Addressing Domestic Violence
Among Married Women in India
is Critical for HIV Prevention: the
Indian Family Violence and
Control Scale
Ameeta Kalokhe, MD MSc
Emory University School of Medicine, Infectious Diseases
Emory Rollins School of Public Health, Global Health
Atlanta, GA, USA
S
Domestic Violence (DV)
Physical, sexual, verbal, emotional, and economic abuse
against a woman by a partner or family member within a
shared household or joint family.
—The India Protection of Women from
Domestic Violence Act 2005
DV and HIV in India
S 36% of married Indian women report lifetime physical or sexual
abuse by an intimate partner
S Experience of physical and sexual intimate partner violence is linked
to a 3.92 higher odds of being HIV-infected
S Why the increased HIV risk?
S Diminished condom use
S Sexually transmitted infections
S High-risk partners
S Multiple partners
S Substance abuse
Need for addressing DV to address HIV in India
Need for an effective instrument to measure DV in the Indian context
Silverman J. JAMA 2008
Study setting
and perceived
safety
Perpetrator
surveyed
Interviewer
Methodology
(ACASI vs. FTFI)
Domestic
Violence
prevalence
estimates
Cultural and
socio-economic
determinants of
DV acceptance
Study population
DV forms and
multitude of
forms surveyed
Time Frame
National Family Health Survey-3
Does/did your (last) husband ever do any of the following things to you?
S Slap you?
S Twist your arm or pull your hair?
S Push you, shake you, or throw something at you?
S Punch you with his fist or with something that could hurt you?
S Kick you, drag you or beat you up?
S Try to choke you or burn you on purpose?
S Threaten or attack you with a knife, gun, or any other weapon?
S Physically force you to have sexual intercourse with him even when you
did not want to?
S Force you to perform any sexual acts you did not want to?
S Say or do something to humiliate you in front of others?
S Threaten to hurt or harm you or someone close to you?
S Insult you or make you feel bad about yourself?
IIPS and Macro International. NFHS-3 2005-2006, Chp 15
Hypothesis & Aims
Hypothesis: Currently-available DV scales are
inadequate for measuring DV in the Indian context
S Aim 1: to develop a culturally-tailored scale to effectively
measure DV among married women in Pune, India
S Aim 2: to validate the scale among married women in
Pune, India
Methods
Phase I: Formative Phase
- In-depth review of the Indian DV literature
- In-depth interviews of DV experts in the community
- Focus groups with community members
- Field pretesting of instrument and item review by experts/NARI
Ethics Committee
Indian Family Violence and Control Scale (IFVCS)
Phase II: Quantitative Phase
- Testing of the item pool: married women in Pune
- Assess internal consistency (Cronbach’s α; item-total score)
- Assess construct validity (CTS-2 module from NFHS-3; demographic
variables)
Pune, India
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http://www.anusha.com/mohandas.htm
Located in the state of Maharashtra
Population: 3.1 million
Age: 62% under age 30
Female-male sex ratio: 0.945
Literacy: 95% men, 88% women
32% below the poverty line
Mean age of marriage: 20.6 years
• NFHS-3 33.4% IPV prevalence
(urban Maharashtra)
• Pune slums61.5% physical IPV
prevalence
2011 Census of India
IIPS and Macro International. NFHS-3 2005-2006, Chp 15
Ruikar Indian J Public Health 2008
National AIDS Research Institute
• established over 20 years prior
• nodal HIV research institute of the Indian Council of Medical Research
Our study team
NARI mentor: Seema Sahay, PhD
Recruitment/Enrollment Specialist:
Ratnaprabha Potdar, MSW
Emory mentor: Carlos del Rio, MD
The Department of Social and
Behavioral Sciences
Methods
Phase I: Formative Phase
- In-depth review of the Indian DV literature
- In-depth interviews of DV experts in the community
- Focus groups with community members
- Field pretesting of instrument and item review by experts/NARI
Ethics Committee
Indian Family Violence and Control Scale (IFVCS)
Phase II: Quantitative Phase
- Testing of the item pool: married women in Pune
