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Risk Factors for Severe Intimate Partner Violence and Violence-Related Injuries Among Women in India a
b
Bushra Sabri PhD , Lynette M. Renner PhD , Jamila K. Stockman c
d
e
PhD , Mona Mittal PhD & Michele R. Decker PhD a
School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA b
School of Social Work, University of Minnesota, St. Paul, Minnesota, USA c
Division of Global Public Health, Department of Medicine, University of California, San Diego, California, USA d
Department of Public Health Sciences, University of Rochester, Rochester, New York, USA e
Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA Accepted author version posted online: 11 Mar 2014.Published online: 16 May 2014.
To cite this article: Bushra Sabri PhD, Lynette M. Renner PhD, Jamila K. Stockman PhD, Mona Mittal PhD & Michele R. Decker PhD (2014) Risk Factors for Severe Intimate Partner Violence and Violence-Related Injuries Among Women in India, Women & Health, 54:4, 281-300, DOI: 10.1080/03630242.2014.896445 To link to this article: http://dx.doi.org/10.1080/03630242.2014.896445
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Women & Health, 54:281–300, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.896445
Risk Factors for Severe Intimate Partner Violence and Violence-Related Injuries Among Women in India BUSHRA SABRI, PhD Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
LYNETTE M. RENNER, PhD School of Social Work, University of Minnesota, St. Paul, Minnesota, USA
JAMILA K. STOCKMAN, PhD Division of Global Public Health, Department of Medicine, University of California, San Diego, California, USA
MONA MITTAL, PhD Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
MICHELE R. DECKER, PhD Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
Relying on an ecological framework, we examined risk factors for severe physical intimate partner violence (IPV) and related injuries among a nationally representative sample of women (N = 67,226) in India. Data for this cross-sectional study were derived from the 2005–2006 India National Family Health Survey, a nationally representative household-based health surveillance system. Logistic regression analyses were used to generate the study findings. We found that factors related to severe physical IPV and injuries included low or no education, low socioeconomic status, rural residence, greater number of children, and separated or divorced marital status. Husbands’ problem drinking, jealousy, suspicion, control, and emotionally and sexually abusive behaviors were also related to an increased likelihood of women experiencing severe IPV and injuries. Other factors included women’s exposure Received August 4, 2013; revised January 21, 2014; accepted January 29, 2014. Address correspondence to Bushra Sabri, PhD, School of Nursing, Johns Hopkins University, 816 N. Washington Street, Baltimore, MD 21205. E-mail: [email protected] 281
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to domestic violence in childhood, perpetration of IPV, and adherence to social norms that accept husbands’ violence. Practitioners may use these findings to identify women at high risk of being victimized by severe IPV or injuries for prevention and intervention strategies. Policies and programs that focus on empowering abused women and holding perpetrators accountable may protect women at risk for severe IPV or injuries that may result in death.
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KEYWORDS India
intimate partner, physical violence, injuries, women,
Intimate partner violence (IPV) is a global public health problem with consequences including premature deaths and injuries (Kyricou et al., 1999; National Center for Injury Prevention and Control, 2012). In a World Health Organization (WHO) multi-country study (N = 24,000), between 19–55% of the women reported being injured as a result of physical IPV, often more than once (Garcia-Moreno et al., 2005). Severe physical violence, including injuries, is a risk factor for lethality. In an 11-city study of female deaths in the United States, women with an increase in severity of physical violence were 5.2 times more likely than other women to be murdered (Campbell et al., 2003). IPV was cited as a cause of 40–60% of female deaths and maternal mortality in the United States, Bangladesh, and India (Garcia-Moreno et al., 2005; Krug et al., 2002). India suffers a high burden of IPV, with prevalence estimates ranging from 6% in one state (i.e., Himachal Pradesh) to 59% in another (i.e., Bihar; Charlette, Nongkynrih, & Gupta, 2012; Garcia-Moreno et al., 2005). The 2011 national statistics show a large number of IPV-related crimes against women in India (99,135 incidents of cruelty and 8,618 deaths; Karhad, 2013). Reporting inaccuracies also persist in India, with some IPV-related crimes against women being falsely labeled “suicides” or “accidents” (United Nations Office on Drugs and Crime, 2011). Although IPV is a public health problem in India, little is known about risk factors for severe abuse. This knowledge may help guide the development of assessment instruments and targeted interventions. For example, the Danger Assessment, based on risk factors identified through U.S.-based samples, is used to help women assess their danger of being severely assaulted or killed by their partners (Campbell et al., 2003). However, no such assessment is used in health care and social service settings in India. Factors such as dowry demands (i.e., money from the wife’s family; Vindhya, 2000) and IPV in current relationships (Sabri, Campbell, & Dabby, in press) may be risk factors for severe IPV and homicides in Indian families. Because severe physical IPV (e.g., attempted strangulation) and injuries often precede homicides, prevention efforts must begin with identifying factors that place women at risk. An ecological framework can
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be useful for understanding the presence of violence-related risk factors in women’s lives and for developing risk assessments for safety. We were not able to locate any published research that presented risk factors for both severe violence and injuries among women in India using an ecological approach. The goal of our study was to fill this gap.
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BACKGROUND LITERATURE IPV is a multifaceted phenomenon resulting from the interaction between the individual and their environment (Heise, 1998; Krug et al., 2002; Stith et al., 2004), and is a product of factors at individual, microsystem (relationship), exosystem (community), and macrosystem (societal) levels (Heise, 1998; WHO/London School of Hygiene and Tropical Medicine, 2010). The individual level includes personal history factors that may increase the likelihood of IPV victimization (WHO/London School of Hygiene and Tropical Medicine, 2010), such as younger age (Campbell et al., 2007; Pratt, & Deosaransingh, 1997), marriage before 18 years of age (United Nations International Children’s Emergency Fund [UNICEF], 2005, as cited in the International Center for Research on Women, 2006), low education (Ackerson et al., 2008), divorce (Campbell et al., 2007), and alcohol misuse by women (Sharps, Campbell et al., 2001; Weisenheimer et al., 2005) and their partners (Barrett, Habibov, and Chernyak, 2012; Campbell et al., 2007; Jeyaseelan et al. 2007; Thompson & Kingree, 2006). Women’s exposure to IPV in childhood has been linked to their psychological distress and poor social adjustment in adulthood, which may place them at a greater risk for IPV (Davis & Briggs, 2000; Henning et al., 1996). Husbands’ low levels of education (Ackerson et al., 2008), low socioeconomic status (Jeyaseelan et al., 2007), and unemployment (Campbell et al., 2007; Krishnan et al., 2010; Kyriacou et al., 1999) have also been found to increase a woman’s risk for IPV. While some evidence in India shows that women’s employment reduces the incidence of IPV (Chin, 2012), other researchers have found an increased risk for violence (Krishnan et al., 2010). The microsystem level includes risk factors in the immediate setting, such as families with multiple children (Martin et al., 1999), a woman’s perpetration of IPV or reciprocal violence (Whitaker et al., 2007), forced sex (Campbell et al., 2003; McFarlane et al., 2005), and psychological abuse that involves partners’ threats of harm, jealousy, and controlling behaviors (Dalal & Lindqvist, 2012; Pandey, Dutt, & Banerjee, 2009). Relationship length has been positively associated with IPV (Brown & Bulanda, 2005; Pandey et al. 2009), with women who remain in abusive relationships for longer periods of time being more likely to experience severe physical IPV or injuries. The exosystem level in which social relationships are embedded (WHO/London School of Hygiene and Tropical Medicine, 2010) include
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factors such as resources for social support (Stith et al., 2004). Urban women, with more resources available, may be at lower risk than women in rural areas (Peek-Asa et al., 2011). Research, however, shows women are typically less likely to seek formal help, and often seek help as a last resort when they can no longer endure abuse, or when abuse becomes life threatening (Naved et al., 2006; Panchanadeswaran & Koverola, 2005). Finally, the macrosystem level includes cultural values and beliefs, such as attitudes that condone violence as a means to settle disputes (Abraham, 1998; Heise, 1998; Krug et al., 2002; Stith et al., 2004), inhibit women from seeking help (Kamat et al., 2010), and relates to the acceptance of violence at the individual level. As outlined, an ecological model focuses on risk factors for IPV across multiple levels of the environment. Also, as noted, only some risk factors for IPV have been explored among women in India, and the focus has not been on risk factors for severe physical IPV and injuries. In this study, we explored which factors put women in India at an increased risk for severe IPV and injuries. Our findings can be informative to health care professionals during both assessment and intervention.
METHODS Design and Procedures Data for this study were derived from the 2005–2006 India National Family Health Survey (NFHS-3; International Institute for Population Sciences and Macro [IIPS], 2007), a nationally representative household-based health surveillance system. Details of data collection procedures have been previously published (IIPS, 2007). The NFHS-3 survey collected data from a nationally representative probability sample. Briefly, a total of 116,652 households were selected, and 109,041 households participated in interviews. The interviews were conducted with respondents meeting the following eligibility criteria. The Household Questionnaire was completed by the head of the household or any adult household member. The Woman’s Questionnaire was completed by women (ever-married and never-married) aged 15–49 years who were usual residents of the sample household or visitors who stayed in the sample household the night before the survey. The Man’s Questionnaire was employed to interview men aged 15–54 years who were usual residents of the sample household or visitors who stayed in the sample household the night before the survey. The household response rate was 97.7% for India as a whole (96.9% for urban areas and 98.5% for rural areas). A total of 131,596 women were eligible, and 85,373 men were eligible. A total of 124,385 women (aged 15–49 years) and 74,369 men (aged 15–54 years) were interviewed, which yielded a 94.5% response rate for women and an 87.1% response rate for
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men (IIPS, 2007). The domestic violence (DV) module was administered to one randomly selected woman per household, with a total sample of 83,703 women (ever-married, N = 69,704, and never married, N = 13,999). For our analyses, we selected the 69,704 ever-married women who completed the DV module. Approximately four percent of the cases with missing data were deleted, yielding complete data on 67,226 ever-married women for our analyses. The interviewer-administered DV module covered information on different forms of violence experienced and help-seeking behavior as a result of DV. The study procedures were reviewed and approved by the IIPS ethical review board, and informed consent was obtained from all women who participated.
