Domestic violence against women: A hidden and deeply rooted health issue in India.

BACKGROUND: Domestic violence was identified as a major contributor to the global burden of ill health in terms of female morbidity leading to psychological trauma and depression, injuries, sexually transmitted diseases, suicide, and murder. AIMS: The study was conducted to find out the prevalence of different types of lifetime domestic violence against women, factors associated with it, and care-seeking behavior. SETTINGS AND
DESIGN: An observational cross-sectional study conducted at a slum of Burdwan district of West Bengal, India. METHODS AND MATERIAL: Study was done among 320 ever-married women of 15-49 years of age using a predesigned pretested proforma from March 2019 to December 2019 by face-to-face interview. STATISTICAL ANALYSIS USED: Data were compiled and analyzed by EpiInfo 6 and SPSS 20 version. RESULTS AND
CONCLUSIONS: The overall prevalence of any form of violence during the lifetime among the study population was 35.63%. Verbal/psychological violence was the most common form of domestic violence (91.23%) followed by physical (82.46%) and sexual violence (64.91%). Slapping and/or beating, kicking, and object throwing were the major forms of physical violence; humiliation (88.46%) was the commonest form of psychological violence and most common form of sexual violence was forced sexual intercourse (51.35%). About 20% of the study population faced violence every day. Older age, lower age at marriage, longer duration of marriage, lower education of husband and wife, lower family income, unemployment of the husband, and alcohol consumption of husband were associated with the occurrence of domestic violence. We have found that the prevalence of domestic violence in this group of population is high. The alarming issue is that approximately one-third of women (32.46%) who faced violence in their lifetime had never sought any help. The findings indicate to develop appropriate and culturally relevant public health interventions to increase awareness. Copyright:

Introduction

The Fourth United Nations World Conference on Women 1995 in Beijing stated that violence against women (VAW) is a manifestation of the historically unequal power relations between men and women.[1] United Nations declaration on the elimination of Violence against Women (VAW), in 1993, defined VAW as “any act of gender-based violence that results in, or is likely to result in physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation of liberty, whether occurring in public or private life.”[2]

The WHO Multi-country Study on “Women's Health and Domestic Violence Against Women” indicated that the range of lifetime physical violence by a male, intimate partner, ranged from 13% in Japan to 61% in Peru with most sites falling between 23% and 49%; range of lifetime prevalence of sexual violence by an intimate partner was between 6% (Japan) and 59% (Ethiopia) with most sites falling between 10% and 50%; range of lifetime prevalence of physical or sexual violence, or both, by an intimate partner, was 15% to 71% with most sites ranged from 30% to 60%.[3] Likewise, regarding current violence acts of physical or sexual violence in the year prior to being interviewed—the range was between 3% and 54%, with most sites falling between 20% and 33%.[3] Commonly mentioned perpetrators included fathers, other family members, and teachers. The highest levels of sexual violence by nonpartners ranged between 10% and 12% in Peru, Samoa, and Tanzania city to 1% in Bangladesh and Ethiopia.[3]

Only one in four abused women have ever sought help to end the violence they have experienced. Only two percent of abused women have sought help from police.[4]

Domestic violence is an underreported phenomenon in India including West Bengal, although West Bengal stands in the 8th position according to the burden of domestic violence among all Indian states.[4] A need was, therefore, felt for a community-based study focusing on domestic violence against women (DVAW) to gather data that would improve our understanding of this “sleeping giant.”[5]

In this background, the present study was conducted with the objective of to find out the prevalence of different types of “lifetime” domestic violence against ever-married women in reproductive age group (15–49 years) in an urban area of a district of West Bengal, to identify the factors associated with it and also to estimate their care-seeking behavior.

Materials and Methods

A cross-sectional, community-based descriptive, and observational epidemiological study was carried out among all ever-married women of 15–49 years of age residing at a slum of Burdwan district of West Bengal, India from March 2019 to December 2019.

