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

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…

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

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…

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-3 2005-2006, Chp 15

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

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)

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

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

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

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) 2002-2012: 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)

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)

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)

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

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

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)

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)

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);

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)

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

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)

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

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

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 TW009337-01) NIH/FIC K01 TW009664 Check basit momin

Questions? Contact Information Ameeta Kalokhe akalokh@emory.edu

146 articles evaluating the DV experiences of women in India 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 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

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.”

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]

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.”

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

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, 1.41-10.94; 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

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