- Assess internal consistency (Cronbach’s α; item-total score)
- Assess construct validity (CTS-2 module from NFHS-3; demographic
variables)
Large variance in DV prevalence estimates
Prior 12-month period
Prevalence estimate as reported by study (%)
Lifetime
Form(s) of domestic violence assessed
Only one-third of studies used validated DV instruments (CTS-2, ISA, AAS)
Methods
Phase I: Formative Phase
- In-depth review of the Indian DV literature
- In-depth interviews of DV experts in the community
- Focus groups with community members
- Field pretesting of instrument and item review by experts/NARI
Ethics Committee
Indian Family Violence and Control Scale (IFVCS)
Phase II: Quantitative Phase
- Testing of the item pool: married women in Pune
- Assess internal consistency (Cronbach’s α; item-total score)
- Assess construct validity (CTS-2 module from NFHS-3; demographic
variables)
Methods: Qualitative
S Key Informant Interviews (16): psychiatrist, gynecologist,
police commissioner, DV and human rights lawyers, NGO
leaders, sociologists, anthropologist, religious leaders,
HIV/DV/family court counselors
S Gender-concordant focus groups (2): community members
S Domains of Inquiry: definition/forms/examples of DV,
strategies/barriers to asking about DV, differences in DV by
setting, SES, age, marital duration, and prevention strategies
Results: Qualitative
Major themes informing the development of the Indian
Family Violence and Control Scale (IFVCS) item pool
S Multiple perpetrators
S Need for introductory, rapport-building questions
S Normalization and acceptance of DV
S Differences by region, SES, age, marital duration,
profession  need for extensive validation
S Additional forms of DV identified
Results: Qualitative (63 question-item pool)
Psychological
S sent to maher [natal family
home] against will
S harassment for
maanpaan/dowry
S harassment for girl-child,
infertility
S threats to her maher
Physical
S tried to poison
S burned using cigarettes, kerosene,
chemicals, acids, etc
S threatened/attacked with a belt,
stone, broomstick, or rolling pin
S forced to work excessively to the
point of exhaustion
Sexual
S forced to have sex against will
during menses, pregnancy, with
someone else
S forced to replicate a sexual
behavior from a pornographic film
S forced videotaping of sexual
intercourse
S threatened to sexually abuse
family member for refusing sex
Control/Isolation
S prevented from spending money on
children/natal family/friends
S prevented visits of natal family/friends
S forced to leave a job/take up a job
S limited family-planning decisions
S restricted/stalked phone, text
messages, emails, social networking
S forced to change physical
appearance, diet (i.e. vegnon-veg),
or perform upvas (fast)
Methods
Phase I: Formative Phase
- In-depth review of the Indian DV literature
- In-depth interviews of DV experts in the community
- Focus groups with community members
- Field pretesting of instrument and item review by experts/NARI
Ethics Committee
Indian Family Violence and Control Scale (IFVCS)
Phase II: Quantitative Phase
- Testing of the item pool: married women in Pune
- Assess internal consistency (Cronbach’s α; item-total score)
- Assess construct validity (CTS-2 module from NFHS-3; demographic
variables)
Field pre-testing
63 items to 10 female NARI staff members and affiliated NGO peers
 Numerous afternoon disruptions  strategies
 Difficulty with Likert Scale lengths  strategies
 Translation issues  misinterpretations
 i.e. ‘mitra’ (boyfriend) to ‘mitra/maitrin’ (boyfriend/girlfriend)
 Participant desire to explain answers  debriefing
Methods
Phase I: Formative Phase
- In-depth review of the Indian DV literature
- In-depth interviews of DV experts in the community
- Focus groups with community members
- Field pretesting of instrument/Expert/NARI Ethics Committee item
review
Indian Family Violence and Control Scale (IFVCS)
Phase II: Quantitative Phase
- Initial testing of the item pool: married women in Pune
- Assess internal consistency (Cronbach’s α; item-total score)