Measures The DV module for the survey was developed based on WHO guidelines and available research (WHO, 2011; Hindin, Kishor, & Ansara, 2008) on reliable and valid measurement of DV. Partner violence was assessed using a modified version of the Conflict Tactics Scale (Straus, 1979, 1990), covering a series of behavioral-specific acts of physical violence (Hindin, Kishor, & Ansara, 2008). Further, to maximize reliability and validity, DHS questionnaires were translated into local languages in which interviews took place. The translated questionnaires were back translated into English from local languages to ensure accuracy and any discrepancies were resolved (ICF International, 2012). Two outcome measures were included in our study. Severe physical violence was defined as a woman’s husband had ever in her lifetime: tried to choke her or burn her on purpose or threatened or attacked her with a knife, gun, or other weapon (United Nations Statistics Division, 2009). Participants who reported having ever experienced cuts, bruises, or aches; eye injuries, sprains, dislocations, or burns; or deep wounds, broken bones, broken teeth, or any other serious injury as a result of their husbands’ violence were classified as having experienced an violence-related injury. The independent variables in this study represented risk factors at three ecological levels: individual, microsystem, and exosystem. INDIVIDUAL Age and age at marriage were included as continuous variables. Education level was assessed for both women and their husbands and categorized into three groups: no education, primary education, and secondary or higher education. Employment was assessed for both women and their husbands. Marital status was measured using three categories: married, widowed, and separated/divorced/abandoned. Socioeconomic status was measured using the Wealth Index (IIPS, 2007), which was calculated using data on ownership
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of 33 selected assets, as well as housing quality and facilities (e.g., material used to construct houses, drinking water source, cooking fuel). The index used principal component analysis to assign a weight (factor score) to each of the items included in the wealth index, placing households on a continuous scale of relative wealth. Each woman was ranked according to the score of the household in which she resided. The original scale was standardized and scores were used to create wealth quintiles (i.e., poorest, poorer, middle, richer, and richest) in which one was the poorest 20% of the households and 5 was the wealthiest 20% of the households (Kishor & Johnson, 2004; Sreeramareddy, Shidhaye, & Sathiakumar, 2011). For this study, we created three categories: poor, middle, and rich. The poorest and poorer quintiles were combined to create a single poor category and richer and richest were combined for the rich category. Alcohol use was assessed for women and their husbands based on questions on if women or their husbands ever used alcohol (response options were yes or no for both women’s use and their husbands’ use). Exposure to DV in childhood was assessed using a question asking women if they witnessed their fathers beating their mothers in childhood (response options were yes or no). Personal acceptance of IPV was measured by responses to questions regarding whether women would justify wife beating under the following circumstances: she goes out without telling him, she neglects the children, she argues with him, she refuses to have sex with him, and she burns the food (response options were yes or no). MICROSYSTEM The duration of relationship and number of children with the abusive husband were each measured using continuous variables. A woman’s perpetration of IPV was defined as if they ever hit, slapped, kicked, or did anything else to physically hurt their husband at times when he was not already beating or physically hurting them (response options were yes or no’. Participants who reported having ever experienced humiliation, threats to hurt or harm, or insults by an intimate partner were classified as having experienced emotional abuse. Women who reported ever being forced into sex against their will by their husbands were considered to have experienced forced sex. To measure partners’ jealous/suspicious behaviors, women were asked if their husbands were jealous or angry if they talked to other men or frequently accused them of being unfaithful. A dichotomous variable was created from responses to these two items (yes to any of the questions indicated husbands’ jealousies or suspicious behaviors). To assess controlling behaviors, a dichotomous variable was created if women’s husbands exhibited any of the following behaviors: did not permit them to meet their female friends, tried to limit contact with their families, or insisted on knowing where they were at all times (response options were yes or no).
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EXOSYSTEM
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Place of residence was categorized as mega city, large city, small city, large town, small town, or rural, based on classification of urban and rural areas in the 2001 Census of India (IIPS, 2007). Resources of social support were measured by creating two dichotomous variables: formal and informal support received. Women were asked from whom they sought help for IPV. Formal resources included doctor/medical personnel, police, lawyers, and social service organizations. Informal resources included family, friends and neighbors.
Analysis Procedures First, descriptive statistics were calculated for each of the variables. Next, bivariate analyses were performed to examine the association between the covariates and each dependent variable. Only variables that were significant at the .05 level in the bivariate analyses were entered in the multivariate regression models. Last, two separate multivariate logistic regression analyses were conducted to test the independent effects of ecological-level variables on the two binary outcomes (i.e., severe physical violence and violencerelated injuries). All covariates that were significant in bivariate analyses were entered simultaneously (i.e., not using a stepwise or hierarchical procedure) into each of the multiple regression models. DV weights were applied to yield nationally representative results. These weights take into account the differential probably of the selection of participants for the DV module. The Wald test was used to assess model fit. The level of significance for all analyses was p < .05. Analyses were conducted using Statistical Package for Social Sciences (SPSS) version 19 and accounted for a clustered sampling design.
RESULTS Study Participants The sample consisted of 67,226 women aged 15–49 years (M = 31.5). Approximately 70% (n = 46,721) were from rural areas and 30.5% (n = 20,504) from urban parts of India (i.e., cities and towns). Nearly half of the women (48%, n = 32,284) had no education; 15.4% (n = 10,320) had primary education; 31.1% (n = 20884) had secondary education; and only 5.6% (n = 3,736) had higher education. Approximately two-thirds of women were unemployed at the time of the survey (62.2%; n = 41,771). Forty percent (n = 26,522) had low socioeconomic status, 20.1% (n = 13,505) were in the medium range, and 40.5% (n = 27,199) were in the high socioeconomic status group (see Table 1). Nearly 12% (n = 7938) reported experiencing severe
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TABLE 1 Descriptive Characteristics
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Total sample (N = 67226) Individual Woman’s age (years), Mean (SD) Age at marriage (years), Mean (SD) Woman’s education No education Primary Secondary Higher Husband’s education No education Primary Secondary Higher Current employment Woman Yes No Husband Yes No Socioeconomic statusa Low Middle High Alcohol use Woman Husband Personal acceptance of intimate partner violence (IPV) Woman exposed to domestic violence (DV) in childhood Microsystem Duration of relationship, Mean (SD) Marital status Married Widowed Separated/divorced Number of children, Mean (SD) Jealous/suspicious behaviors Controlling behaviors Emotional abuse Forced sex Woman’s perpetration of IPV Exosystem Resources for social support Formal Informal Type of Site Mega city Large city Small city Large town Small town Rural a
Weighted count
Weighted % or Mean (SD) 31.5 (0.05) 17.1 (0.03)
32,284 10,320 20,884 3,736
48.0 15.4 31.1 5.6
18,294 10,776 29,927 7,579
27.5 16.2 45.0 11.4
25,374 41,771 65,663 1,374
37.8 62.2 97.9 2.1
26,522 13,505 27,199
39.5 20.1 40.5
1706 22,022 32,843 12,454
2.5 33.1 48.9 20.1 3.40 (0.01)
63,220 2,692 1,314 18,297 17,541 10,533 3,686 481
94.0 4.0 2.0 2.81 (0.01) 27.2 26.1 15.8 5.5 0.7
216 6,812
0.3 8.1
2007 4,887 5,569 1,377 66,665 46,721
3.0 7.3 8.3 2.0 9.9 69.5
Socioeconomic status was assessed using the Wealth Index (IIPS, 2007), based on ownership of 33 assets, as well as housing quality and facilities; low = respondents in the poorest and poorer category, medium = those in the middle category; high = women in the richer and richest category.
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physical violence from an intimate partner and 14% (n = 9408) reported violence-related injuries.
Multivariate Analyses
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SEVERE PHYSICAL VIOLENCE A lack of education or low education among both women and their husbands (Adj Odds ratio [OR] = 1.45–2.59) and women’s exposure to IPV significantly increased the odds of women having ever experienced severe physical violence. Women’s history of exposure to DV during childhood (Adj OR = 1.72) was also significantly associated with their experiences of severe physical violence by their husbands (Table 2). Compared to being separated/divorced, being married or widowed was associated with at least a 50% decrease in severe physical violence (Adj OR = 0.42 and Adj OR = 0.51, respectively). Women with more children in the household were at increased odds for severe physical violence (Adj OR = 1.12). Women with husbands who were jealous/suspicious (Adj OR = 1.83), controlling (Adj OR = 1.15), and emotionally (Adj OR = 4.35) and sexually abusive (Adj OR = 2.78) were at increased odds of experiencing severe physical violence in the relationship. Women’s perpetration of IPV (Adj OR = 2.78) and husbands’ alcohol use (Adj OR = 1.79) were positively associated with severe physical violence. Women who were employed were more likely than unemployed women to experience severe physical violence (Adj OR = 1.21). Low (Adj OR = 1.38) and medium (Adj OR=1.41) socioeconomic statuses (vs. high socioeconomic status) were each associated with increased odds of severe physical violence. Women residing in mega cities were approximately 25% less likely to be severely victimized than women residing in rural areas. Women who sought formal (Adj OR = 16.6) and informal (Adj OR = 5.83) help were also significantly more likely to have experienced severe physical violence. Women’s acceptance of violence (Adj OR = 1.14) also significantly increased the odds of severe physical violence victimization. V IOLENCE-RELATED INJURIES Younger aged women (Adj OR = 0.98), women with no (Adj OR = 2.53) or low education (Adj OR = 2.22), and women from low (Adj OR = 1.37) and middle socioeconomic status (Adj OR = 1.26) were significantly more likely to have violence-related injuries. Women residing in mega cities were 29% less likely to have experienced IPV injuries compared to those residing in rural areas. Witnessing DV between parents in childhood increased the likelihood of injurious violence in an adult intimate partner relationship by 84% (Adj OR = 1.84). Women’s personal acceptance of husbands’ use of violence
