violence. Prevalence of physical violence was 65.8%, sexual abuse was 17.5%, and emotional abuse was 54.2%. Alcohol consumption by husband (adjusted odds ratio [AOR] 4.37; 1.35, 14.18), controlling behavior by family member (AOR 8.07; 2.47, 26.37), and woman's employment (AOR 4.33; 1.27, 14.77) were statistically significant determinants of domestic violence. Three-fourth (73.1%) of the women felt that being subjected to domestic violence has affected their physical and mental health.
CONCLUSIONS: The high prevalence of domestic violence in our community needs to be addressed as it has tacit implications on socioeconomic well-being, physical and mental health of a woman, her family, and thereby, society as a whole. Copyright:

INTRODUCTION

According to United Nations, domestic violence includes physical, sexual, and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation, and other traditional practices harmful to women, nonspousal violence and violence related to exploitation.[1]

Domestic violence has been recognized since 1983 as a criminal offence under Indian Penal Code 498-A. India passed Protection of Women from Domestic Violence Act 2005 which defined “Domestic violence” as one which includes any act, omission or commission or conduct of actual abuse or the threat of abuse that is physical, sexual, verbal, emotional, and economic. Harassment by way of unlawful dowry demands to the woman or her relatives would also be covered under this definition.

“Physical abuse” means any act or conduct which is of such a nature as to cause bodily pain, harm, or danger to life, limb, or health or impair the health or development of the aggrieved person and includes assault, criminal intimidation, and criminal force.

“Sexual abuse” includes any conduct of a sexual nature that abuses, humiliates, degrades, or otherwise violates the dignity of woman.

“Verbal and emotional abuse” includes (a) insults, ridicule, humiliation, name calling, and (b) repeated threats to cause physical pain to any person in whom the aggrieved person is interested.[2]

Violence against women – particularly intimate partner violence (IPV) and sexual violence – is a major public health problem and a violation of women's human rights. Women are more likely to experience IPV if they have low education, exposure to mothers being abused by a partner, abuse during childhood, and attitudes accepting violence, male privilege, and women's subordinate status. Intimate partner (physical, sexual, and emotional) and sexual violence cause serious short- and long-term physical, mental, sexual, and reproductive health problems for women. They also affect their children and lead to high social and economic costs for women, their families, and societies.[3] Increasing research has highlighted the health burdens, intergenerational effects, and demographic consequences of such violence.

We aimed to estimate the prevalence of domestic violence among women between the ages of 15 and 49 years in Kaniyambadi block, Vellore, Tamil Nadu in South India. We also wanted to determine the risk factors for domestic violence.

SUBJECTS AND METHODS

Study design

Community-based cross-sectional study.

Study duration

August to September 2016.

Study setting

This study was done in Kaniyambadi Block which is a revenue block in Vellore district, Tamil Nadu, South India. It comprises of 85 villages and is spread over an area of 127 km2. The occupation of the people in this region is mainly farming, animal husbandry, and unskilled daily labor. The Department of Community Health of the Christian Medical College, Vellore, has been running a community health program in this region from the 1960s.[4]

Participants were chosen from six of these villages by computer-generated simple random sampling from CHAD population database. The six villages were Edayansathu, Pennathur, Munjurpet, Adukkamparai, A. Kattupadi, and Mettu-Edayampatti. The women study participants selected by simple random sampling were visited by female investigators at their households, and the questions were asked verbatim from the questionnaire in local language after building rapport, in privacy without the interference of family members.

Study subjects

Women between the ages of 15 and 49 years, who were permanent residents of the block, were eligible to be included in the study. Women having lack of insight, comprehension, and expression were excluded from the study.

Sample size

According to NFHS-3 (2005–2006) data for the state of Tamil Nadu, proportion of women who have ever experienced spousal violence in rural households was 44.4%.[5] Considering relative precision of 20% and confidence level of 95% (1−α), the sample size was calculated to be 120.

