Indian Journal of Medical Sciences Medknow Publications on behalf of Indian Journal of Medical Sciences Trust ISSN: 0019-5359 EISSN: 1998-3654 Vol. 61, Num. 5, 2007, pp. 253-262

Indian Journal of Medical Sciences, Vol. 61, No. 5, May, 2007, pp. 253-262

Original Contributions

Determinants of domestic violence among women attending an Human Immunodeficiency Virus voluntary counseling and testing center in Bangalore, India

Chandrasekaran Varalakshmi, Krupp Karl, George Ruja, Madhivanan Purnima

CSI Holdsworth Memorial Hospital, Mysore
Correspondence Address:Room 16A, CSI Holdsworth Memorial Hospital, Mandi Mohalla, Mysore - 570 021, varimph@yahoo.com

Code Number: ms07040

Abstract

Keywords: Domestic Violence, HIV, India, Voluntary Counseling and Testing Center, Women

Violence against women is a global phenomenon that cuts across all social and economic classes. In a survey of more than 24,000 women in 10 countries, the World Health Organization (WHO) found that 10-69% of women reported being physically assaulted by an intimate male partner at some point in their lives. ^[1] Much of this violence is accompanied with psychological and sexual abuse. ^{[1],[2],[3],[4],[5]} The issue has emerged as a central public health concern since victims are at high risk for adverse health outcomes, including sexually transmitted diseases, ^[5] HIV, ^[6] alcohol abuse and drug dependence, ^[7] homicides and suicides, ^[8] mental disorders, ^[9] miscarriages, preterm labor, fetal distress and low birth weight infants. ^[10]

Although there is a paucity of data on domestic violence (DV) from some parts of India, available research suggests that the scope of the problem is large. One study in five districts of Uttar Pradesh found that 18-45% percent of men reported that they physically abused their wives, and 18-40% indicated that they had nonconsensual sex with their spouses. ^[1] A household survey conducted in six Indian states found that 40% of women respondents reported being physically assaulted at some point in their life. ^[1] In another study of married women in rural Maharashtra, Jain et al. found that almost half of the respondents said they had been slapped, hit, kicked or beaten by their husbands at some time - 24% reported being kicked, 44% during pregnancy; 12% were specifically threatened by their husbands with having kerosene oil poured on them to set them on fire; and 30% of assaults required medical care. ^[11]

There is controversy regarding the underlying determinates of domestic violence. Much of the research has been carried out in North America, so this poses some questions about generalizability to developing countries. Widely differing prevalence rates across the world do suggest that DV occurs within a social and cultural context. Accepting that, there are a number of risk factors that appear to be reasonably universal. Strong associations have been found between DV and low household income, ^{[12],[13],[14]} low educational level of husband, ^{[15],[16],[17]} consumption of alcohol and drugs ^{[18],[19],[20],[21]} and witnessing domestic violence during childhood. ^[22],[23] Researchers have also identified an inverse relationship between a woman′s educational attainment and domestic violence. ^{[16],[24],[25]}

Other determinates of domestic violence are not so clear. Some studies have found an association between DV and positive HIV status, ^[26],[27] polygamy, ^[28] multiple sexual partners ^[29] and use of contraceptives. ^[30] Younger age has also been cited as a risk factor. ^[31] In addition several studies showed that a woman′s increased status as evinced by control over resources is protective against DV, ^[32],[33] while others demonstrated that employment and increased status do not necessarily reduce domestic violence ^[34] and may in culturally conservative areas increase it. ^[35]

This study examines violence among a sample group of women attending a voluntary counseling and testing center at a nongovernment organization located in Bangalore, India.

Materials and Methods

Study design

A cross-sectional study was conducted among women and couples visiting Freedom Foundation from September to November 2005. Freedom Foundation is a free-standing, voluntary HIV counseling and testing (VCT) clinic providing care and treatment services for people infected and affected with HIV in Bangalore, Karnataka.

Women between the ages of 18 and 45 years visiting Freedom Foundation and its affiliate hospitals for counseling and testing facilities were invited to participate. At registration, patients were informed about the study. They were told that participation was anonymous and completely voluntary and that refusal would in no way affect their care. Those who agreed to participate were interviewed while waiting for services. Because of limitations of funds, a convenience sample was utilized for this study.

Human subjects

The study was approved by the independent Ethics Committee of the School of Medical Education, Mahatma Gandhi University. Data were only collected from eligible participants who gave their written informed consent to participate.

Data collection

Women interested in participating were privately administered a structured questionnaire in the local language, viz., Kannada. The questionnaire included sections on demographic information; household socioeconomic status; indicators of financial autonomy; partner characteristics; HIV testing and disclosure experiences; history of violence; associated consequences of violence; and attitudes regarding violence.