290 3949 3982 7722 198 4276 (16.3) 1863 (13.9) 1799 (6.6)
Employment Woman Yes No (ref) Husband Yes No (ref)
Socioeconomic statusb Low Middle High (ref group)
(15.7) (9.6) (11.8) (16.1)
(17.3) (14.9) (9.7) (3.3)
3127 1604 2878 251
Husband’s education No education Primary Secondary Higher (ref group)
(16.0) (13.2) (6.9) (1.7)
5103 1352 1421 61
32.67 (0.15) 16.25 (0.1)
Weighted count (%) N = 7938 (11.9)
Woman’s education No education Primary Secondary Higher (ref group)
Individual level Woman’s age∗a , Mean (SD) Age at marriage, years, Mean (SD)
Independent variables 0.99 (0.98−1.01) 0.98 (0.95−1.02)
Adjusted OR (95 % CI)
1.38 (1.16−1.62) 1.41 (1.21−1.65)
0.89 (0.63−1.25)
0.69 (0.55−0.88)
2.74 (2.47−3.04) 2.27 (2.04−2.54)
1.21 (1.08−1.34)
1.52 (1.14−2.04) 1.53 (1.14−2.06) 1.45 (1.12−1.89)
1.75 (1.62−1.89)
6.03 (4.85−7.48) 5.08 (4.08−6.32) 3.11 (2.51−3.85)
11.31 (8.24−15.5) 2.59 (1.73−3.88) 9.05 (6.55−12.50) 2.46 (1.64−3.69) 4.40 (3.20−6.06) 1.86 (1.27−2.71)
1.02 (1.01−1.02) 0.91 (0.89−0.92)
Unadjusted OR (95 % CI)
Severe physical violence
TABLE 2 Multivariate Results: Logistic Regression Analysis
(14.3) (9.5) (13.9) (16.3)
(20.0) (17.0) (11.4) (5.5)
(17.6) (12.7) (5.6) (1.5)
5076 (16.5) 2074 (12.4) 2258 (6.2)
4362 5037 9158 223
3653 1833 3417 414
6009 1536 1771 93
32.31 (0.14) 16.23 (0.05)
2.97 (2.65−3.32) 2.12 (1.89−2.36)
0.83 (0.66−1.05)
1.59 (1.46−1.72)
4.32 (3.54−5.28) 3.55 (2.89−4.35) 2.23 (1.86−2.69)
13.83 (10.9−17.6) 9.39 (7.35−12.0) 3.88 (3.05−4.93)
1.04 (1.03−1.04) 0.90 (0.89−0.91)
Unadjusted OR (95 % CI)
Violence-related injuries Weighted count (%) N = 9408 (14.0)
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1.37 (1.16−1.63) 1.26 (1.08−1.46)
0.92 (0.67−1.25)
0.99 (0.89−1.11)
1.03 (0.81−1.31) 0.98 (0.76−1.26) 0.95 (0.77−1.18)
2.53 (1.84−3.48) 2.22 (1.61−3.06) 1.79 (1.33−2.40)
0.98 (0.96−0.99) 0.99 (0.96−1.03)
Adjusted OR (95 % CI)
291 4.82 (4.45−5.22)
2.69 (2.46−2.93) 1.15 (1.02−1.29) 11.01 (9.99−12.12) 4.35 (3.88−4.89) 8.32 (6.33−10.92) 2.78 (1.68−4.60)
4701 (25.7) 3616 (20.6) 4446 (42.2) 249 (52.2)
1.83 (1.63−2.04)
1.12 (1.08−1.15)
1.16 (1.14−1.18)
3.4 (0.1)
1.04 (0.96−1.11)
1.72 (1.54−1.92)
1.14 (1.03−1.27)
1.02 (0.81−1.29) 1.79 (1.62−1.98)
0.42 (0.33−0.54) 0.51 (0.37−0.69)
Adjusted OR (95 % CI)
1.14 (1.11−1.16)
3.04 (2.78−3.31)
1.59 (1.47−1.72)
2.37 (1.97−2.85) 3.16 (2.91−3.42)
0.17 (0.14−0.20) 0.25 (0.20 (0.32)
Unadjusted OR (95 % CI)
3.8 (.03)
2811 (22.8)
4683 (14.4)
403 (23.7) 4544 (20.6)
6958 (11.1) 422 (15.9) 558 (42.7)
Weighted count (%) N = 7938 (11.9)
Relationship/Microsystem level Duration of relationship, Mean (SD) Number of children, Mean (SD) Jealous/suspicious behaviors Controlling behaviors Emotional abuse Woman’s physical violence when the partner was not hurting her
Personal acceptance for intimate partner violence (IPV) Women’s exposure to domestic violence in childhood
Alcohol use Woman Husband
Marital status Married Widowed Separated/divorced (ref group)
Independent variables
Severe physical violence
4207 (24.0) 4991 (47.4) 286 (59.5)
5432 (29.7)
3.37 (0.04)
3.73 (0.03)
3321 (21.4)
5559 (14.0)
451 (24.5) 5294 (24.0)
8401 (13.3) 434 (16.1) 572 (43.6)
3.69 (3.38−4.03) 10.5 (9.61−11.6) 9.19 (7.13−11.8)
6.52 (6.04−7.04)
1.27 (1.25−1.28)
1.28 (1.26−1.30)
3.02 (2.77−3.28)
1.71 (1.58−1.85)
2.64 (2.19−3.19) 3.12 (2.87−3.38)
0.19 (0.17−0.24) 0.25 (0.19−0.32)
Unadjusted OR (95 % CI)
Violence-related injuries Weighted count (%) N = 9408 (14.0)
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(Continued)
1.23 (1.09−1.39) 4.44 (3.98−4.95) 3.47 (2.23−5.40)
1.75 (1.56−1.96)
1.11 (1.07−1.13)
1.11 (1.07−1.13)
1.84 (1.65−2.06)
1.19 (1.07−1.32)
0.97 (0.76−1.23) 1.88 (1.70−2.08)
0.54 (0.42−0.71) 0.53 (0.38−0.76)
Adjusted OR (95 % CI)
292 173 (79.8) 3229 (52.1)
Resources for social support Formal Informal
0.73 1.00 1.27 1.27 1.16
(0.57−0.94) (0.77−1.29) (0.94−1.71) (0.86−1.87) (0.94−1.42)
2.77 (2.32−3.31)
Adjusted OR (95 % CI)
(4.7) (8.1) (7.4) (11.4) (9.1) (12.8) 172 (76.0) 3684 (54.1)
128 528 553 214 785 7198
1453 (7.2)
Weighted count (%) N = 9408 (14.0)
(0.28−0.39) (0.47−0.77) (0.44−0.66) (0.64−1.21) (0.59−0.79)
0.71 1.12 0.96 1.33 0.88
(0.55−0.92) (0.82−1.53) (0.76−1.23) (0.89−1.98) (0.72−1.09)
2.57 (2.13−3.08)
Adjusted OR (95 % CI)
25.48 (16.3−39.9) 13.42 (8.1−22.2) 14.65 (13.2−16.2) 6.77 (5.96−7.69)
0.33 0.59 0.54 0.88 0.68
0.54 (0.49−0.60)
Unadjusted OR (95 % CI)
Violence-related injuries
Note. OR = odds ratios; CI= 95% confidence intervals. Percentages are within each ecological level variable. a The data for age, age at marriage and number of children represent averages for women who experienced severe violence and those who experienced injuries. b Socioeconomic status was assessed using the Wealth Index (IIPS, 2007), based on ownership of 33 assets, as well as housing quality and facilities; low = respondents in the poorest and poorer category, medium = those in the middle category; high = women in the richer and richest category. ∗ Significance at p < .05 level.
29.85 (19.01−46.9) 16.63 (9.86−28.1) 12.84 (11.59−14.2) 5.83 (5.16−6.59)
(0.30−0.45) (0.46−0.73) (0.57−0.88) (0.72−1.36) (0.71−0.98)
0.37 0.58 0.71 0.99 0.83
104 389 533 176 736 5999
(5.2) (8.0) (9.6) (12.9) (11.1) (13.0)
6.82 (5.97−7.79)
Unadjusted OR (95 % CI)
1349 (44.1)
Weighted count (%) N = 7938 (11.9)
Forced sex Community Exosystem level Type of Site Mega city Large city Small city Large Town Small town Rural (ref group)
Independent variables
Severe physical violence
TABLE 2 Multivariate Results: Logistic Regression Analysis (Continued)
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was also significantly related to women’s experiences of IPV injuries compared to women who did not justify use of violence under any circumstances (Adj OR = 1.19). Longer relationship duration (Adj OR = 1.11) and a greater number of children (Adj OR = 1.11) were associated with increased odds of violencerelated injuries. Women who were married or widowed were 46–47% less likely than separated/divorced women to have experienced injuries. Both victimization and perpetration of physical IPV increased the odds of experiencing injuries. If a woman experienced emotional or sexual abuse by her husband, the odds that she experienced injuries increased by factors of 4.44 (Adj OR = 4.44) and 2.57 (Adj OR = 2.57), respectively. Husbands’ jealous/suspicious (Adj OR = 1.75) and controlling behaviors (Adj OR = 1.23) also significantly increased the odds of women’s experiences of IPV-related injuries. Additionally, women’s own perpetration of IPV was significantly related to an increased risk of injuries (Adj OR = 3.47). While women’s alcohol use had no significant effect on their victimization, alcohol use by their husbands was related to 88% increase in the odds of experiencing injurious violence (Adj OR = 1.88). Compared with women who did not seek any help, women who sought help from formal (Adj OR = 13.42) and informal (Adj OR = 6.77) sources of support were significantly more likely to have experienced injuries.
DISCUSSION We examined factors related to severe physical IPV and IPV-related injuries among ever-married women in India. The literature on risk factors for IPV victimization is largely U.S.-based, with no study having focused on this group of ecological risk factors for both severe physical IPV and resulting injuries using a nationally representative sample of women in India. Among the factors examined, low or no education, low socioeconomic status and rural residence were significantly related to women being at high risk for IPV (i.e., both severe physical IPV and injuries), as reported in the existing literature (Jeyaseelan et al., 2007; Kyriacou et al., 1999; Martin et al., 1999; Peek-Asa et al., 2011). Further, for every additional child in the family, there was an 11–12% increase in women’s exposure to severe physical IPV and IPV-related injuries. Among families with inadequate income and difficulties in meeting basic needs, large numbers of children in the family may be an additional source of stress that can contribute to problematic or conflictual family interaction patterns, including IPV, and can limit women’s options for disengaging from abusive partners. Contrary to prior research (Campbell et al., 2007; Krishnan et al., 2010), partners’ unemployment was not found to be a significant factor in victimization by severe physical IPV or IPV-related injuries. We found that
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women’s employment was positively related to them reporting severe physical violence and researchers who have focused on samples from India have reported similar findings (Dalal, 2011; Kamat et al., 2010; Krishnan et al., 2010). In some instances, it is possible that violence may have prompted some women to seek outside employment as a means of securing support. Employment may serve as a protective factor if it is connected with education and awareness and modified cultural norms against gender roles (Dalal, 2011). Among microsystem variables, women who were separated and divorced were more likely to report severe lifetime IPV than women who were married. Women’s separation or divorce may be in response to lifethreatening abuse by husbands. Due to sociocultural norms in India, women are more likely to remain married, and divorce or separation may occur in cases of severe or life threatening IPV (Sabri et al., in press). The relationship between recent separation/divorce and partner violence has been documented in research on U.S.-based samples (Campbell et al., 2007; Reckdenwald & Parker, 2010). Separation/divorce may invoke feelings of rage among controlling men and may drive them to injure their intimate partners. Psychological abuse in the relationship, partners’ jealous, suspicious, and controlling behaviors, and forced sex were particularly strongly associated with both severe physical IPV and injuries, as consistent with prior literature from the United States (Campbell et al., 2003; McFarlane et al., 2005; Stark & Flitcraft, 1996; Wiltsey, 2008). In abusive relationships, women live under a constant threat of danger, powerlessness, or lack of control (Jun et al., 2008), which increases their likelihood of experiencing more severe IPV. Being in a longer-term relationship was associated with an increased likelihood of experiencing violence-related injuries. Violence often escalates over the course of the relationship (Kelly & Johnson, 2008) leading to potentially grave injuries for women. Women’s acceptance of the husband’s violence was significantly related to their experiences of severe physical IPV and IPV-related injuries. Due to social norms, women may continue to remain in abusive relationships and perceive IPV as a common and acceptable. This places women at risk for increased violence, as violence tends to escalate over time. Acceptance of IPV has also been negatively associated with women’s help-seeking (Sudha & Morrison, 2011). As found by other researchers (Davis & Briggs, 2000; Henning et al., 1996), we found that exposure in childhood to DV increased women’s risk of victimization. This finding may be partially explained by poor mental health and behavioral functioning associated with traumatic life experiences (Kimerling et al., 2007). Moreover, women who are exposed to IPV in childhood may be more likely to accept violence as a normative behavior than other women; thus, increasing their risk for victimization by an intimate partner (Kamat et al., 2010).