Tool

An interviewer-based semistructured questionnaire was prepared based on the WHO multi-country study on women's health and domestic violence against women.[6] This was translated into Tamil and backtranslated into English. EpiData version 3.1 (Epidata Association, Odense Denmark) was used for data entry and analysis was done using SPSS v20 (IBM Corporation SPSS statistics, New York, United States of America).

This research was approved by the Institutional Review Board at CMC, Vellore.

RESULTS

The participants from each of the six villages were almost equal in number and had similar sociodemographic characteristics. The median age of the participants was 33.5 years with a mean age of 33.6 ± 7.65 years and 90% of them were Hindus. Most of the women (59%) belonged to the upper-lower socioeconomic status according to the modified Kuppuswamy scale. More than half of the individuals had studied only till middle school (55.8%) and 42.5% of all women were homemakers. Of those who were employed, 53.6% were involved in unskilled daily labor. We included unmarried and widowed women too in the study who comprised of 3.3% and 1.7% of the participants, respectively. Among the households surveyed, 18% had the study participant woman as the highest-earning member of the family.

The husbands of the individuals also had similar level of education, and majority of them were involved in farming their own land, doing clerical jobs, shopowners, and semiprofessional jobs (52.6%). Among the households surveyed, 80% had monthly family income of Rs. 10,000 or lesser. About 51% of the households had more than 4 members living together. Almost half of the men in the household (49.2%) had history of alcohol consumption and 33.3% had the habit of tobacco use in any form.

Of the 116 married women, 37% had some degree of consanguinity. Twenty women (17.2%) were not asked for consent before their marriage, and 24 women (21%) were <18 years of age at the time of their marriage. Majority (72%) had two or more children. About half of the women (51%) did not practice any method of contraception. Family related details of study participants associated with violence are described in Table 1.

Table 1

Family-related variables of study participants associated with violence (n=116)

Categories	Frequency (%)
Choice of husband
Self	25 (21.6)
Parents	45 (38.8)
Relatives	42 (36.2)
Friends and others	4 (3.4)
Dowry
Asked and given	21 (18.1)
Not asked but given	44 (38.1)
Asked but not given	6 (5.1)
Neither asked nor given	45 (38.7)
Age difference (years) between husband and wife
0-4	43 (37.7)
5-9	49 (43.0)
≥10	22 (19.3)

Among the participants, 46.7% responded that they often quarrel at home, and 67.5% women acknowledged that alcohol and tobacco chewing or smoking would influence the men of the household displaying aggressive behavior.

Among the study participants, prevalence of controlling behavior by others in the household on the study participants was 72.5% (64.4%–80.6%), prevalence of emotional abuse was 54.2% (45.1%–63.3%), physical violence was 65.8% (57.2%–74.4%), and spousal sexual abuse among the married study participants was 17.5% (10.6%–24.4%).

During their course of pregnancy, 17 women (16.3%) confessed to have been physically assaulted at home, and 6 women (5.8%) were punched or kicked in the abdomen Table 2.

Table 2

Different components of domestic violence (n=120)

Components of abuse	Yes, n (%)
Emotional abuse
Insulted and made her feel bad about herself	58 (48.3)
Belittled or humiliated her in front of everyone	44 (36.7)
Done things to scare and intimidate her on purpose	34 (28.3)
Threatened to hurt her or someone she cares about	29 (24.2)
Physical violence
Slapped or thrown something at her	70 (58.3)
Pushed or shoved her	49 (40.8)
Hit her with fist or something that could hurt her	39 (32.5)
Ever choked or burnt her on purpose	9 (7.5)
Threatened to use or actually used a gun, knife, or other weapon	4 (3.3)
Kicked, dragged, and beaten her	28 (23.3)
Since age 15 anyone other than husband had physically mistreated her	10 (8.3)
Sexual abuse
Has he physically forced you to have sexual intercourse when you didn’t want to	21 (17.8)
Did you ever have sexual intercourse when you didn’t want to because you were afraid of what he might do	13 (11)
Did he ever force you to do something degrading or humiliating during sexual intercourse	5 (4.3)
Since age 15 years, has someone other than your husband forced you to perform sexual act when you didn’t want to	0