Inclusion criteria were all ever-married women of 15–49 years of age, permanent residents of the studied slum, and willing to participate. Exclusion criteria were women below 15 years and above 49 years, mothers-in-law, unmarried, divorced and separated women, widows, noncooperative women who refused to furnish necessary information, women who were seriously physically or mentally ill, and visitors to that locality. Considering the prevalence of domestic violence as 41.8%,[4] confidence level of 95%, 15% relative precision, and 10% nonresponse rate, the sample size was computed to be 357.

A sampling frame of the above population was prepared with the help of urban health post. Sampling technique was census population. The study tool was a predesigned pretested semistructured interview schedule. The schedule was prepared in the local language (Bengali) with the help of three experts of community medicine. The new tool was validated by three public health specialists. The pretesting was done among the married women of the adjacent slum area and the women were not included in the sampling frame and minor modifications were done in the tool. Then, the final tool was applied in data collection. Study variables were age in years, age at marriage, duration of marriage, religion, literacy status of study population, husband's education, occupation of study population, employment status of the husband, socioeconomic status (as per Modified Kuppuswamy's Scale 2019),[6] prevalence, type and frequency of domestic violence, addiction of husbands to alcohol, and their care-seeking behavior.

Procedure for data collection

Home visits were carried out, and face-to-face interview with these women was done in the absence of their guardian/husband by Principal Investigator (PI) and/or Co PIs. The purpose of the study was explained to the participants, informed consent was obtained, and initial rapport was built with the help of female Community Leader. They were also assured that anonymity and strict confidentiality would be maintained. In case the sampled woman was not at home at the time of visit, the next visit was scheduled after prior appointment. Information was gathered about the sociodemographic profile of the participants and whether they were subjected to any domestic violence or not.

The interview lasted for 30–45 min depending on the women's experiences. The reference period considered was any time preceding the survey.

Ethical permission was obtained from the Institutional Review Board of Burdwan Medical College, West Bengal, India.

Data were compiled and analyzed by Epi Info 6 version and SPSS 20 version. Proportions and Chi-square tests were used for analysis of data.

Results

The present study was conducted among ever-married women of reproductive age group (15–49 years) in an urban area of Burdwan District. Out of 357 women, 320 participated while 27 (10.36%) refused because of feelings of shame and fear; thus, the response rate was 89.64%.

Mean age of the participants was 28 ± 5.34 years and majority of the women were in the age group of 25–35 years (33.94%). All were Hindu and were currently in monogamous relationship during the time frame of preceding 12 months of the study. Regarding educational status, 151 (47.19%) were illiterate, and only 4.68% had studied up to higher secondary and above. Majority (92.31%) of the respondents were homemakers and rest 7.69% were unskilled laborers. With regard to socioeconomic status (according to modified Kuppuswamy's Classification 2019),[6] a majority of the participants (36.56%) belonged to the lower middle class. So far as the occupation of husband was concerned, 277 (86.56%) were employed; 36.54% were unskilled laborers, 33.07% were skilled laborers, 4.61% were doing service, and 13.47% were self- employed. About 60.94% of the husbands of the study population were addicted to alcohol. A considerable number of husbands of participants 102 (31.88%) were illiterate and only 15 (4.69%) passed higher secondary and above. Majority 198 (61.88%) of the study population married after 18 years of age and 86 (26.88%) had married life for more than 10 years.

The overall prevalence of any form of violence during the lifetime among the study population was found to be 35.63% and husband was the main perpetrator followed by other family members.

Verbal/psychological violence was the most common form of domestic violence (91.23%) followed by physical (82.46%) and sexual violence (64.91%) among the subjects.

Slapping and or beating, kicking, and throwing objects were the major forms of physical violence experienced by these women. Humiliation 92 (88.46%) was the commonest form of psychological violence. Most common sexual violence was the use of physical force to have sexual intercourse (51.35%) [Table 1].