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Husbands’ use of alcohol was significantly related to women’s increased likelihood of experiencing severe physical IPV and IPV-related injuries. Alcohol use has been associated with lowered inhibition to violence and increases the risk for perpetrating severe IPV (Buzawa & Buzawa, 2013; Johnson, 2001), with many women killed by husbands in fits of alcoholic rage (Vindhya, 2000). Research in India shows objecting to husband’s alcohol consumption is a significant trigger for IPV (Kamat et al., 2010). Women’s alcohol misuse, however, was not a significant factor. Only 2.5% of the women in the sample reported use of alcohol. Alcohol use is infrequently reported among married women in Indian context and is typically considered a male problem in India (Davar, 1995; Vindhya, 2000). In U.S. samples, partner’s alcohol misuse is found to be a stronger predictor of risk for severe violence (Campbell et al., 2003) than women’s alcohol use. Women who received formal and informal sources of support were also more likely to report severe IPV. Women may resort to help-seeking only when violence becomes severe (Decker et al., 2013). Factors related to delayed help-seeking among women include low self-confidence stemming from lack of education and skills, hope that circumstances would improve, and responsibilities towards their children (Panchanadeswaran & Koverola, 2005).
Strengths and Limitations of Study This study has both strengths and limitations. One strength is that we relied on a nationally representative sample of Indian women. A second strength is that we identified some risk factors for severe physical IPV and violencerelated injuries in a cross-cultural sample, which have also been identified as risk factors for intimate partner homicides (IPH) in the United States. For instance, in the United States, researchers have found that partner’s alcohol use, forced sex, jealousy, controlling behaviors, and separation are associated with increased risk of IPH (Campbell et al., 2003). Our findings support these findings and we found additional risk factors for severe physical IPV (e.g., women’s employment) that apply to women in India. One of the limitations of the study is that all of the measures were self-reported and not all measures were derived from standardized instruments, which could have resulted in misclassification and non-comparability or results to other studies that have used standardized instruments. Further, due to secondary analysis, we were limited to variables that were available in the dataset and could not assess other potential risk factors at the exosystem and macrosystem levels (e.g., community sanctions and norms). In addition, the study was cross-sectional and we are unable to determine the direction of causality. In future studies, researchers should use a longitudinal design in order to identify precursors of severe physical violence and violence-related injuries.
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Study Implications An ecological, person-in-environment framework can be used to identify factors associated with severe IPV for women in multiple contexts. Some of these risk markers of violence are more static (e.g., women’s history of witnessing IPV in childhood) while others are dynamic (e.g., partners’ use of alcohol), and each can be potential areas of intervention. Practitioners might use these findings to identify women at-risk for experiencing severe violence/injuries and to help them develop safety plans. Health care providers are the main institutional contact for women experiencing IPV in India (Chibber, Krishnan, & Minkler, 2011), and research confirms women’s acceptance of IPV screening in the health care sector (Decker et al., 2013). However, limited information regarding the perpetrator, location of the incident or possible future risk of harm to the woman is recorded (Jaswal, 2000). In a study of medical records from 1997–1999 in a health facility in Mumbai, India, IPV was found to be a causal factor of injuries in 53% of the probable (i.e., 38.8% cases established through other sources) and recorded cases of IPV; yet, IPV was actually mentioned in only 13.5% of these cases (Jaswal, 2000). Clearly, improvements must be made to the assessment and intervention of IPV in healthcare and social settings in India. Prevention strategies may include promoting public education and awareness that there is no justification for the use of violence and the importance of seeking help for abuse. Although policies are in place to address IPV in India, there is a gap between enactment and implementation. Many women in India still adhere to traditional cultural expectations and are socialized to accept violence in their lives. Indian women may be hesitant to report IPV due to sociocultural norms and the tendency of the legal system to trivialize IPV (Kimuna et al. 2012). It is necessary to ensure adequate implementation of policies and to make sure that law enforcement officers are receptive to the needs of women’s experiences of IPV (Kimuna et al, 2012). Health care settings may play an important role in protecting women from severe violence and injuries in India. In a U.S. multi-site study, 41% of the women who were killed by their partners had been seen in the health care system in the year prior to their murder (Sharps, Koziol-McLain et al., 2001). Policies to screen women for IPV in healthcare settings may help identify women in abusive relationships and to prevent future harm (Boinville, 2013). Policies are needed to hold perpetrators accountable through the criminal justice system and to enhance provisions for victims’ safety. It is necessary to empower victims to reduce their dependence on dangerous abusive partners through education and employment opportunities. Further, policies and programs that promote healthy relationships and improved access to socioeconomic and educational opportunities for at-risk families may reduce the risk of severe physical IPV/injuries or IPHs in Indian families.
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REFERENCES Abraham, M. 1998. Speaking the unspeakable: Marital violence against South Asian immigrant women in the United States. Indian J Gend Stud 5:215–41. Ackerson, L. K., I. Kawachi, E. M. Barbeau, and S. V. Subramanian. 2008. Effects of individual and proximate educational context on intimate partner violence: A population-based study of women in India. Am J Public Health 98:507–14. Barrett, B. J, N. Habibov, and E. Chernyak. 2012. Factors affecting prevalence and extent of intimate partner violence in Ukraine: Evidence from a nationally representative survey. Violence Against Wom 18:1147–76. Boinville, M. 2013. Screening for domestic violence in health care settings. ASPE Policy Brief . Retrieved April 5, 2013 from http://aspe.hhs.gov/hsp/13/dv/pb_ screeningDomestic.cfm Brown, S. L., and J. R. Bulanda. 2005. Relationship violence in young adulthood: A Comparison of daters, cohabitors, and marrieds. Bowling State University, Center for Family and Demographic Research working paper 06–06. Buzawa, E. S., and C. G. Buzawa. 2013. What does research suggest are the primary risk and protective factors for intimate partner violence and what is the role of economic factors. J Policy Anal Manag 32:128–37. Campbell, J. C., N. E. Glass, P. W. Sharps, K. Laughon, and T. Bloom. 2007. Intimate partner homicide: Review and implications for research and policy. Violence, Trauma, Abuse 8:246–69. Campbell. J. C., D. Webster, J. Koziol-McLain, C. Block, D. Campbell, M. A. Curry, et al. 2003. Risk factors for femicide in abusive relationships: Results from a multisite case control study. Am J Public Health 93:1089–97. Charlette, S. L., B. Nongkynrih, and S. K. Gupta. 2012. Domestic violence in India: Need for public health action. Indian J Public Health 56:140–5. Chibber, K. S., S. Krishnan, and M. Minkler. 2011. Physician practices in response to intimate partner violence in Southern India: Insights from a qualitative study. Women Health 51:168–85. Chin, Y.-M. 2012. Male backlash, bargaining, or exposure reduction? Women’s working status and physical spousal violence in India. Journal of Population Economics 25:175–200. Dalal, K. 2011. does economic empowerment protect women from intimate partner violence? J Inj Violence Res 3:35–44. Dalal, K., and K. Lindqvist. 2012. A national study of the prevalence and correlates of domestic violence among women in India. Asia-Pac J Public He 24:265–77. Davar, B. V. 1995. Mental illness in Indian women. Econo Polit Weekly 30:2879–86. Davis, J., and E. Briggs. 2000. Witnessing violence fact sheet. Retrieved January 16, 2013 from http://www.musc.edu/vawprevention/research/witnessing.shtml Decker, M., S. Nair, N. Saggurti, B. Sabri, M. Jethva, A. Raj, et al. 2013. Violencerelated coping, help-seeking and health care based intervention preferences among perinatal women in Mumbai, India. J Interpers Violence 28:1924–47. Garcia-Moreno, C., H. A. F. M. Jansen, M. Ellsberg, L. Heise, and C. Watts. 2005. WHO multi-country study on women’s health and domestic violence against women. Retrieved April 2, 2013 from http://www.who.int/gender/violence/ who_multicountry_study/en/
Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
298
B. Sabri et al.
Heise, L. L. 1998. Violence against women: An integrated, ecological framework. Violence Against Wom 4:262–90. Henning, K., H. Leitenberg, P. Coffey, T. Turner, and R. T. Bennett. 1996. Long-term psychological and social impact of witnessing physical conflict between parents. J Interpers Violence 11:35–51. Hindin, M., S. Kishor, and D. L. Ansara. 2008. Intimate partner violence among couples in 10 DHS countries: Predictors and health outcomes. Retrieved February 6, 2013 from http://pdf.usaid.gov/pdf_docs/pnadn620.pdf International Center for Research on Women. 2006. Child marriage and domestic violence. Retrieved February 6, 2013 from http://www.icrw.org/files/images/ Child-Marriage-Fact-Sheet-Domestic-Violence.pdf International Institute for Population Sciences and Macro. 2007. National Family Health Survey (NFHS-3), 2005-06. Mumbai, India: IIPS. ICF International. 2012. Demographic and health surveys methodology. Survey Organization Manual. Retrieved May 6, 2013 from http://www.measuredhs. com/pubs/pdf/DHSM10/DHS6_Survey_Org_Manual_7Dec2012_DHSM10.pdf Jaswal, S. 2000. Health records and domestic violence in Thane District, Maharashtra. In Domestic violence in India a summary report of four records studies, Burton, B., Duvvury, N., Rajan, A., & Varia, N. Washington, DC: International Center for Research on Women [ICRW], 2000 May. 6-14. (Domestic Violence in India 2; USAID Cooperative Agreement No. FAO-A-00-95-00030-00). Jeyaseelan, L., S. Kumar, N. Neelakantan, A. Peedicayil, R. Pillai, and N. Duvvury. 2007. Physical spousal violence against women in India: Some risk factors. J Biosoc Sci 39:657–70. Johnson, H. 2001. Contrasting views of the role of alcohol in cases of wife assault. J InterpersViolence 16:54–72. Jun, H., J. W. Rich-Edwards, R. Boynton-Jarrett, and R. J. Wright. 2008. Intimate partner violence and cigarette smoking: association between smoking risk and psychological abuse with and without co-occurrence of physical and sexual abuse. Am J Public Health 98:527–35. Kamat, U., A. M. A. Ferreira, D. D. Motghare, N. Kamat, and N. R. Pinto. 2010. A cross-sectional study of physical spousal violence against women in Goa. Healthline 1(1):34–40. Karhad, B. D. 2013. Statistical review of the problem of crime against women in India. JASCR IV(1–2):13–9. Kelly, J. B. and M. P. Johnson. 2008. Differentiation among types of intimate partner violence: Research update and implications for interventions. Fam Court Rev 46:476–99. Kimerling, R., J. Alvarez, J. Pavao, A. Kaminski, and N. Baumrind. 2007. Epidemiology and consequences of women’s revictimization. Women’s Health Issues 17(2):101–6. Kimuna, S. R., Y. K. Djamba, G. Ciciurkaite, and S. Cherukuri. 2012 Domestic violence in India: Insights from the 2005–2006 National Family Health Survey. J Interpers Violence 28:773–807. Kishor, S., and K. Johnson. 2004. Profiling domestic violence—Multi-country study. Calverton, MD: ORC Macro. Retrieved December 3, 2012 from http://www. measuredhs.com/pubs/pdf/OD31/OD31.pdf
Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
Risk for Severe Violence and Injuries
299
Krishnan, S., C. H. Rocca, A. E. Hubbard, K. Subbiah, J. Edmeades, and N. S. Padian. 2010: Do changes in spousal employment status lead to domestic violence? Insights from a prospective study in Bangalore, India. SocSci Med 70:136–43. Krug, E. G., J. A. Mercy, L. L. Dahlberg, and A. B. Zwi. 2002. The world report on violence and health. Lancet 360(9339):1083–8. Kyriacou, D. N., D. Anglin, E. Taliaferro, S. Stone, T. Tubb, J. A. Linden, et al. 1999. Risk factors for injury to women from domestic violence. New Engl J Med 341(25):1892–8. Martin, S. L., A. M. Tsui, K. Maitra, and R. Marinshaw. 1999. Domestic violence in northern India. Am J Epidemiol 150:417–26. McFarlane, J., A. Malecha, J. Gist, K. Watson, E. Batten, I. Hall, and S. Smith. 2005. Intimate partner sexual assault against women and associated victim substance use, suicidality, and risk factors for femicide. Issues Ment Health Nurs 26:953–67. National Center for Injury Prevention and Control. 2012. Understanding intimate partner violence: Factsheet 2012. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved June 14, 2013 from http://www.cdc.gov/ violenceprevention/pdf/ipv_factsheet2012-a.pdf Naved, R. T., S. Azim, A. Bhuiya, and L. A. Persson, 2006. Physical violence by husbands: Magnitude, disclosure and help-seeking behavior of women in Bangladesh. Soc Sci Med 62:2917–29. Panchanadeswaran, S., and C. Koverola. 2005. The voices of battered women in India. Violence Against Wom 11:736–58. Pandey, G. K., D. Dutt, and B. Banerjee. 2009. Partner and relationship factors in domestic violence: Perspectives of women from a slum in Calcutta, India. J Interpers Violence 24:1175–91. Peek-Asa, C., A. Wallis, K. Harland, K. Beyer, P. Dickey, and A. Saftlad. 2011. rural disparity in domestic violence: Prevalence and access to resources. J Womens Health 20:1743–9. Pratt, C., and K. Deosaransingh. 1997. Gender differences in homicide in Contra Costa County, California: 1982–1993. Am J Prev Med 13(suppl no. 6):19–24. Reckdenwald, A., and K. F. Parker. 2010. Understanding gender-specific intimate partner homicide: A theoretical and domestic service-oriented approach. J Crim Just 39:951–8. Sabri, B., J. C. Campbell, and C. Dabby. in press. Gender differences in intimate partner homicides among ethnic subgroups of Asians. Violence Against Wom. Sharps, P. W., J. C. Campbell, D. W. Campbell, F. A. Gary, and D. W. Webster. 2001. The role of alcohol use in intimate partner femicide. Am J Addiction 10: 122–5. Sharps, P. W., J. Koziol-McLain, J. C. Campbell, J. McFarlane, C. Sachs, X. Xu. 2001. Health care providers’ missed opportunities for preventing femicide. Prev Med 33:373–80. Sreeramareddy, C. T., R. R. Shidhaye, and N. Sathiakumar. 2011. Association between biomass fuel use and maternal report of child size at birth-an analysis of 2005–2006 India Demographic Health Survey data. BMC Public Health 11(403):1–10. Stark, E., and A. Flitcraft. 1996. Women at risk: Domestic violence and women’s health. Thousand Oaks, CA: Sage Publications.
Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
300
B. Sabri et al.
Stith, S. M., D. B. Smith, C. E. Penn, D. B. Ward, and D. Tritt. 2004. Intimate partner physical abuse perpetration and victimization risk factors—A meta-analytic review. Aggress Violent Beh 10:65–98. Straus, M. A. 1979. Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. J Marriage Fam 41(1):75–88. Straus, M. A. 1990. Measuring intrafamily conflict and violence: The Conflict Tactic (CT) Scales. In Physical violence in American families: Risk factors and adaptations to violence in 8,145 families, ed. M. A. Straus and R. J. Gelles, 29–47. New Brunswick, NJ: Transaction Publishers. Sudha, S., and S. Morrison. 2011. Marital violence and women’s reproductive health care in Uttar Pradesh, India. Womens Health Iss 21:214–21. Thompson, M. P., and J. B. Kingree. 2006. The roles of victim and perpetrator alcohol use in intimate partner violence outcomes. J Interpers Violence 21:163–77. United Nations International Children Emergency Fund. 2005. Early marriage: A harmful traditional practice: A statistical exploration. New York, NY: UNICEF. Retrieved April 1, 2013 from http://www.unicef.org/publications/files/ Early_Marriage_12.lo.pdf United Nations Office on Drugs and Crime. 2011. 2011 Global study on homicide: Trends, contexts, data. Retrieved April 13, 2013 from http://www.unodc.org/ documents/data-and-analysis/statistics/Homicide/Globa_study_on_homicide_ 2011_web.pdf United Nations Statistics Division. 2009. Methodological overview of surveys on violence against women. Retrieved January 10, 2013 from http://unstats.un.org/ unsd/demographic/meetings/vaw/docs/Paper1.pdf. Vindhya, U. 2000. Dowry deaths in Andhra Pradesh, India. Violence Against Wom 6:1085–108. Weinsheimer, R. L., C. R. Schermer, L. H. Malcoe, L. M. Balduf, and L. A. BloomfieldA. 2005. Severe intimate partner violence and alcohol use among female trauma patients. The J Traum 58:22–9. Whitaker, D. J., T. Haileyesus, M. Swahn, and L. S. Saltzman. 2007. Differences in frequency of violence and reported injury between relationships with reciprocal and nonreciprocal intimate partner violence. Am J Public Health 97:941–7. Wiltsey, M. T. 2008. Risk factors for intimate partner homicide. Doctoral Dissertation. Retrieved January 30, 2013 from http://idea.library.drexel.edu/bitstream/1860/ 2713/1/Wiltsey_Michael.pdf World Health Organization/London School of Hygiene and Tropical Medicine. 2010. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: World Health Organization. Retrieved February 10, 2013 from http://www.who.int/violence_injury_prevention/ publications/violence/9789241564007_eng.pdf
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Risk Factors for Severe Intimate Partner Violence and Violence-Related Injuries Among Women in India a
b
Bushra Sabri PhD , Lynette M. Renner PhD , Jamila K. Stockman c
d
e
PhD , Mona Mittal PhD & Michele R. Decker PhD a
School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA b
School of Social Work, University of Minnesota, St. Paul, Minnesota, USA c
Division of Global Public Health, Department of Medicine, University of California, San Diego, California, USA d
Department of Public Health Sciences, University of Rochester, Rochester, New York, USA e
Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA Accepted author version posted online: 11 Mar 2014.Published online: 16 May 2014.
To cite this article: Bushra Sabri PhD, Lynette M. Renner PhD, Jamila K. Stockman PhD, Mona Mittal PhD & Michele R. Decker PhD (2014) Risk Factors for Severe Intimate Partner Violence and Violence-Related Injuries Among Women in India, Women & Health, 54:4, 281-300, DOI: 10.1080/03630242.2014.896445 To link to this article: http://dx.doi.org/10.1080/03630242.2014.896445
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Women & Health, 54:281–300, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.896445
Risk Factors for Severe Intimate Partner Violence and Violence-Related Injuries Among Women in India BUSHRA SABRI, PhD Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
LYNETTE M. RENNER, PhD School of Social Work, University of Minnesota, St. Paul, Minnesota, USA
JAMILA K. STOCKMAN, PhD Division of Global Public Health, Department of Medicine, University of California, San Diego, California, USA
MONA MITTAL, PhD Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
MICHELE R. DECKER, PhD Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
Relying on an ecological framework, we examined risk factors for severe physical intimate partner violence (IPV) and related injuries among a nationally representative sample of women (N = 67,226) in India. Data for this cross-sectional study were derived from the 2005–2006 India National Family Health Survey, a nationally representative household-based health surveillance system. Logistic regression analyses were used to generate the study findings. We found that factors related to severe physical IPV and injuries included low or no education, low socioeconomic status, rural residence, greater number of children, and separated or divorced marital status. Husbands’ problem drinking, jealousy, suspicion, control, and emotionally and sexually abusive behaviors were also related to an increased likelihood of women experiencing severe IPV and injuries. Other factors included women’s exposure Received August 4, 2013; revised January 21, 2014; accepted January 29, 2014. Address correspondence to Bushra Sabri, PhD, School of Nursing, Johns Hopkins University, 816 N. Washington Street, Baltimore, MD 21205. E-mail: [email protected] 281
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to domestic violence in childhood, perpetration of IPV, and adherence to social norms that accept husbands’ violence. Practitioners may use these findings to identify women at high risk of being victimized by severe IPV or injuries for prevention and intervention strategies. Policies and programs that focus on empowering abused women and holding perpetrators accountable may protect women at risk for severe IPV or injuries that may result in death.
