INTRODUCTION
Gender-based violence (GBV) refers to any act of violence or threats of such acts, coercion, or the arbitrary deprivation of liberty resulting in physical, sexual, or psychological harm or suffering directed at an individual based on their gender – violation of basic human rights.[1] It extends beyond socioeconomic, cultural, racial, and class distributions.[2] Domestic violence includes violence by spouses as well as by other household members[3] and is the most common form of GBV against women in the form of threatening. Women bear the brunt of domestic violence and the associated health burden (disease and disability), poor quality of life, intergenerational effects, and demographic and economic (medical costs and loss of labor hours/wages) consequences.[4,5]
Domestic violence has been recognized as a criminal offence in India since 1983 and is charged under section 498A of the Indian Penal Code (IPC) for any act of cruelty by a husband (or his family) toward his wife.[6] However, considering the complexities associated with specific cases of domestic violence, Protection of Women from Domestic Violence Act (PWDVA, 2005) came into effect. PWDVA, 2005 defines domestic violence to include all forms of physical, emotional, verbal, sexual, and economic violence and covers both actual acts of such violence and threats of violence. Also, PWDVA recognizes marital rape and covers harassment in the form of unlawful dowry demands as a form of abuse.[7]
Importantly, women subjected to domestic violence are abused inside their own homes – which should be the most secure environment – and by their husbands – who should be the person they trust most. Spousal or intimate partner violence is the most common form of domestic violence.[8] The global prevalence of physical and/or sexual intimate partner violence among all ever-partnered women was 30.0% (95% confidence interval [CI] 27.8–32.2), highest in the age group of 20–44 years (31.1%–37.8%) and in the South-East Asia regions, where approximately 37% of ever-partnered women reported having experienced physical and/or sexual intimate partner violence at some point in their lives.[9] Women experiencing spousal violence have a significant association with increase in unwanted pregnancy, abortion, miscarriages, and pregnancy terminations. Even during pregnancy, the risk of prolonged labor is substantially increased. The risk of sexually transmitted infection increases 77% by sexual violence and 44% by emotional violence among battered women.[10]
Domestic or spousal or intimate partner violence is a preventable cause of morbidity and mortality in women.[11] Against this background, the need to know the prevalence and factors associated with spousal violence is imperative. The primary objective of this study was to estimate the prevalence of spousal violence among reproductive age group women in central India. We also assessed the various types of spousal violence among them and factors associated with it.
MATERIALS AND METHODS
This was a community-based analytical cross-sectional study conducted at Urban Health Training Center (UHTC) area, an adopted urban slum area under the administrative control of N. K. P. Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India. The study was conducted between 2016 and 2018. All married women between 15 and 49 years of age (reproductive age group) in urban field practice area who were willing to give consent were included in the study. Women who were unmarried, divorced, menopausal, and not willing to give consent were excluded. Using prevalence of any form of physical and/or sexual and/or emotional violence ever in the past 12 months (39.7%),[3] absolute error (d) of 5%, and 95% CI, the minimum required sample size was calculated to be 368. Statistical significance was considered at P values < 0.05.
Based on a health survey done (2012) in the study area, 3985 women were within reproductive age group among a total population of approximately 23,365. Line list of reproductive age group women was prepared, and the sampling interval was calculated to be 11. Systematic random sampling was done – lottery method was used to select the first woman, followed by every 11th woman in the list. In case women were not available, two additional visits were made on different days, and if not available, the very next woman in the list was included. The data was collected by face-to-face interview with the help of pre-designed, pre-tested, and semi-structured questionnaire that included sociodemographic characteristics, emotional support, and factors related to dowry and spousal violence.
The primary outcome or dependent variable “spousal or intimate partner violence” refers to married women aged 15–49 who have experienced various forms of violence (physical, sexual, and emotional) ever, committed or perpetrated by their husband. Based on modified conflict tactics scale (CTS),[3,12,13] women were asked about seven sets of acts of physical violence, two acts of sexual violence, and three acts of emotional violence as described in Table 1.
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Table 1: Spousal violence - various forms
Data was collected from 373 participants and analyzed using Statistical Package for the Social Sciences (SPSS) v21. The study sample was presented using numbers and percentages. Chi-square (two-sided) test was used to test the association for categorical variables, and odds ratios (ORs) are presented with 95% CI. All predictor variables significant at P < 0.05 in univariate analysis were included in multiple logistic regression analysis. The study was approved by the Institutional Ethics Committee (IEC) of N. K. P. Salve Institute of Medical Sciences and Research Centre. To ensure special protection for women (study participants), information on sources of help for abused women was given and specialized training was provided for study investigators keeping with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001).[14]
RESULTS
Data was collected from 373 women of reproductive age group. Mean age and standard deviation (SD) of the sample was 27.5 ± 2.2 years. Majority were less than 25 years of age at marriage (53.1%) and followed Hindu religion (76.1%). Higher proportion of husbands were literate in comparison to their wives (68.8% vs. 60.1%), but unemployment was marginally higher among husbands (37.8% vs. 35.9%). More than half (52.3%) of the women belonged to nuclear families, and 47.4% were of either upper or upper middle socioeconomic status. Three-fourths of the women (74.5%) reported that their spouses regularly consumed alcohol, and 48.6% reported lack of emotional support from family members. Nearly one in five (15.3%) women reported economic or materialistic dowry-related problems in the family.
Spousal violence
The prevalence of spousal violence among reproductive age group (15–49 years) women was found to be 59.7% [Table 2]. Emotional violence (54.1%) was the most common type of spousal violence, followed by physical (51.2%) and sexual (43.4%) violence in that order.