Table 1

Types of physical, psychological, and sexual violence

Type of violence*	Respondents
	Number	Percentage
Physical violence (n-94)
Slapping/beating	76	80.85
Kicking	64	68.09
Object throwing	41	43.62
Others (Chocking, punching, threatening to kill)	28	29.79
Verbal/Emotional violence (n-104)
Humiliation	92	88.46
Blaming character of spouse	84	80.77
Threats to leave her	76	73.08
Dowry issues	63	60.58
Others	48	46.15
Sexual violence (n-74)
Pressure for sex	38	51.35
Hurt for sex	36	48.65
Others (angry when rejected)	22	29.73

*Multiple responses

In response to the frequency of domestic violence, the response of the participants was: every day 23 (20.18%), weekly 25 (21.93%), once in 15 days 29 (25.44%), monthly 21 (18.42%), and occasionally 16 (14.04%) [Table 2].

Table 2

Frequency of domestic violence

Frequency	Respondents
	Number	Percentage
Daily	23	20.18
Weekly	25	21.93
Fortnightly	29	25.44
Monthly	21	18.42
Occasionally	16	14.04
Total	114	100.00

Prevalence of all forms of violence increased along with the age of the respondents. Women aged 25–35 years 99 (47.47%) and 35–45 years 42 (51.85%) reported higher. Prevalence of violence in women aged less than 25 years was 22 (28.21%) and this difference was statistically significant (P < 0.05) [Table 3].

Table 3

Sociodemographic characteristics and prevalence of domestic violence

Characteristics	Experience of domestic violence				Statistical values
	Yes		No
	No	Percentage	No	Percentage
Age group (in years)
18-25	22	28.21	56	71.79	χ2=12.62 (P<0.05)
25-35	47	47.47	52	52.53
35-45	42	51.85	39	48.15
>45	24	38.71	38	61.29
Education of wife
Illiterate	65	43.05	86	56.95	χ2=1.97 (P>0.05)
Primary	37	44.58	46	55.42
Secondary	29	40.85	42	59.15
Higher Secondary and above	4	26.67	11	73.33
Education of husband
Illiterate	48	47.06	54	52.94	χ2=5.08 (P>0.05)
Primary	52	46.02	61	53.98
Secondary	32	35.56	58	64.44
Higher Secondary and above	3	20.00	12	80.00
Employment status of husband
Unemployed	32	74.42	11	25.58	χ2=25.31 (P<0.05)
Employed	103	37.18	174	62.82
Socioeconomic status
Upper middle	10	40.00	15	60.00	χ2=9.65 (P<0.05)
Lower middle	39	33.33	78	66.67
Upper lower	45	45.45	54	54.55
Lower	41	51.90	38	48.10
Age at marriage (in years)
<18	85	69.67	37	30.33	χ2=18.97 (P<0.05)
≥18	96	48.48	102	51.52
Duration of marriage (in years)
<5	62	47.69	68	52.31	χ2=6.94 (P<0.05)
5-10	45	43.27	59	56.73
>10	28	32.56	58	67.44
Alcoholism of husband
Yes	110	56.41	85	43.59	χ2=55.43 (P<0.05)
No	25	20.00	100	80.00
Total	135	42.19	185	57.81

Though no significant difference was found so far as literacy of both partners was concerned, the data revealed that education had an impact on the prevalence of domestic violence. The prevalence of violence decreased as educational levels of women and their husbands increased. Sixty-five women (43.05%) with no education had experienced physical or sexual violence, as compared with two women (26.67%) with 12 or more completed years of education. Similarly the women whose husbands were illiterate 48 (47.06%) faced more violence than women whose husbands had higher secondary and above 3 (20%). Study population with unemployed husbands reported more violence 32 (74.42%) than their counterparts with employed husbands 103 (37.18%) and the difference was statistically significant (P < 0.05) [Table 3].

It was seen [Table 3] that as the age at marriage of the participants was increased (69.67% for those who married before 18 years), the prevalence of domestic violence decreased (48.48% for those who married at 18 years and more). It was also reported that as the duration of married life increased prevalence of domestic violence decreased; those who married for less than 5 years had experienced higher prevalence (47.69%) of domestic violence than those married for more than 10 years (32.56%) (P < 0.05). Women whose husbands addicted to alcohol (56.41%) experienced more violence than those without alcoholic husbands (20%), which was again statistically significant (P < 0.05).

About one-third (32.46%) of women who faced violence in their lifetime had never sought any help. More than 23.68% women sought help from their parents, followed by 20.18% from neighbors and only 9.68% had reported to police [Table 4].