Among the 79 women who were ever subject to physical assault, 22 (28%) of them gave history of injuries as a result of violence. Of the 22 who sustained injuries, 50% were injured more than 6 times and 13 women (59.1%) were hurt so bad that they had to seek healthcare and 10 of them spent more than a day in the hospital. Most of them had sustained bruises (24%) or cuts (15%). There were two women who have had fractures, and loss of function was seen in three women due to physical violence.

When asked about situations leading to violence, alcohol (37.6%) seemed to be the major contributing factor. Others factors included family issues such as child care, disobedience to in-laws, household work not done up to expectation, sexual dominance, trivial misunderstandings (50.5%), money issues (15%), and suspicion of extramarital affair (9%). There were 7 women who disclosed dowry demands as the reason for domestic violence.

Among those who were subject to physical violence, 78.5% of women did not or could not fight back when physically hit. Three-fourth (73.1%) of the women felt that being subjected to domestic violence has affected their physical and mental health.

Prevalence of domestic violence (*figures in parenthesis indicate 95% confidence interval)

According to WHO, if the answer to any of the questions asked for emotional abuse, physical violence, or sexual violence is “Yes,” it is considered as domestic violence.[7] From our study, the prevalence of all forms of domestic violence among women aged 15–49 years in rural Kaniyambadi was 77.5% (69.9%–85.1%)* i.e., 93/120 households. According to standard definition, 40% (31.1%–48.9%)* were classified as having been subjected to severe domestic violence.[8] The participants whom we found to have ever experienced domestic violence were given the contact details of our hospital counselor and the area health aide in case of any help.

Determinants of domestic violence [Table 3]

Employed women (odds ratio [OR] 2.41; 1.005, 5.781), women belonging to lower socioeconomic status (OR 3.24; 1.33, 7.89), women whose husbands consumed alcohol (OR 6.09; 2.12, 17.49), and women whose family members showed controlling behavior (OR 6.50; 2.56, 16.48) were found to have statistically significant associations of having experienced domestic violence [Table 4].

Table 4

Significant determinants of various forms of domestic violence

Determinants	Physical violence	Emotional abuse	Sexual violence	Severe domestic violence
Low socioeconomic status	2.23 (1.03-4.81)	2.17 (1.03-4.56)	3.54 (1.12-11.28)	4.49 (1.94-10.36)
Alcohol consumption by the husband	5.06 (2.17-11.79)	2.62 (1.25-5.50)	4.16 (1.41-12.27)	3.89 (1.79-8.46)
Controlling behavior by household members	4.83 (2.06-11.35)	3.27 (1.40-7.60)	9.55 (1.22-74.35)	3.31 (1.30-8.43)

After adjusting for all independent variables which were statistically significant on univariate analysis, we found that the associations of alcohol consumption by husband (adjusted OR [AOR] 4.37; 1.35, 14.18), controlling behavior by family member (AOR 8.07; 2.47, 26.37), and occupation of the woman (AOR 4.33; 1.27, 14.77) with domestic violence were statistically significant on multivariate logistic regression. Age of the woman at marriage, age difference between the husband and wife, number of children, and the education of the husband were not determinants to whether the woman was subject to domestic violence or not [Table 5].