Domestic violence variables

Variables related to abuse included presence of different types of physical abuse (slap or punch, kick, push, etc.), psychological abuse (threats, insults, humiliating remarks, abnormal jealousy, fear, etc.) or sexual abuse (nonconsensual sex) with the woman′s current partner or a previous partner. Each woman was asked, ′Has your partner ever done any of the following: slapped you, thrown something at you to hurt you? pushed or shoved you? hit you with his fist or with an object that could hurt you? kicked you, dragged you or beaten you? choked or burned you on purpose? physically forced you to have sexual intercourse when you did not consent? ever forced you to do something sexual that made you feel degraded or humiliated? insulted you or made you feel bad about yourself? humiliated you in front of others? scared or intimidated you? threatened to hurt you or someone you cared for?′

Each of these questions had three possible responses: 'Many times, 'Sometimes' or 'Never.' The woman was considered to have experienced violence if she answered 'Many times' or 'Sometimes' to any of the above questions related to abuse. The items were designed on the basis of scales used in earlier studies, including the WHO Multi-Country Study on Women's Health and Domestic Violence Against Women. ^[36]

Data analysis

Data were entered in MS Access (Microsoft Corporation, Redmond, WA) and analyzed in Stata 8.0 (Stata Corporation, College Station, TX). The primary outcome was a composite variable ′Domestic Violence′ (DV) analyzed as a binomial variable. DV is defined as having experienced physical, sexual, psychological violence or a combination of these. Univariate associations of baseline characteristics with DV were made using Pearson Chi-squared test or Fisher-exact method. Continuous variables were compared between groups using Student t-test or the Mann-Whitney test for nonparametric data. Variables with P values less than 0.1 were considered for inclusion in unadjusted and adjusted logistic regression models, with tests of significance being 2-tailed (P < 0.05). Confidence intervals were calculated at the 95% level.

Results

Sociodemographic characteristics of the respondents are shown in [Table - 1]. Over 80% of the participants were between 15 and 25 years of age with two-thirds reporting less than 10 years of education. One quarter of the study participants lived in a rural area (n = 61), and 43% lived in a joint family setting with husband′s extended family. About 54% were housewives, with 59% of the women reporting a total household income of less than INR 4,000 ($1 = INR 45). A third of the women reported being married before the age of 18 years. Almost all women included in the study had arranged marriages (91%), and the families of 34% women had given dowry to their husband′s family. A small number of women (7%) reported that the dowry had positive impact on their marriage. Two-thirds of the women respondents lived in urban communities. One-third of the women reported that their earnings were the family′s main source of income.

Study participants′ husbands′ characteristics are described in [Table - 2]. Sixty-one percent were reported to have had less than 10 years of education, and 50% were reported to be HIV seropositive. Sixty-eight percent of the interviewees reported more than 5 years of age difference between themselves and their partners. More than half of study participants reported that their husbands used alcohol (58%), and 33% reported that they were victims of DV while their husbands were under the influence of alcohol.

Participants reported the following types of DV [Table - 3]: Forty-two percent reported having experienced some type of violence, including sexual abuse (1%), physical abuse (29%) and psychological abuse (69%). Among the women who reported violence of any kind, 67% also reported that they were HIV seropositive. The most common reasons for violence included financial problems (38%), husband′s alcohol use (29%) and woman′s HIV serostatus (18%). Among the women who reported violence, 29% had never received medical care after DV and 10% had never told a health worker about being abused. Only 5% of the women reported speaking to the health worker about problems of violence at home. Among the 233 women who reported being pregnant, 44 (19%) were beaten while they were pregnant. The most common perpetrators of violence included husband or mother-in-law but rarely husband′s relatives.

Forty-six percent of participants reported employment and 13% reported that their husband took their wages or earning. Surprisingly, 75% of working respondents reported being abused because of their employment status. Twenty-nine percent of participants reported that their earnings were the main source of income for the family, with 58% of those reporting violence. Nearly 89% of the women reported they had no savings of any kind.

DV and associated factors

Sociodemographic factors: Older women were more likely to report violence as compared to younger women (P < 0.001). Women with the lowest income (P = 0.02). Living in a nuclear family was associated with experiencing DV (P = 0.004). Interestingly, having employment was significantly associated with violence (P < 0.001). No association was found, however, between women′s educational level and DV.

Other factors associated with DV included husband′s education, HIV seropositivity and alcohol or tobacco use (P < 0.001). Dowry payments were also significantly associated with domestic violence.

Unadjusted univariate logistic regression showed that the relative odds of experiencing violence of any kind was 3.6 times for women whose monthly income was less than INR 2,000 (Odds Ratio [OR]: 3.6; 95% Confidence Interval [95% CI]: 1.1-11.6; P = 0.03) as compared to women whose household income was more than INR 2,000 [Table - 4]. The relative odds for experiencing violence also increased for women living in nuclear families (OR: 2.14; 95% CI: 1.3-3.6; P = 0.004), with partner having less than 10 years of education (OR: 2.46; 95% CI: 1.4-4.2; P = 0.001).