Table 4

Care-seeking behavior of victims

Kind of help*	Respondents (n-114)
	No	Percentage
Informed parents	27	23.68
Informed in-laws	17	14.91
Informed friends/neighbors	23	20.18
Informed police	11	9.65
Others (Professional help)	13	11.40
Did not seek help	37	32.46

*Multiple responses

Discussion

Prevalence of domestic violence

The present study identified that 35.63% had faced domestic violence in any form or in combination in their lifetime. India's National Family Health Survey-III, carried out in 29 states during 2005-06, found that nation-wide, 37.2% of women experienced violence after marriage.[4] A similar study conducted in a slum of Kolkata revealed that the prevalence of domestic violence was 54%.[7] Another study in Delhi showed that the prevalence of psychological, physical, sexual, physical, or sexual violence and any form of violence was very high. Domestic violence against women is inversely associated with their mental health. A multisectoral approach is needed to address this problem.[8] A study on the same topic done by Sarkar[9] in rural setting of West Bengal showed that the prevalence of domestic violence was 23.4%. Babu and Kar[10] reported the prevalence of domestic violence of 56.3% in eastern India; 60.7% in Orissa, 51.8% in West Bengal, and 58.9% in Jharkhand. A study by Jeyaseelan et al.[11] in India showed 26% spousal physical violence during the lifetime of their marriage. The proportion of women who reported physical violence by their spouse was 26.6% in Goa,[12] 39% in six zones of India,[13] a total of 69% among nurses in AIIMS of Delhi,[14] 42.8% in a colony of Delhi,[15] and 29.57% in Bangalore.[16]

Prevalence of different types of domestic violence

In a study conducted in Uttar Pradesh by Koenig et al.,[17] the prevalence of lifetime physical and sexual violence was found to be 25.1% and 30.1%, respectively, which was found to be higher (71.4% and 57.1%, respectively) in our study. The corresponding figures were 35.5% and 10.0% in NFHS III,[4] 35.9% and 54.1% in Kolkata,[7] 52.1% and 52.5% in Orissa, 14.6% and 50.6% in West Bengal, 21.2% and 54.5% in Jharkhand, 16.1% and 52.3% in eastern India,[10] 43.3% and 30% among nurses in AIIMS,[14] 14% and 14% in six zones,[15] 31.6% and 10.5% in Bangalore,[16] and 84% and 90% in a study on five adjoining states of Andhra Pradesh, Chhattisgarh, Gujarat, Madhya Pradesh, and Maharashtra.[18]

In the present study, women also suffered from more than one type of violence. This was similar with the findings of other studies[41418] where the reported violence was multiple in nature and most of the women were subjected to more than one type of violence.

Different forms of physical, psychological, and sexual violence

The most common form of lifetime physical violence was slapping and/beating (80.85%), kicking (68.09%), object throwing (43.62%), and choking and punching the women (29.79%), which was consistent with the findings of other studies.[48910121418] According to NFHS III, the most common physical violence was slapping (34%) followed by twisting of arms or pulling of hairs (15.4%), throwing something (14%), kicking (12%), and choking (2%).[4] Humiliation was the most common form of emotional violence in this study and other studies.[4912] The most common form of sexual violence was physically forced her to have sexual intercourse (58.3%).[49]

Frequency of domestic violence

In the present study response to frequency of domestic violence, the response of the participants was: every day 23 (20.18%), weekly 25 (21.93%), once in 15 days 29 (25.44%), monthly 21 (18.42%), and occasionally 16 (14.04%). In a study in five states,[18] about 16% of women reported that they were facing domestic violence once or twice in a week, or once or twice in a month and the percentage of respondents against whom domestic violence was committed practically every day was 15%; which was similar to the present study. In Singur, the study also found that 9.1% faced violence few times in a week or few times in a month, whereas 81.8% faced it in a year.[9] In Bangalore study, the frequency of violence was at least once in a week in 34.21% women, once in 15 days in 31.58% women, once in a month in 26.32%, and once in 1–3 months in 7.89% women.[16]

Relation of domestic violence with sociodemographic variables

Age had a profound association with the prevalence of domestic violence. Prevalence of all forms of violence was increased along with the increasing age of the women in the present study and other studies also[4910121315] but Bangalore study[16] did not reveal this association where it was observed that as age of the women increased, the prevalence of domestic violence decreased.