Table 2: Prevalence of spousal violence and its types
Factors associated with spousal violence
Women married at less than 25 years of age were at increased risk of spousal violence in comparison to those married at or after 25 years (OR 1.60, 95% CI 1.10–2.49) [Table 3]. Literacy was associated with increased risk of spousal violence (literacy of women: OR 1.82, 95% CI 1.20–2.77; literacy of husband: OR 2.07, 95% CI 1.03–3.25). Similarly, the employment status of women and husbands increased the risk of spousal violence by 2.08 (95% CI 1.36–3.21) and 5.25 (95% CI 3.31–8.32) times, respectively. Other factors that increased the risk of spousal violence were lack of emotional support from the family (OR 3.19, 95% CI 2.09–4.89), regular alcohol consumption of husband (OR 12.51, 95% CI 6.51–24.03), and presence of dowry-related problems (OR 4.93, 95% CI 2.46–9.87). Of the factors considered, women’s religion, type of family, and socioeconomic status of the family were not statistically associated with spousal violence (P > 0.05).
Table 3: Factors associated with spousal violence among reproductive age group women
The variables significant in univariate analysis were included in the multivariate logistic regression analysis. The results showed that employment of husband (adjusted odds ratio (AOR) 2.93, 95% CI 1.24–4.28), regular alcohol consumption by husband (AOR 4.73, 95% CI 2.50–7.83), and dowry-related problems in the family (AOR 1.97, 95% CI 1.04–4.45) were independent predictors of spousal violence among reproductive age group (15–49 years) women.
DISCUSSION
It was found in the study that more than half of the women of reproductive age group had encountered spousal violence, with emotional violence being the most common. The prevalence of any form of spousal violence ever found in this study was higher than that reported in the National Family Health Survey (NFHS)-4 (31.0%).[15] The study investigators are familiar to the study participants as the study area has been adopted for routine academic teaching and training purposes, field work, and service delivery. This may have caused women to disclose violence within the family.[3,15] Like the findings of this study, in a study from a slum area of Kolkata, prevalence of domestic violence among women of reproductive age group was 54%, of which 41.9% suffered from both current and lifetime physical and psychological violence.[16] This may be attributed to the similarity in baseline characteristics (type of family, literacy and occupation of women, alcohol consumption by husband) of the study population. Various studies have reported spousal violence or abuse ranging between 29% and 40.5% across India.[17–19] In addition to this, the ongoing coronavirus disease 2019 pandemic and its consequences like chronic entrapment, overcrowding in families, enhanced substance use, distorted relationship dynamics, travel restrictions, and reduced health-care access have reportedly increased intimate partner violence to the height of “hidden pandemic.”[20–23]
Early age at marriage was significantly associated with increased spousal violence. The dominant nature of elder male partner may influence violence as studies show that length of marriage, age difference of the couple, and type of marriage may all be precipitating factors.[16,17] Though education status has variably been associated with domestic violence,[16,18,24] literate and employed women were at increased risk of domestic violence in this study. This may be attributed to the fact that literate employed women are more outspoken that they disclose domestic violence in comparison to illiterate unemployed women, or high self-esteem in literate employed women may result in more domestic violence. However, evidence shows that women subjected to domestic violence have lower self-efficacy and self-esteem consequently.[25,26]
The insignificant relation between domestic violence and religion, type of family, socioeconomic status, together with the significant association of women lacking emotional support from the family highlights that women of reproductive age group face spousal violence irrespective of family settings, but because of lack of empathy within the family.[27] These findings are similar to the findings of other studies conducted across different study settings.[16–18]
The co-occurrence of alcohol dependence or abuse and domestic violence including forced sex within marriage in India is widely acknowledged.[28–30] Among the factors associated with spousal violence in this study, regular alcohol consumption of husband had the highest odds of spousal violence among women (OR 12.51, 95% CI 6.51–24.03). Dowry, both economic and materialistic, and its consequent problems in the family increased the risk of spousal violence, similar to other studies.[31–33] These factors stress the widening gender inequality being a social “un-equalizer.”[34]
The strengths of this study include previous sample size estimation and inclusion of optimal sample, robust design, use of standardized study tools, and study investigators being familiar to the study participants (would have reduced underreporting due to stigma and embarrassment). However, the study had a few limitations – non-inclusion of all factors associated with spousal violence, inability to establish temporality between associated factors and spousal violence (inherent limitation of study design), possibility of recall bias, and inability to rule out conscious falsification of data by the study participants. The findings may only be generalizable to other similar settings. Large-scale community-based studies preferably with a qualitative component should be conducted to understand the roots and branches of spousal violence as the patterns and prevalence of spousal violence vary with time, person, and locality.
CONCLUSION AND RECOMMENDATIONS
The toll of spousal violence in the country will not ease out until a multifaceted approach including legal measures, empowerment of women (through programs like “Beti Bachao Beti Padhao”), and sociocultural factors is employed involving families, institutions, governmental, nongovernmental, and civil society organizations. Involving woman self-help groups in rural areas and introduction of helplines at a block or district level are shown to be effective. It is the need of the hour to integrate opportunistic screening for domestic violence (in addition to alcohol dependence) by physicians at primary health-care facilities. To train physicians in these focus areas, platforms like “NIMHANS digital academy – Virtual Knowledge Network” would be helpful. In addition to women, these services should be focusing family members in the form of “participatory care” that would bring changes in attitude fostering spousal violence and to promote equity in marital relationships.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients 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 are no conflicts of interest.
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