Controlling for partner′s age, the relative odds ratio of reporting violence was 0.49 for couples with more than 5 years of age difference as compared to couples with less than 5 years of age difference (95% CI 0.27, 0.89).

Multivariable logistic regression analysis showed that older age, lower income, employment status of women and alcohol use by men were independently associated with DV after adjusting for family type, dowry payment, HIV serostatus of the woman and her partner and the partner′s education [Table - 4].

Discussion

The results of our study largely corroborate findings of previous studies from India ^[11] and around the world. ^[1] Forty-two percent of all respondents reported experiencing some type of violence, with 29% reporting physical violence and 69%, psychological abuse. Interestingly, the amount of sexual abuse reported was very low (1%), possibly reflecting the view by many Indian women that providing sex to their husbands is a marital duty. In addition, talking about sex and sexual acts is highly stigmatized; this may have led to underreporting.

Not surprisingly, having low income was highly correlated with DV in both unadjusted and adjusted analysis. This finding is consistent with a large body of research suggesting that the stressors of poverty may put a significant burden on families and these tensions can erupt into violence. ^[37] In a related finding, however, a woman′s employment, contribution to household budget and access to savings were not found to be protective against DV. Being employed actually increased the likelihood that a woman would have experienced domestic violence. This is consistent with findings from another study in Bangladesh, which found that in culturally conservative areas, higher status of women vis-à-vis that of their husband predisposed women to DV. ^[35]

Consistent with past research, other variables found associated with DV included alcohol but not tobacco use and lower educational level of husband. Other variables which have been noted in past studies such as living in a nuclear family and age difference between husband and wife were not found to be significantly associated with violence. Interestingly, when we adjusted for the husband′s age, having an age gap of more than 5 years was protective of women against DV. More research is needed to understand the relationship between partners′ age difference and domestic violence in India.

The study also found an association between seropositivity and DV, but the cross-sectional nature of the research makes it impossible to determine the temporality of the variables. There is literature to show both - that DV predisposes women to HIV infection ^[6] and that HIV infection increases women′s risk for DV. ^[26] Further research is needed to shed light on this important issue.

There are several limitations to this study. Since all behaviors were self-reported, it is likely that there was some degree of recall bias and misreporting. Furthermore, since certain behaviors such as talking about sex are stigmatized, women may have underreported sexual violence, leading to a lower overall estimate of DV in the community. Because of the cross-sectional design, it is also difficult to establish any causal relationships. In addition, associations may have been influenced by recall bias due to exposure misclassification. Finally, the study utilized a convenience sample from a clinic-based population that may not be representative of the general population. Women attending a VCT center may be more prone to violence, more willing to report DV or may have other characteristics that distinguish them from other women. Other limitations include lack of verification of various economic variables and limited data on the severity and frequency of DV. All of these limitations may have led to an underestimation of actual DV prevalence.

It should also be noted that estimates about DV are extremely sensitive to the specific definitions used and to the way questions are asked. ^[6] We used a brief interviewer-administered questionnaire, in which questions queried specific behaviors rather than general abuse. Previous research has shown that this technique yields more positive answers than questions inquiring about violence in general. Moreover, the phrasing of the questions was based on the WHO Multi-Country Study on Women′s Health and Life Events. ^[36]

These limitations notwithstanding, the present study corroborates the high prevalence of DV among women in clinical settings. While this study may not have wide generalizability, it may provide useful insights for health care providers, particularly in HIV prevention and testing settings. Our finding that 42% of women attending a VCT clinic had been abused at some time in their lives is cause for concern and action. At the minimum, health care professionals providing services in these settings have the obligation to ascertain whether DV has occurred, determine the severity of partner abuse and intervene where possible on the patient′s behalf. In particular, providers at VCT centers should be trained in asking appropriate screening questions, detecting physical signs of abuse and providing referrals to counseling facilities, shelters and community-based organizations.

Acknowledgements

The authors would like to thank the Executive Director of Freedom Foundation, Mr. Ashok Rau, for his unconditional support during the research project. This study would not have been possible without the able guidance and advice from Dr. Nirmala Skill. In addition, we would like to acknowledge the dedicated efforts of the research team, including Mr. Regi Ram, Mrs. Soya Sadanandan, Mr. Shibu Puttenparambil, Mrs. Ann Mattews, Mrs. Hepzibah Sharmila of Freedom Foundation, Mr. Sujith Vijayakumar and the women who spared time to participate in this study. Purnima Madhivanan was supported by the Fogarty AIDS International Training and Research Program (Grant 1-D43-TW00003-16).

References

Copyright 2007 - Indian Journal of Medical Sciences

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