Education had impact on the prevalence of domestic violence which was inversely associated with education levels of the women and their husbands and it was corroborative with the findings of some other studies.[49101112131418] In this study, families with low-income level showed a higher rate of violence and the rate of domestic violence decreased as the socioeconomic level increased; some other studies also supported this finding.[49111213]

Alcohol addiction of the husband was found to be strongly related to the presence of domestic violence in this study and other studies.[471112131416] NFHS III reported that women whose husbands drink alcohol had significantly higher rates of violence than women whose husbands did not drink at all; emotional violence was three times as high, physical violence was more than two times as high, and sexual violence was four times as high.[4]

Majority of the victimized women preferred to be silent sufferers. The help-seeking behavior was found in one-third (31.5%) of women who had faced violence in their lifetime. These women had never sought any help, even from their relatives and close friends, and preferred to rely upon their own strategies to deal with the situation. This was corroborative to some other studies where 32.7% and 74.4% did not report the abusive situations in which they were living.[1213] In urban and rural areas of Haryana, 37% of the married females had ever experienced domestic violence.[14]

In our study, 23.68% women sought help from their parents, followed by 20.18% from friends/neighbors while only 9.65% had reported to police which represented the tip of the iceberg. Notably few women seek help from any institutional sources such as the police, medical personnel, or social service organizations.[4] In a study in five states, among the respondents who sought help, 26.3% abused women had approached their parents, 15.6% to relatives, and 57.9% to friends.[18] Goa study revealed that 31.1% talked to relatives or close friends and only 4.4% took legal help.[12] In the Bangalore study, nobody informed the police.[16] The present study and some other studies highlighted the factors which had positive influence for domestic violence like young age at marriage,[121618] duration of marriage,[414] as well as husband's employment status.[14]

Factors associated with an increased risk of perpetrating violence include low education, child maltreatment, exposure to violence in the family, use of alcohol, attitudes accepting of violence, and gender inequality.[19]

Emotional and verbal type of violence is the most common type. Caste, religion, literacy status of study subjects, and occupational status of spouses of study subjects were reported as significant correlates affecting the causation of domestic violence among the subjects.[20]

The effects of violence on a victim's health are severe. Domestic violence can lead to serious short- and long-term physical, mental, sexual, and reproductive health problems for women and lead to high social and economic costs.[2122] Domestic violence is associated with mental health problems such as anxiety, post-traumatic stress disorder, and depression. Intimate partner violence in pregnancy also increases the likelihood of unplanned or early pregnancies and sexually transmitted diseases, miscarriage, stillbirth, preterm delivery, and low birth weight babies.[2122]

Limitations of the Study

The sensitivity and stigma associated with violence, as well as fear of reprisal, may lead to under-reporting of violence. A small sample size has limited the generalizability of the present study. Investigation of the effects of violence on health would provide a clearer picture of short- and long-term suffering of the victims.

Conclusion

The present study found that the overall prevalence of physical, psychological, sexual and any forms of violence among women were 69.63%, 77.04%, and 54.81% respectively. The study revealed the high prevalence of all forms of violence against women in an urban area of Burdwan, India. Older age, lower age at marriage, longer duration of marriage, lower education of husband and wife, lower family income, unemployment of the husband, and alcohol consumption of husband were associated with the occurrence of domestic violence.

Ending violence against women needs to be addressed at various levels. The coordinated efforts of various sectors such as social, legal, educational, medical, etc., are essential to address the various economic and sociocultural factors that foster a culture of violence against women in India by strengthening women's human and economic rights and reducing gender gaps in relation to employment and education.

Ethical approval

Ethical and institutional clearance obtained from the Institutional Review Board of Burdwan Medical College, West Bengal, India 04.02.2019.

Declaration of patient consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflicts of interest.