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Ameeta Kalokhe, MD MSc Emory University School of Medicine, Infectious Diseases

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.

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Ameeta Kalokhe, MD MSc Emory University School of Medicine, Infectious Diseases

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  1. 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

  2. Domestic Violence (DV) • Physical, sexual, verbal, emotional, and economic abuse against a woman by a partner or family memberwithin a shared household or joint family. • —The India Protection of Women from Domestic Violence Act 2005

  3. DV and HIV in India • 36% of married Indian women report lifetime physical or sexual abuse by an intimate partner • Experience of physical and sexual intimate partner violence is linked to a 3.92 higher odds of being HIV-infected • Why the increased HIV risk? • Diminished condom use • Sexually transmitted infections • High-risk partners • Multiple partners • 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

  4. National Family Health Survey-3 Does/did your (last) husband ever do any of the following things to you? • Slap you? • Twist your arm or pull your hair? • Push you, shake you, or throw something at you? • Punch you with his fist or with something that could hurt you? • Kick you, drag you or beat you up? • Try to choke you or burn you on purpose? • Threaten or attack you with a knife, gun, or any other weapon? • Physically force you to have sexual intercourse with him even when you did not want to? • Force you to perform any sexual acts you did not want to? • Say or do something to humiliate you in front of others? • Threaten to hurt or harm you or someone close to you? • Insult you or make you feel bad about yourself? IIPS and Macro International. NFHS-3 2005-2006, Chp 15

  5. Hypothesis & Aims Hypothesis: Currently-available DV scales are inadequate for measuring DV in the Indian context • Aim 1: to develop a culturally-tailored scale to effectively measure DV among married women in Pune, India • Aim 2: to validate the scale among married women in Pune, India

  6. 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’sα; item-total score) • Assess construct validity (CTS-2 module from NFHS-3; demographic variables)

  7. Pune, India • 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 http://www.anusha.com/mohandas.htm 2011 Census of India IIPS and Macro International. NFHS-3 2005-2006, Chp 15 RuikarIndian J Public Health 2008

  8. National AIDS Research Institute • established over 20 years prior • nodal HIV research institute of the Indian Council of Medical Research

  9. Our study team NARI mentor: SeemaSahay, PhD Emory mentor: Carlos del Rio, MD Recruitment/Enrollment Specialist: Ratnaprabha Potdar, MSW The Department of Social and Behavioral Sciences

  10. 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’sα; item-total score) • Assess construct validity (CTS-2 module from NFHS-3; demographic variables)

  11. Large variance in DV prevalence estimates Lifetime Prior 12-month period Prevalence estimate as reported by study (%) Form(s) of domestic violence assessed • Only one-third of studies used validated DV instruments (CTS-2, ISA, AAS)

  12. 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’sα; item-total score) • Assess construct validity (CTS-2 module from NFHS-3; demographic variables)

  13. Methods: Qualitative • Key Informant Interviews (16): psychiatrist, gynecologist, police commissioner, DV and human rights lawyers, NGO leaders, sociologists, anthropologist, religious leaders, HIV/DV/family court counselors • Gender-concordant focus groups (2): community members • 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

  14. Results: Qualitative • Major themes informing the development of the Indian Family Violence and Control Scale (IFVCS) item pool • Multiple perpetrators • Need for introductory, rapport-building questions • Normalization and acceptance of DV • Differences by region, SES, age, marital duration, profession need for extensive validation • Additional forms of DV identified

  15. Results: Qualitative (63 question-item pool) • Psychological • sent to maher [natal family home] against will • harassment for maanpaan/dowry • harassment for girl-child, infertility • threats to her maher • Physical • tried to poison • burned using cigarettes, kerosene, chemicals, acids, etc • threatened/attacked with a belt, stone, broomstick, or rolling pin • forced to work excessively to the point of exhaustion • Sexual • forced to have sex against will during menses, pregnancy, with someone else • forced to replicate a sexual behavior from a pornographic film • forced videotaping of sexual intercourse • threatened to sexually abuse family member for refusing sex • Control/Isolation • prevented from spending money on children/natal family/friends • prevented visits of natal family/friends • forced to leave a job/take up a job • limited family-planning decisions • restricted/stalked phone, text messages, emails, social networking • forced to change physical appearance, diet (i.e. vegnon-veg), or perform upvas (fast)

  16. 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’sα; item-total score) • Assess construct validity (CTS-2 module from NFHS-3; demographic variables)

  17. 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

  18. 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’sα; item-total score) • Assess construct validity (CTS-2 module from NFHS-3; demographic variables)

  19. Results: Quantitative • 630 surveys administered to random (geographically-clustered) sample of married women randomly from 16 wards in Pune • 94% Marathi, 5% Hindi, and 1% English • 96% Verbal, 2% Written, 2% Both Verbal/Written • 3 scale versions with differing item order

  20. IFVCS Developmental Sample (n=630) • Sample demographics: • Average age: 35 years (range: 19-69y) • 78% Hindu, 12% Buddhist, 7% Muslim, 2% Christian, 1% Jain • 42% employed • Education: 33% ≤ primary, 28% secondary, 39%>secondary • Monthly family income: 19% ≤ Rs 6,000, 30% Rs 6,000-10, 44%>10,000 • Marriage: average 15 yrs (range: 1-60); 87% arranged; 98% first marriage • Family type: 58% nuclear family; 42% joint family • Demographics of participant’s husband • Average age: 39 years (range: 22-73y) • 93% employed • education: 27% ≤ primary; 29% secondary; 44% >secondary

  21. IFVCS Psychometrics • Internal Consistency • Control subscale 0.84 • Psychological DV subscale 0.88 • Physical DV subscale 0.85 • Sexual DV subscale 0.70 • Construct validity: • NFHS-3 CTS-2 module • DV correlates (education, family income, number of pregnancies, age of participant at 1st child, housing material) • Scale order nor language of administration affected response

  22. Conclusions/Future Directions • Indian Family Violence and Control Scale • Culturally-tailored, good internal consistency, construct validity • Requires future widespread validation (rural/tribal, other regions of India) • May be used to inform and evaluate future domestic violence prevention strategies, including those for HIV high-risk and HIV-positive women in India

  23. Thank you NARI, Pune, India • Seema Sahay, PhD • Ramesh Paranjape, PhD • Qualitative Team: Ratnaprabha Potdar, VidishaKanthe, MufidBaig, VinodBalerao, JayeshriGudade, RahulKantikar, Sanjay Kulkarni, NitinPatil, ArchanaVerma • Quantitative Team: VikramSolas, LatikaKarve, MeenaChivate, VidulaHulyalkar, YoginiBurhade • Data Management: NayanaYenbhar, BasitMomin Emory University • Carlos del Rio, MD • Rob Stephenson, PhD • KristinDunkle, 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

  24. Contact Information Questions? Ameeta Kalokhe akalokh@emory.edu

  25. 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

  26. Control: a commonly identified form of DV • 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.” • 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.”

  27. Control: a commonly identified form of DV • 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.” • 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….”

  28. Sexual abuse: accepted, under-recognized, and influenced by affluence • 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.”

  29. 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.”

  30. 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?”

  31. 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.”

  32. 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 • 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

  33. Conclusions from literature review • Large variety of study designs, settings, and populations Underrepresentation: • Northwestern and Eastern states • Age 50+, same-sex, live-in, HIV+/discordant • Two-thirds limited to two forms of DV • One-third used validated scale (CTS, AAS, ISA) Submitted to Trauma, Violence, and Abuse

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