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KEYWORDS India
intimate partner, physical violence, injuries, women,
Intimate partner violence (IPV) is a global public health problem with consequences including premature deaths and injuries (Kyricou et al., 1999; National Center for Injury Prevention and Control, 2012). In a World Health Organization (WHO) multi-country study (N = 24,000), between 19–55% of the women reported being injured as a result of physical IPV, often more than once (Garcia-Moreno et al., 2005). Severe physical violence, including injuries, is a risk factor for lethality. In an 11-city study of female deaths in the United States, women with an increase in severity of physical violence were 5.2 times more likely than other women to be murdered (Campbell et al., 2003). IPV was cited as a cause of 40–60% of female deaths and maternal mortality in the United States, Bangladesh, and India (Garcia-Moreno et al., 2005; Krug et al., 2002). India suffers a high burden of IPV, with prevalence estimates ranging from 6% in one state (i.e., Himachal Pradesh) to 59% in another (i.e., Bihar; Charlette, Nongkynrih, & Gupta, 2012; Garcia-Moreno et al., 2005). The 2011 national statistics show a large number of IPV-related crimes against women in India (99,135 incidents of cruelty and 8,618 deaths; Karhad, 2013). Reporting inaccuracies also persist in India, with some IPV-related crimes against women being falsely labeled “suicides” or “accidents” (United Nations Office on Drugs and Crime, 2011). Although IPV is a public health problem in India, little is known about risk factors for severe abuse. This knowledge may help guide the development of assessment instruments and targeted interventions. For example, the Danger Assessment, based on risk factors identified through U.S.-based samples, is used to help women assess their danger of being severely assaulted or killed by their partners (Campbell et al., 2003). However, no such assessment is used in health care and social service settings in India. Factors such as dowry demands (i.e., money from the wife’s family; Vindhya, 2000) and IPV in current relationships (Sabri, Campbell, & Dabby, in press) may be risk factors for severe IPV and homicides in Indian families. Because severe physical IPV (e.g., attempted strangulation) and injuries often precede homicides, prevention efforts must begin with identifying factors that place women at risk. An ecological framework can
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be useful for understanding the presence of violence-related risk factors in women’s lives and for developing risk assessments for safety. We were not able to locate any published research that presented risk factors for both severe violence and injuries among women in India using an ecological approach. The goal of our study was to fill this gap.
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BACKGROUND LITERATURE IPV is a multifaceted phenomenon resulting from the interaction between the individual and their environment (Heise, 1998; Krug et al., 2002; Stith et al., 2004), and is a product of factors at individual, microsystem (relationship), exosystem (community), and macrosystem (societal) levels (Heise, 1998; WHO/London School of Hygiene and Tropical Medicine, 2010). The individual level includes personal history factors that may increase the likelihood of IPV victimization (WHO/London School of Hygiene and Tropical Medicine, 2010), such as younger age (Campbell et al., 2007; Pratt, & Deosaransingh, 1997), marriage before 18 years of age (United Nations International Children’s Emergency Fund [UNICEF], 2005, as cited in the International Center for Research on Women, 2006), low education (Ackerson et al., 2008), divorce (Campbell et al., 2007), and alcohol misuse by women (Sharps, Campbell et al., 2001; Weisenheimer et al., 2005) and their partners (Barrett, Habibov, and Chernyak, 2012; Campbell et al., 2007; Jeyaseelan et al. 2007; Thompson & Kingree, 2006). Women’s exposure to IPV in childhood has been linked to their psychological distress and poor social adjustment in adulthood, which may place them at a greater risk for IPV (Davis & Briggs, 2000; Henning et al., 1996). Husbands’ low levels of education (Ackerson et al., 2008), low socioeconomic status (Jeyaseelan et al., 2007), and unemployment (Campbell et al., 2007; Krishnan et al., 2010; Kyriacou et al., 1999) have also been found to increase a woman’s risk for IPV. While some evidence in India shows that women’s employment reduces the incidence of IPV (Chin, 2012), other researchers have found an increased risk for violence (Krishnan et al., 2010). The microsystem level includes risk factors in the immediate setting, such as families with multiple children (Martin et al., 1999), a woman’s perpetration of IPV or reciprocal violence (Whitaker et al., 2007), forced sex (Campbell et al., 2003; McFarlane et al., 2005), and psychological abuse that involves partners’ threats of harm, jealousy, and controlling behaviors (Dalal & Lindqvist, 2012; Pandey, Dutt, & Banerjee, 2009). Relationship length has been positively associated with IPV (Brown & Bulanda, 2005; Pandey et al. 2009), with women who remain in abusive relationships for longer periods of time being more likely to experience severe physical IPV or injuries. The exosystem level in which social relationships are embedded (WHO/London School of Hygiene and Tropical Medicine, 2010) include
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factors such as resources for social support (Stith et al., 2004). Urban women, with more resources available, may be at lower risk than women in rural areas (Peek-Asa et al., 2011). Research, however, shows women are typically less likely to seek formal help, and often seek help as a last resort when they can no longer endure abuse, or when abuse becomes life threatening (Naved et al., 2006; Panchanadeswaran & Koverola, 2005). Finally, the macrosystem level includes cultural values and beliefs, such as attitudes that condone violence as a means to settle disputes (Abraham, 1998; Heise, 1998; Krug et al., 2002; Stith et al., 2004), inhibit women from seeking help (Kamat et al., 2010), and relates to the acceptance of violence at the individual level. As outlined, an ecological model focuses on risk factors for IPV across multiple levels of the environment. Also, as noted, only some risk factors for IPV have been explored among women in India, and the focus has not been on risk factors for severe physical IPV and injuries. In this study, we explored which factors put women in India at an increased risk for severe IPV and injuries. Our findings can be informative to health care professionals during both assessment and intervention.
METHODS Design and Procedures Data for this study were derived from the 2005–2006 India National Family Health Survey (NFHS-3; International Institute for Population Sciences and Macro [IIPS], 2007), a nationally representative household-based health surveillance system. Details of data collection procedures have been previously published (IIPS, 2007). The NFHS-3 survey collected data from a nationally representative probability sample. Briefly, a total of 116,652 households were selected, and 109,041 households participated in interviews. The interviews were conducted with respondents meeting the following eligibility criteria. The Household Questionnaire was completed by the head of the household or any adult household member. The Woman’s Questionnaire was completed by women (ever-married and never-married) aged 15–49 years who were usual residents of the sample household or visitors who stayed in the sample household the night before the survey. The Man’s Questionnaire was employed to interview men aged 15–54 years who were usual residents of the sample household or visitors who stayed in the sample household the night before the survey. The household response rate was 97.7% for India as a whole (96.9% for urban areas and 98.5% for rural areas). A total of 131,596 women were eligible, and 85,373 men were eligible. A total of 124,385 women (aged 15–49 years) and 74,369 men (aged 15–54 years) were interviewed, which yielded a 94.5% response rate for women and an 87.1% response rate for
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men (IIPS, 2007). The domestic violence (DV) module was administered to one randomly selected woman per household, with a total sample of 83,703 women (ever-married, N = 69,704, and never married, N = 13,999). For our analyses, we selected the 69,704 ever-married women who completed the DV module. Approximately four percent of the cases with missing data were deleted, yielding complete data on 67,226 ever-married women for our analyses. The interviewer-administered DV module covered information on different forms of violence experienced and help-seeking behavior as a result of DV. The study procedures were reviewed and approved by the IIPS ethical review board, and informed consent was obtained from all women who participated.
Measures The DV module for the survey was developed based on WHO guidelines and available research (WHO, 2011; Hindin, Kishor, & Ansara, 2008) on reliable and valid measurement of DV. Partner violence was assessed using a modified version of the Conflict Tactics Scale (Straus, 1979, 1990), covering a series of behavioral-specific acts of physical violence (Hindin, Kishor, & Ansara, 2008). Further, to maximize reliability and validity, DHS questionnaires were translated into local languages in which interviews took place. The translated questionnaires were back translated into English from local languages to ensure accuracy and any discrepancies were resolved (ICF International, 2012). Two outcome measures were included in our study. Severe physical violence was defined as a woman’s husband had ever in her lifetime: tried to choke her or burn her on purpose or threatened or attacked her with a knife, gun, or other weapon (United Nations Statistics Division, 2009). Participants who reported having ever experienced cuts, bruises, or aches; eye injuries, sprains, dislocations, or burns; or deep wounds, broken bones, broken teeth, or any other serious injury as a result of their husbands’ violence were classified as having experienced an violence-related injury. The independent variables in this study represented risk factors at three ecological levels: individual, microsystem, and exosystem. INDIVIDUAL Age and age at marriage were included as continuous variables. Education level was assessed for both women and their husbands and categorized into three groups: no education, primary education, and secondary or higher education. Employment was assessed for both women and their husbands. Marital status was measured using three categories: married, widowed, and separated/divorced/abandoned. Socioeconomic status was measured using the Wealth Index (IIPS, 2007), which was calculated using data on ownership
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of 33 selected assets, as well as housing quality and facilities (e.g., material used to construct houses, drinking water source, cooking fuel). The index used principal component analysis to assign a weight (factor score) to each of the items included in the wealth index, placing households on a continuous scale of relative wealth. Each woman was ranked according to the score of the household in which she resided. The original scale was standardized and scores were used to create wealth quintiles (i.e., poorest, poorer, middle, richer, and richest) in which one was the poorest 20% of the households and 5 was the wealthiest 20% of the households (Kishor & Johnson, 2004; Sreeramareddy, Shidhaye, & Sathiakumar, 2011). For this study, we created three categories: poor, middle, and rich. The poorest and poorer quintiles were combined to create a single poor category and richer and richest were combined for the rich category. Alcohol use was assessed for women and their husbands based on questions on if women or their husbands ever used alcohol (response options were yes or no for both women’s use and their husbands’ use). Exposure to DV in childhood was assessed using a question asking women if they witnessed their fathers beating their mothers in childhood (response options were yes or no). Personal acceptance of IPV was measured by responses to questions regarding whether women would justify wife beating under the following circumstances: she goes out without telling him, she neglects the children, she argues with him, she refuses to have sex with him, and she burns the food (response options were yes or no). MICROSYSTEM The duration of relationship and number of children with the abusive husband were each measured using continuous variables. A woman’s perpetration of IPV was defined as if they ever hit, slapped, kicked, or did anything else to physically hurt their husband at times when he was not already beating or physically hurting them (response options were yes or no’. Participants who reported having ever experienced humiliation, threats to hurt or harm, or insults by an intimate partner were classified as having experienced emotional abuse. Women who reported ever being forced into sex against their will by their husbands were considered to have experienced forced sex. To measure partners’ jealous/suspicious behaviors, women were asked if their husbands were jealous or angry if they talked to other men or frequently accused them of being unfaithful. A dichotomous variable was created from responses to these two items (yes to any of the questions indicated husbands’ jealousies or suspicious behaviors). To assess controlling behaviors, a dichotomous variable was created if women’s husbands exhibited any of the following behaviors: did not permit them to meet their female friends, tried to limit contact with their families, or insisted on knowing where they were at all times (response options were yes or no).