Table 5

Multivariate analysis to study the association of each determinant adjusting for all other covariables

Determinants	Status	AOR (95% CI)
Alcohol consumption by husband	Yes	4.37 (1.35-14.18)
	No	1
Controlling behavior of family member	Yes	8.07 (2.47-26.37)
	No	1
Occupation of woman	Employed	4.33 (1.27-14.77)
	Homemaker	1

Included variables in the model are religion, occupation of the woman, socioeconomic status, alcohol consumption by the husband, dowry given, controlling behavior by household members.CI: Confidence interval, AOR: Adjusted odds ratio

DISCUSSION

Domestic violence against women is a pervasive social problem that fundamentally threatens women's physical and mental health and which prevents them from participating fully in social and cultural life. Understanding the local issues regarding violence against women was warranted to further plan and implement appropriate community-based interventions.

Global estimates published by WHO indicate that about 1 in 3 (35%) women worldwide have experienced either physical and/or sexual IPV or nonpartner sexual violence in their lifetime.[6] In a systematic review of 137 quantitative studies published in the prior decade that directly evaluated the domestic violence experiences of Indian women, a median 41% of women reported experiencing domestic violence during their lifetime.[9] The prevalence of domestic violence in separate studies undertaken in the urban slums of Mumbai showed prevalence to be as low as 15%–21.2%, whereas in an urban slum in Kolkata, it was 51%.[101112] Spousal violence was reported by 26.6% of the respondents in a study conducted in Goa.[13] In urban and rural areas of Haryana, 37% of the married females had ever experienced domestic violence.[14] In a study carried out in a rural area of Puducherry, 56.7% of them reported some form of domestic violence.[15] NFHS-4 Tamil Nadu state report states 46% women aged 15–49 years have experienced physical or sexual violence.[16]

Our study documented higher prevalence of domestic violence than all the studies cited above. This can be due to the questionnaire we adopted which was based on WHO “multi-country study on women's health and domestic violence against women,” by assuming any aspect of physical or emotional or sexual abuse as domestic violence, whereas most other studies followed the Women's Questionnaire (used in National Family Health Survey) which is according to the Modified Conflict Tactics Scale. The high prevalence can also be attributed to the comfort level and lack of inhibition of the participants with the investigators and the institution carrying out this research. This has been due to decades of ground-level healthcare and social upliftment activities by the institution.

Our study indicates employed women are at 2.4 times more risk of experiencing domestic violence as compared to homemakers. This is not in accordance to popular belief that employed women are financially and socially empowered, thus experience lesser violence at home. A study conducted in Orissa, West Bengal, and Bihar suggests that although high occupational status can protect women from violence, it can also have the opposite effect (i.e., it can increase the likelihood of partner violence) if their status exceeds that of their husband.[17] In a study by Kamat et al.,[13] women who were employed had experienced IPV significantly higher than homemakers. This evolves from the women's subordinate social status, and any transgression from the expected behavior in the form of excessive social involvement or any situation which endangers the male supremacy in the family is likely to invite violence. A study from Mysore suggested that although women with jobs were more likely to suffer IPV than women without jobs, those with skilled occupations were at lower risk.[18] Similar study by George et al. conducted at Puducherry reiterates this same.[15]

Low socioeconomic status was found to be a major determinant for domestic violence in our study which can be due to accompanying factors such as alcohol, job dissatisfaction, frustration of limited resources, and patriarchal upbringing among others. Studies by Reichel,[19] Rocca et al.,[20] Jeyaseelan et al.,[21] and Das et al.[10] echo our findings. Dowry demand being a social evil is prevalent in most parts of India. In our study, 23.2% participants confessed that they were asked dowry by the grooms' families, and 58% marriages had some sort of dowry involved. There is a direct correlation between dowry and domestic violence as documented in previous studies in India.[202122] There was an association between dowry and violence in our study too (OR 2.29; 0.92, 5.65) leaning toward statistical significance (P = 0.06).

In our study, alcohol consumption by the husband has been found to be significantly associated with domestic violence as in most other studies conducted not only in India but globally. WHO's multicentric study has stated in no unclear terms that men are more likely to perpetrate violence if they are exposed to harmful use of alcohol.[3] From urban slums[101112] to rural areas,[23] North,[24] West,[13] East,[17] and South India,[161825] alcohol stands out as a major risk factor for domestic violence and directs the public health scientists toward formulating and implementing interventions toward alcohol cessation and prevention.