- Assess construct validity (CTS-2 module from NFHS-3; demographic
variables)
Results: Quantitative
S 630 surveys administered to random (geographically-
clustered) sample of married women randomly from 16
wards in Pune
S 94% Marathi, 5% Hindi, and 1% English
S 96% Verbal, 2% Written, 2% Both Verbal/Written
S 3 scale versions with differing item order
IFVCS Developmental Sample (n=630)
S Sample demographics:
S Average age: 35 years (range: 19-69y)
S 78% Hindu, 12% Buddhist, 7% Muslim, 2% Christian, 1% Jain
S 42% employed
S Education: 33% ≤ primary, 28% secondary, 39%>secondary
S Monthly family income: 19% ≤ Rs 6,000, 30% Rs 6,000-10, 44%>10,000
S Marriage: average 15 yrs (range: 1-60); 87% arranged; 98% first marriage
S Family type: 58% nuclear family; 42% joint family
S Demographics of participant’s husband
S Average age: 39 years (range: 22-73y)
S 93% employed
S education: 27% ≤ primary; 29% secondary; 44% >secondary
IFVCS Psychometrics
S Internal Consistency
S Control subscale 0.84
S Psychological DV subscale 0.88
S Physical DV subscale 0.85
S Sexual DV subscale 0.70
S Construct validity:
S NFHS-3 CTS-2 module
S DV correlates (education, family income, number of
pregnancies, age of participant at 1st child, housing material)
S Scale order nor language of administration affected response
Conclusions/Future Directions
S Indian Family Violence and Control Scale
S Culturally-tailored, good internal consistency, construct
validity
S Requires future widespread validation (rural/tribal,
other regions of India)
S May be used to inform and evaluate future domestic
violence prevention strategies, including those for HIV
high-risk and HIV-positive women in India
Thank you
NARI, Pune, India
•
Seema Sahay, PhD
•
Ramesh Paranjape, PhD
Qualitative Team: Ratnaprabha Potdar,
Vidisha Kanthe, Mufid Baig, Vinod
Balerao, Jayeshri Gudade, Rahul
Kantikar, Sanjay Kulkarni, Nitin Patil,
Archana Verma
Quantitative Team: Vikram Solas, Latika
Karve, Meena Chivate, Vidula
Hulyalkar, Yogini Burhade
Data Management: Nayana Yenbhar,
Basit Momin
Emory University
• Carlos del Rio, MD
• Rob Stephenson, PhD
• Kristin Dunkle, PhD
• Mary Kelley, PhD
Temple University
• Anuradha Paranjape, MD
Study participants
Funding source
• NIH/FIC (Vanderbilt-Emory-Cornell
Duke Consortium for Global Health
Fellows Program 1 R25 TW009337-01)
• NIH/FIC K01 TW009664
Questions?
Contact
Information
Ameeta Kalokhe
akalokh@emory.edu
PubMed search results for August 2002 - 2012
 “domestic violence” and “India”189 articles
 “spouse abuse” and “India”80 articles
 “intimate partner violence” and “India”39 articles
Total: 308 articles
duplicate articles (107)
articles with extraneous focus (55)
146 articles evaluating the DV experiences of women in India
Qualitative studies13 articles
Case reports/studies3 articles
Commentaries/Letters/editorials14 articles
Reviews7 articles
Qualitative description of methods3 articles
106 quantitative studies
Medical/legal/NGO/post-mortem documentation 9
Others’ accounts (i.e. male partner) 5
Awareness /acceptability 2
Measured women’s agency only (not DV) 3
Violence among sex workers (familial perpetrator not
specified/differentiated from commercial partners) 2
85 studies in which DV questions were directly asked of women
Control: a commonly identified form of DV
S DV-FGD1-R9: “Now the wife is forced to have many kids. If
there are only daughters, then she is forced to have another
child until she bears a son. Somewhere the husband and the
mother-in-law keep on pressuring her. So, until she bears a
son, she keeps on conceiving even if she is going through
excruciating pain.”
S DV-KI-03: “And the woman doesn’t have the right to say that I
want to undergo a family planning operation. I have two
children. Enough is enough for me. I don’t want any more
children. Even this decision she cannot take. He will not listen
to anything…A woman knows feeding more than two children
or a lot more than two children is very difficult. She knows she
cannot afford to have more children. Physically she cannot
afford—her health doesn’t permit that. But even these
decisions she cannot take.”