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EXOSYSTEM
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Place of residence was categorized as mega city, large city, small city, large town, small town, or rural, based on classification of urban and rural areas in the 2001 Census of India (IIPS, 2007). Resources of social support were measured by creating two dichotomous variables: formal and informal support received. Women were asked from whom they sought help for IPV. Formal resources included doctor/medical personnel, police, lawyers, and social service organizations. Informal resources included family, friends and neighbors.
Analysis Procedures First, descriptive statistics were calculated for each of the variables. Next, bivariate analyses were performed to examine the association between the covariates and each dependent variable. Only variables that were significant at the .05 level in the bivariate analyses were entered in the multivariate regression models. Last, two separate multivariate logistic regression analyses were conducted to test the independent effects of ecological-level variables on the two binary outcomes (i.e., severe physical violence and violencerelated injuries). All covariates that were significant in bivariate analyses were entered simultaneously (i.e., not using a stepwise or hierarchical procedure) into each of the multiple regression models. DV weights were applied to yield nationally representative results. These weights take into account the differential probably of the selection of participants for the DV module. The Wald test was used to assess model fit. The level of significance for all analyses was p < .05. Analyses were conducted using Statistical Package for Social Sciences (SPSS) version 19 and accounted for a clustered sampling design.
RESULTS Study Participants The sample consisted of 67,226 women aged 15–49 years (M = 31.5). Approximately 70% (n = 46,721) were from rural areas and 30.5% (n = 20,504) from urban parts of India (i.e., cities and towns). Nearly half of the women (48%, n = 32,284) had no education; 15.4% (n = 10,320) had primary education; 31.1% (n = 20884) had secondary education; and only 5.6% (n = 3,736) had higher education. Approximately two-thirds of women were unemployed at the time of the survey (62.2%; n = 41,771). Forty percent (n = 26,522) had low socioeconomic status, 20.1% (n = 13,505) were in the medium range, and 40.5% (n = 27,199) were in the high socioeconomic status group (see Table 1). Nearly 12% (n = 7938) reported experiencing severe
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TABLE 1 Descriptive Characteristics
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Total sample (N = 67226) Individual Woman’s age (years), Mean (SD) Age at marriage (years), Mean (SD) Woman’s education No education Primary Secondary Higher Husband’s education No education Primary Secondary Higher Current employment Woman Yes No Husband Yes No Socioeconomic statusa Low Middle High Alcohol use Woman Husband Personal acceptance of intimate partner violence (IPV) Woman exposed to domestic violence (DV) in childhood Microsystem Duration of relationship, Mean (SD) Marital status Married Widowed Separated/divorced Number of children, Mean (SD) Jealous/suspicious behaviors Controlling behaviors Emotional abuse Forced sex Woman’s perpetration of IPV Exosystem Resources for social support Formal Informal Type of Site Mega city Large city Small city Large town Small town Rural a
Weighted count
Weighted % or Mean (SD) 31.5 (0.05) 17.1 (0.03)
32,284 10,320 20,884 3,736
48.0 15.4 31.1 5.6
18,294 10,776 29,927 7,579
27.5 16.2 45.0 11.4
25,374 41,771 65,663 1,374
37.8 62.2 97.9 2.1
26,522 13,505 27,199
39.5 20.1 40.5
1706 22,022 32,843 12,454
2.5 33.1 48.9 20.1 3.40 (0.01)
63,220 2,692 1,314 18,297 17,541 10,533 3,686 481
94.0 4.0 2.0 2.81 (0.01) 27.2 26.1 15.8 5.5 0.7
216 6,812
0.3 8.1
2007 4,887 5,569 1,377 66,665 46,721
3.0 7.3 8.3 2.0 9.9 69.5
Socioeconomic status was assessed using the Wealth Index (IIPS, 2007), based on ownership of 33 assets, as well as housing quality and facilities; low = respondents in the poorest and poorer category, medium = those in the middle category; high = women in the richer and richest category.
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physical violence from an intimate partner and 14% (n = 9408) reported violence-related injuries.
Multivariate Analyses
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SEVERE PHYSICAL VIOLENCE A lack of education or low education among both women and their husbands (Adj Odds ratio [OR] = 1.45–2.59) and women’s exposure to IPV significantly increased the odds of women having ever experienced severe physical violence. Women’s history of exposure to DV during childhood (Adj OR = 1.72) was also significantly associated with their experiences of severe physical violence by their husbands (Table 2). Compared to being separated/divorced, being married or widowed was associated with at least a 50% decrease in severe physical violence (Adj OR = 0.42 and Adj OR = 0.51, respectively). Women with more children in the household were at increased odds for severe physical violence (Adj OR = 1.12). Women with husbands who were jealous/suspicious (Adj OR = 1.83), controlling (Adj OR = 1.15), and emotionally (Adj OR = 4.35) and sexually abusive (Adj OR = 2.78) were at increased odds of experiencing severe physical violence in the relationship. Women’s perpetration of IPV (Adj OR = 2.78) and husbands’ alcohol use (Adj OR = 1.79) were positively associated with severe physical violence. Women who were employed were more likely than unemployed women to experience severe physical violence (Adj OR = 1.21). Low (Adj OR = 1.38) and medium (Adj OR=1.41) socioeconomic statuses (vs. high socioeconomic status) were each associated with increased odds of severe physical violence. Women residing in mega cities were approximately 25% less likely to be severely victimized than women residing in rural areas. Women who sought formal (Adj OR = 16.6) and informal (Adj OR = 5.83) help were also significantly more likely to have experienced severe physical violence. Women’s acceptance of violence (Adj OR = 1.14) also significantly increased the odds of severe physical violence victimization. V IOLENCE-RELATED INJURIES Younger aged women (Adj OR = 0.98), women with no (Adj OR = 2.53) or low education (Adj OR = 2.22), and women from low (Adj OR = 1.37) and middle socioeconomic status (Adj OR = 1.26) were significantly more likely to have violence-related injuries. Women residing in mega cities were 29% less likely to have experienced IPV injuries compared to those residing in rural areas. Witnessing DV between parents in childhood increased the likelihood of injurious violence in an adult intimate partner relationship by 84% (Adj OR = 1.84). Women’s personal acceptance of husbands’ use of violence
290 3949 3982 7722 198 4276 (16.3) 1863 (13.9) 1799 (6.6)
Employment Woman Yes No (ref) Husband Yes No (ref)
Socioeconomic statusb Low Middle High (ref group)
(15.7) (9.6) (11.8) (16.1)
(17.3) (14.9) (9.7) (3.3)
3127 1604 2878 251
Husband’s education No education Primary Secondary Higher (ref group)
(16.0) (13.2) (6.9) (1.7)
5103 1352 1421 61
32.67 (0.15) 16.25 (0.1)
Weighted count (%) N = 7938 (11.9)
Woman’s education No education Primary Secondary Higher (ref group)
Individual level Woman’s age∗a , Mean (SD) Age at marriage, years, Mean (SD)
Independent variables 0.99 (0.98−1.01) 0.98 (0.95−1.02)
Adjusted OR (95 % CI)
1.38 (1.16−1.62) 1.41 (1.21−1.65)
0.89 (0.63−1.25)
0.69 (0.55−0.88)
2.74 (2.47−3.04) 2.27 (2.04−2.54)
1.21 (1.08−1.34)
1.52 (1.14−2.04) 1.53 (1.14−2.06) 1.45 (1.12−1.89)
1.75 (1.62−1.89)
6.03 (4.85−7.48) 5.08 (4.08−6.32) 3.11 (2.51−3.85)
11.31 (8.24−15.5) 2.59 (1.73−3.88) 9.05 (6.55−12.50) 2.46 (1.64−3.69) 4.40 (3.20−6.06) 1.86 (1.27−2.71)
1.02 (1.01−1.02) 0.91 (0.89−0.92)
Unadjusted OR (95 % CI)
Severe physical violence
TABLE 2 Multivariate Results: Logistic Regression Analysis
(14.3) (9.5) (13.9) (16.3)
(20.0) (17.0) (11.4) (5.5)
(17.6) (12.7) (5.6) (1.5)
5076 (16.5) 2074 (12.4) 2258 (6.2)
4362 5037 9158 223
3653 1833 3417 414
6009 1536 1771 93
32.31 (0.14) 16.23 (0.05)
2.97 (2.65−3.32) 2.12 (1.89−2.36)
0.83 (0.66−1.05)
1.59 (1.46−1.72)
4.32 (3.54−5.28) 3.55 (2.89−4.35) 2.23 (1.86−2.69)
13.83 (10.9−17.6) 9.39 (7.35−12.0) 3.88 (3.05−4.93)
1.04 (1.03−1.04) 0.90 (0.89−0.91)
Unadjusted OR (95 % CI)
Violence-related injuries Weighted count (%) N = 9408 (14.0)
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1.37 (1.16−1.63) 1.26 (1.08−1.46)
0.92 (0.67−1.25)
0.99 (0.89−1.11)
1.03 (0.81−1.31) 0.98 (0.76−1.26) 0.95 (0.77−1.18)
2.53 (1.84−3.48) 2.22 (1.61−3.06) 1.79 (1.33−2.40)
0.98 (0.96−0.99) 0.99 (0.96−1.03)
Adjusted OR (95 % CI)
291 4.82 (4.45−5.22)
2.69 (2.46−2.93) 1.15 (1.02−1.29) 11.01 (9.99−12.12) 4.35 (3.88−4.89) 8.32 (6.33−10.92) 2.78 (1.68−4.60)
4701 (25.7) 3616 (20.6) 4446 (42.2) 249 (52.2)
1.83 (1.63−2.04)
1.12 (1.08−1.15)
1.16 (1.14−1.18)
3.4 (0.1)
1.04 (0.96−1.11)
1.72 (1.54−1.92)
1.14 (1.03−1.27)
1.02 (0.81−1.29) 1.79 (1.62−1.98)
0.42 (0.33−0.54) 0.51 (0.37−0.69)
Adjusted OR (95 % CI)
1.14 (1.11−1.16)
3.04 (2.78−3.31)
1.59 (1.47−1.72)
2.37 (1.97−2.85) 3.16 (2.91−3.42)
0.17 (0.14−0.20) 0.25 (0.20 (0.32)
Unadjusted OR (95 % CI)
3.8 (.03)
2811 (22.8)
4683 (14.4)
403 (23.7) 4544 (20.6)
6958 (11.1) 422 (15.9) 558 (42.7)
Weighted count (%) N = 7938 (11.9)
Relationship/Microsystem level Duration of relationship, Mean (SD) Number of children, Mean (SD) Jealous/suspicious behaviors Controlling behaviors Emotional abuse Woman’s physical violence when the partner was not hurting her
Personal acceptance for intimate partner violence (IPV) Women’s exposure to domestic violence in childhood
Alcohol use Woman Husband
Marital status Married Widowed Separated/divorced (ref group)
Independent variables
Severe physical violence
4207 (24.0) 4991 (47.4) 286 (59.5)
5432 (29.7)
3.37 (0.04)
3.73 (0.03)
3321 (21.4)
5559 (14.0)
451 (24.5) 5294 (24.0)
