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
Good afternoon, Thank conference organizers and session co-chairs for the opportunity to present work.
by the end of my talk I hope to have convinced you that 1) addressing DV among married women in India is critical for HIV prev, and 2) how/why the development of the IFVCS is among the critical first steps in doing so effectively
Today I will be presenting the results of a collaborative study between Emory and NARI in Pune, India

2. 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
As you know, DV is universal: occurring across countries, continents, and populations, however there are manifestations of DV that are country-specific
While the WHO operational definition largely addresses domestic violence perpetrated by the intimate partner, the Indian legal definition provided by PWDVA expands the definition…

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
STis /RTI sx (yes-NFHS-3)
HIV Risk perception (darak AIDS CARE 2014
High risk partner/multiple partners (schensul, mumbai slums)
Need for an effective instrument to measure DV in the Indian context
Need for addressing DV to address HIV in India
Silverman J. JAMA 2008

4. Domestic Violence prevalence estimates
Study setting and perceived safety
Perpetrator surveyed
Study population
DV forms and multitude of forms surveyed
Time Frame
Cultural and socio-economic determinants of DV acceptance
Methodology (ACASI vs. FTFI)
Interviewer
When we think of DV globally, there are numerous factors that play into measuring it, and depending on whether/not you take certain factors into hand, you can get vastly different estimates…;
study setting/perceived safety (private space in an NGO v. home/work place; procedures to ensure privacy)
Perpetrators surveyed (boyfriends/spouses v. in-laws)
DV forms (i.e. psych, phys, sex, control, economic);
Cultural determinants (acceptance more likely to report)
ACASI (audio computer assisted self-interviews) v. FTFI (Rathod 2011)
interviewer—trained, know when to stop/safe, ease…

5. 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?
Conflict Tactics Scale-2 (abridged)
Family structure Multiple perpetrators of DV (influence w/in joint family and involvement of in-laws even if not co-habitating)
Different readily-available tools of inflicting physical violence (belts, stones, kerosene vs. gun and knife violence)
Sexual violence is less reported; less sex education in schools
Emotional violence and control/isolation are commonplaceneed to ask specific questions
IIPS and Macro International. NFHS , Chp 15

6. 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

7. Indian Family Violence and Control Scale (IFVCS)
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)
Mixed-methods study
Formative phase: To understand and explore the full dimensions of DV experience;
Quant phase to test the item pool in married women in Pune and learn of psychometric properties
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)

8. 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
While city-specific data is not available, Government of Maharashtra estimates suggest that 32% of the state’s urban population lives below the poverty line (previously Rs 33/day)47; and the mean marital age of marriage for girls is 20.6 years.
Per NFHS-3, 33.4% of women in urban Maharashtra reported experiencing physical, sexual, or psychological IPV.35
The one published study evaluating IPV in Pune, estimated lifetime physical IPV in slum-dwelling women to be 61.5%.58 ;
2011 Census of India
IIPS and Macro International. NFHS , Chp 15
Ruikar Indian J Public Health 2008

9. National AIDS Research Institute
clinical, epidemiologic, immunology, virology, and behavioral sciences research
several international collaborations
established over 20 years prior
nodal HIV research institute of the Indian Council of Medical Research

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

11. Indian Family Violence and Control Scale (IFVCS)
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)
: quant self-report DV to explore 1) questions asked to assess DV (validated v. not), 2) forms/examples/contexts of DV provided in Indian literature
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)

12. Form(s) of domestic violence assessed
Large variance in DV prevalence estimates
Lifetime
Prior 12-month period
Prevalence estimate as reported by study (%)
Explain graphs
Physical most commonly measured…followed by psych/sexual..control/neglect much less surveyed
Few surveyed 2 or more forms of violence
Large spread in data…could be for any of the aforementioned reasons: standardized, culturally-tailored scale could reduce the unwanted variation..
Extreme at top of >=2 forms
Hospital-based, New Delhi
60 female nurses
WHO scale: physical, sexual, psychological, control
current/prior marital partner
Lowest point on >=2 forms
Community-based, Goa
821 women (oversampling of those who drank or partners who drank alcohol)
Conflict Tactics Scale
Physical, sexual
Husband/partner
2 point extremes for psych/phys DV
community-based, Chennai, TN
1,974 slum-dwelling women
male intimate partners
Form(s) of domestic violence assessed
Only one-third of studies used validated DV instruments (CTS-2, ISA, AAS)

13. Indian Family Violence and Control Scale (IFVCS)
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)
Formative phase: develop item pool using in-depth interviews with DV experts/FGDs
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)

14. 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
Grounded theory,
Explain pics

15. 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

16. 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, s, social networking
forced to change physical appearance, diet (i.e. vegnon-veg), or perform upvas (fast)

17. Indian Family Violence and Control Scale (IFVCS)
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)
- to identify content/syntax discrepancies in the information intended to be extracted by the DV screening question and actual responses
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)

18. 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
Discuss Scale/initial item pool: 63 items in 4 subscales, husband/family member as perpetrators; I
49 violence items; married life and past-year; 65 pt scale assessing frequency (never, once/yr, once/mo, once/wk, not in past year) (was previously more numeric like CTSonce, twice, 3-5 x/yr, >5 x yr, not in past yr)
14 control items; married life; 64 pt likert never, rarely sometimes, often);

19. Indian Family Violence and Control Scale (IFVCS)
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)
to assess initial scale psychometrics and to reduce the items/eliminate unneccessary items
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)

20. 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

21. 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
Primary cut off is 7th std; secondary is 8-10;
Monthly family income: 7% unknown
(<1% extended jt family)

22. 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
Average scale time: 19.4 mins
3 versions 1,2,3
4 staff

23. 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

24. Thank you NARI, Pune, India Emory University 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 TW )
NIH/FIC K01 TW009664
Check basit momin

25. Questions?
Contact Information
Ameeta Kalokhe

26. 146 articles evaluating the DV experiences of women in India
PubMed search results for August
“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
106 quantitative studies
Qualitative studies13 articles
Case reports/studies3 articles
Commentaries/Letters/editorials14 articles
Reviews7 articles
Qualitative description of methods3 articles
85 studies in which DV questions were directly asked of women
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
7 international, 31 multistate, and 47 single-state

27. 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.”

28. 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….”
Streedhan= [the gold or silver ornaments that are given by the girl’s parents at the time of wedding]

29. 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.”

30. 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.”

31. 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?”

32. 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.”
Maan-paan [/providing the groom’s family members special respect and gifts during the wedding/].”

33. 0.22% of the married women tested positive for HIV
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
One-third of married Indian women (35.49%) reported experiencing physical IPV with or without sexual violence from their husbands; 7.68% reported both physical and sexual IPV, and 27.80% reported experiencing physical IPV in the absence of sexual violence. Approximately 1 in 450 women (0.22%) tested positive for HIV. In adjusted models, married Indian women experiencing both physical and sexual violence from husbands demonstrated elevated HIV infection prevalence vs those not experiencing IPV (0.73% vs 0.19%; adjusted OR, 3.92; 95% CI, ; P = .01). Physical IPV alone was not associated with risk of HIV infection. Women's personal sexual risk behaviors were not associated with HIV infection. 28K
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

34. 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)
In addition to providing us with 40 violence examples…other conclusions were..
Submitted to Trauma, Violence, and Abuse