This study gives the public health specialists a broad idea of the extent of domestic violence prevalent in our society and explores the different forms of it. The effects of physical violence on women in the form of injuries caused in them, as stated in the study, conveys the gravity of the problem, that it not only affects social life, mental, and psychological health but also physical health. These findings would help formulate appropriate interventions not only to deal with further episodes of domestic violence but also to mitigate the problem at large.

The study has few limitations. We calculated the sample size based on the primary objective to find out the prevalence of domestic violence. In determining the associations, we felt a bigger sample size could have given this study more power. We were compelled to exclude those women who were not capable of comprehension and insight as there was no objective method of assessing domestic violence and the study relied on history and recall although we realized that violence they face might be higher. We feel there is a need to extend this exercise to urban and tribal areas of Vellore to get a complete picture of the prevalence and the determinants of domestic violence.

CONCLUSIONS

The prevalence of all forms of domestic violence among women aged 15–49 years in rural Kaniyambadi was 77.5%. Forty percent women were classified as having ever been subjected to severe domestic violence.

Among the study participants, the prevalence of physical violence was 65.8%, sexual abuse was 17.5%, and emotional abuse was 54.2%.

We found that alcohol consumption by husband, controlling behavior by family member, and employment of women were statistically significant determinants of domestic violence on multivariate logistic regression.

Among the women who were ever subject to physical assault, 28% gave a history of injuries as a result of violence. Of them, 59.1% were hurt so bad that they had to seek healthcare. Three-fourth of the women felt that being subjected to domestic violence has affected their physical and mental health.

The high prevalence of domestic violence in our community needs to be addressed as it has tacit implications on socioeconomic well-being and health of a family and society as a whole.

Recommendations

Behavior change communication, mass media “edutainment” strategies should be used to achieve social change. Need of the hour is to design lifeskills and school-based programs and engage men and boys in particular to promote nonviolence and gender equality. As public health specialists, operations and implementation research to identify effective health sector interventions to address violence against women must be undertaken. Based on these, public policy guidelines and implementation tools for strengthening the health sector response to domestic violence need to be developed. One of the strategies could be to provide early-intervention services to at-risk families.

There is emerging evidence that interventions combining microfinance with gender-equality training may be effective at reducing levels of IPV, as illustrated by the IMAGE study in South Africa.[26] There are ongoing efforts in reforming legal frameworks in India by strengthening and expanding laws defining rape and sexual assault within marriage – marital rape.[27] Further research on comprehensive health consequences on victims of domestic violence, impact on children, social and economic costs, and interventions must be conducted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 3

Determinants of domestic violence

Determinants	Variables	Domestic violence (%)	OR (95% CI)	P
Religion	Hindu	80.6	4.14 (1.21-14.14)	0.016
	Christian	50
Education of woman	Up to high school	79.8	1.75 (0.66-4.64)	0.254
	Beyond high school	69.2
Occupation of woman	Employed	84.1	2.41 (1.005-5.78)	0.045
	Homemaker	68.6
Socioeconomic status	Low	85.9	3.24 (1.33-7.89)	0.008
	High	65.3
Alcohol consumption by husband	Yes	91.5	6.09 (2.12-17.49)	<0.0001
	No	63.9
Tobacco use by husband in any form	Yes	86.8	2.42 (0.84-6.98)	0.095
	No	73.2
Choice of husband	Self	80	1.12 (0.37-3.38)	0.831
	Others	78
Dowry given	Yes	84.6	2.29 (0.92-5.65)	0.068
	No	70.6
Controlling behavior by others in the household on the woman	Yes	87.4	6.50 (2.56-16.48)	<0.0001
	No	51.5

OR: Odds ratio, CI: Confidence interval