Control: a commonly identified form of DV
S DV-KI-02: “…Social violence—this is something which is I
don’t think is there in the textbooks—but social violence, what
happens, is that many times, either the husband refuses the
wife to allow to meet her family, her parents, forces her to
break relationships with anyone outside his own family. So
she has to foresee, and she is forced to maintain the
relationship only with the in-laws. She is supposed to black
out her own parents, maybe her brothers, sisters--that is
social violence.”
S DV-KI-16: “Many a times, there is streedhan, streedhan that
she brings, many ornaments at the time of wedding, but all
those are taken away and kept in the cupboard. When the
mother-in-law says, only that day those should be worn. So
that all falls under ‘economical violence.’ Or they dispose of
her wealth and her salary on their own….”
Sexual abuse: accepted, under-recognized, and
influenced by affluence
S DV-KI-03: “You know, if the woman is forced into sex, that is
marital sex, marital rape as we call it. That is also domestic
violence. The woman doesn’t want to have sex, and she is
forced into it by the husband, it is domestic violence. But
unfortunately, in India, women do not look at it like this. This is
violation of their rights to be assertive about sex, they don’t
even look at it like violation. You talk to ten women and nine
will say that that is his right to have sex, to demand sex, and
when he wants, whether the woman wants it or not, is his
right.”
Sexual abuse: accepted, under-recognized, and
influenced by affluence
DV-KI-05: “But in information technology, computer sector, I think
it is my personal opinion, that they are earning out of
proportion and because of that what happens is they do not
have money as an issue or problem. So as money is not an
issue they keep on experimenting things. I mean, there is a
relationship with it, experimentation and money. So then they
watch different blue films [pornography], different sex videos,
sex films, and then they expect their wives to perform like
that… [speaking of a case] He made the rule that all the
windows should be closed and she should do everything in a
naked situation. Everything. She should not wear clothes. And
if she would wear clothes, then he would hit her, that ‘did you
ask me? Why did you wear clothes?’ and whenever he felt like
doing sex, he can do anywhere. So sometimes in the kitchen,
the other time somewhere else, anywhere.”
Experiences of Physical abuse: shaped by readily
available tools and the presence of others
DV-KI-05: “The woman was bedridden because of the burn
injuries. She was attempted to be murdered by burning her.
And see the whole disfigured body that her skin had stuck to
even the hand, even her hand was unable to be taken out, it
was stuck to the body as all her skin had melted…She took
her thumb impression on the authority letter [since] she was
not in a position to sign. Her thumb was burnt. It was taken
like that, all blood and ink together. I mean, even judge asked
us that, ‘how did you take like this red-colored thumb
impression, isn’t that lady educated?’”
DV-KI-03: “He slapped me, he hit me in the head, in front of 4
people he used abusive language, he pulled her sari in the
bazaar and yelled at her. This is all abuse—isn’t it?”
Psychological abuse: humiliation and mental torture
for infertility, dowry, and girl-children
DV-FGD1-R7: “There are some who torture their wives because
she has only daughters. They never consider that even they
[the husbands] are equally responsible. My own sister’s
example, still as in, even after her daughters are reeducated,
they are now engineers, and they are married to good
husbands—still my sister is berated.”
DV-KI-10: “…If she is not able to conceive a child, then torturing
her for that. Or for anything, that your parents did not give this
[a certain thing], so bothering her constantly. There are many
arguments over the give and take [dowry]. Now we are
heading towards 21st century, but still in many cases we are
seeing…like dowry and all doesn’t exist, but still, your parents
did not give this in the marriage’ [or] ‘the wedding should have
been done like this’ [or] ‘they did not do our maan-paan.”
• 36% of married women in India report physical abuse with or
without sexual abuse from their husbands
• 0.22% of the married women tested positive for HIV
•
Married women who experienced physical and sexual
intimate partner violence had a 3.92 higher odds of being HIV
infected than women who were not abused
Silverman J. JAMA 2006
Conclusions from literature review
S Large variety of study designs, settings, and populations
Underrepresentation:
S Northwestern and Eastern states
S Age 50+, same-sex, live-in, HIV+/discordant
S Two-thirds limited to two forms of DV
S One-third used validated scale (CTS, AAS, ISA)
Submitted to Trauma, Violence, and Abuse