8401 (13.3) 434 (16.1) 572 (43.6)
3.69 (3.38−4.03) 10.5 (9.61−11.6) 9.19 (7.13−11.8)
6.52 (6.04−7.04)
1.27 (1.25−1.28)
1.28 (1.26−1.30)
3.02 (2.77−3.28)
1.71 (1.58−1.85)
2.64 (2.19−3.19) 3.12 (2.87−3.38)
0.19 (0.17−0.24) 0.25 (0.19−0.32)
Unadjusted OR (95 % CI)
Violence-related injuries Weighted count (%) N = 9408 (14.0)
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(Continued)
1.23 (1.09−1.39) 4.44 (3.98−4.95) 3.47 (2.23−5.40)
1.75 (1.56−1.96)
1.11 (1.07−1.13)
1.11 (1.07−1.13)
1.84 (1.65−2.06)
1.19 (1.07−1.32)
0.97 (0.76−1.23) 1.88 (1.70−2.08)
0.54 (0.42−0.71) 0.53 (0.38−0.76)
Adjusted OR (95 % CI)
292 173 (79.8) 3229 (52.1)
Resources for social support Formal Informal
0.73 1.00 1.27 1.27 1.16
(0.57−0.94) (0.77−1.29) (0.94−1.71) (0.86−1.87) (0.94−1.42)
2.77 (2.32−3.31)
Adjusted OR (95 % CI)
(4.7) (8.1) (7.4) (11.4) (9.1) (12.8) 172 (76.0) 3684 (54.1)
128 528 553 214 785 7198
1453 (7.2)
Weighted count (%) N = 9408 (14.0)
(0.28−0.39) (0.47−0.77) (0.44−0.66) (0.64−1.21) (0.59−0.79)
0.71 1.12 0.96 1.33 0.88
(0.55−0.92) (0.82−1.53) (0.76−1.23) (0.89−1.98) (0.72−1.09)
2.57 (2.13−3.08)
Adjusted OR (95 % CI)
25.48 (16.3−39.9) 13.42 (8.1−22.2) 14.65 (13.2−16.2) 6.77 (5.96−7.69)
0.33 0.59 0.54 0.88 0.68
0.54 (0.49−0.60)
Unadjusted OR (95 % CI)
Violence-related injuries
Note. OR = odds ratios; CI= 95% confidence intervals. Percentages are within each ecological level variable. a The data for age, age at marriage and number of children represent averages for women who experienced severe violence and those who experienced injuries. b Socioeconomic status was assessed using the Wealth Index (IIPS, 2007), based on ownership of 33 assets, as well as housing quality and facilities; low = respondents in the poorest and poorer category, medium = those in the middle category; high = women in the richer and richest category. ∗ Significance at p < .05 level.
29.85 (19.01−46.9) 16.63 (9.86−28.1) 12.84 (11.59−14.2) 5.83 (5.16−6.59)
(0.30−0.45) (0.46−0.73) (0.57−0.88) (0.72−1.36) (0.71−0.98)
0.37 0.58 0.71 0.99 0.83
104 389 533 176 736 5999
(5.2) (8.0) (9.6) (12.9) (11.1) (13.0)
6.82 (5.97−7.79)
Unadjusted OR (95 % CI)
1349 (44.1)
Weighted count (%) N = 7938 (11.9)
Forced sex Community Exosystem level Type of Site Mega city Large city Small city Large Town Small town Rural (ref group)
Independent variables
Severe physical violence
TABLE 2 Multivariate Results: Logistic Regression Analysis (Continued)
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was also significantly related to women’s experiences of IPV injuries compared to women who did not justify use of violence under any circumstances (Adj OR = 1.19). Longer relationship duration (Adj OR = 1.11) and a greater number of children (Adj OR = 1.11) were associated with increased odds of violencerelated injuries. Women who were married or widowed were 46–47% less likely than separated/divorced women to have experienced injuries. Both victimization and perpetration of physical IPV increased the odds of experiencing injuries. If a woman experienced emotional or sexual abuse by her husband, the odds that she experienced injuries increased by factors of 4.44 (Adj OR = 4.44) and 2.57 (Adj OR = 2.57), respectively. Husbands’ jealous/suspicious (Adj OR = 1.75) and controlling behaviors (Adj OR = 1.23) also significantly increased the odds of women’s experiences of IPV-related injuries. Additionally, women’s own perpetration of IPV was significantly related to an increased risk of injuries (Adj OR = 3.47). While women’s alcohol use had no significant effect on their victimization, alcohol use by their husbands was related to 88% increase in the odds of experiencing injurious violence (Adj OR = 1.88). Compared with women who did not seek any help, women who sought help from formal (Adj OR = 13.42) and informal (Adj OR = 6.77) sources of support were significantly more likely to have experienced injuries.
DISCUSSION We examined factors related to severe physical IPV and IPV-related injuries among ever-married women in India. The literature on risk factors for IPV victimization is largely U.S.-based, with no study having focused on this group of ecological risk factors for both severe physical IPV and resulting injuries using a nationally representative sample of women in India. Among the factors examined, low or no education, low socioeconomic status and rural residence were significantly related to women being at high risk for IPV (i.e., both severe physical IPV and injuries), as reported in the existing literature (Jeyaseelan et al., 2007; Kyriacou et al., 1999; Martin et al., 1999; Peek-Asa et al., 2011). Further, for every additional child in the family, there was an 11–12% increase in women’s exposure to severe physical IPV and IPV-related injuries. Among families with inadequate income and difficulties in meeting basic needs, large numbers of children in the family may be an additional source of stress that can contribute to problematic or conflictual family interaction patterns, including IPV, and can limit women’s options for disengaging from abusive partners. Contrary to prior research (Campbell et al., 2007; Krishnan et al., 2010), partners’ unemployment was not found to be a significant factor in victimization by severe physical IPV or IPV-related injuries. We found that
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women’s employment was positively related to them reporting severe physical violence and researchers who have focused on samples from India have reported similar findings (Dalal, 2011; Kamat et al., 2010; Krishnan et al., 2010). In some instances, it is possible that violence may have prompted some women to seek outside employment as a means of securing support. Employment may serve as a protective factor if it is connected with education and awareness and modified cultural norms against gender roles (Dalal, 2011). Among microsystem variables, women who were separated and divorced were more likely to report severe lifetime IPV than women who were married. Women’s separation or divorce may be in response to lifethreatening abuse by husbands. Due to sociocultural norms in India, women are more likely to remain married, and divorce or separation may occur in cases of severe or life threatening IPV (Sabri et al., in press). The relationship between recent separation/divorce and partner violence has been documented in research on U.S.-based samples (Campbell et al., 2007; Reckdenwald & Parker, 2010). Separation/divorce may invoke feelings of rage among controlling men and may drive them to injure their intimate partners. Psychological abuse in the relationship, partners’ jealous, suspicious, and controlling behaviors, and forced sex were particularly strongly associated with both severe physical IPV and injuries, as consistent with prior literature from the United States (Campbell et al., 2003; McFarlane et al., 2005; Stark & Flitcraft, 1996; Wiltsey, 2008). In abusive relationships, women live under a constant threat of danger, powerlessness, or lack of control (Jun et al., 2008), which increases their likelihood of experiencing more severe IPV. Being in a longer-term relationship was associated with an increased likelihood of experiencing violence-related injuries. Violence often escalates over the course of the relationship (Kelly & Johnson, 2008) leading to potentially grave injuries for women. Women’s acceptance of the husband’s violence was significantly related to their experiences of severe physical IPV and IPV-related injuries. Due to social norms, women may continue to remain in abusive relationships and perceive IPV as a common and acceptable. This places women at risk for increased violence, as violence tends to escalate over time. Acceptance of IPV has also been negatively associated with women’s help-seeking (Sudha & Morrison, 2011). As found by other researchers (Davis & Briggs, 2000; Henning et al., 1996), we found that exposure in childhood to DV increased women’s risk of victimization. This finding may be partially explained by poor mental health and behavioral functioning associated with traumatic life experiences (Kimerling et al., 2007). Moreover, women who are exposed to IPV in childhood may be more likely to accept violence as a normative behavior than other women; thus, increasing their risk for victimization by an intimate partner (Kamat et al., 2010).
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Husbands’ use of alcohol was significantly related to women’s increased likelihood of experiencing severe physical IPV and IPV-related injuries. Alcohol use has been associated with lowered inhibition to violence and increases the risk for perpetrating severe IPV (Buzawa & Buzawa, 2013; Johnson, 2001), with many women killed by husbands in fits of alcoholic rage (Vindhya, 2000). Research in India shows objecting to husband’s alcohol consumption is a significant trigger for IPV (Kamat et al., 2010). Women’s alcohol misuse, however, was not a significant factor. Only 2.5% of the women in the sample reported use of alcohol. Alcohol use is infrequently reported among married women in Indian context and is typically considered a male problem in India (Davar, 1995; Vindhya, 2000). In U.S. samples, partner’s alcohol misuse is found to be a stronger predictor of risk for severe violence (Campbell et al., 2003) than women’s alcohol use. Women who received formal and informal sources of support were also more likely to report severe IPV. Women may resort to help-seeking only when violence becomes severe (Decker et al., 2013). Factors related to delayed help-seeking among women include low self-confidence stemming from lack of education and skills, hope that circumstances would improve, and responsibilities towards their children (Panchanadeswaran & Koverola, 2005).
Strengths and Limitations of Study This study has both strengths and limitations. One strength is that we relied on a nationally representative sample of Indian women. A second strength is that we identified some risk factors for severe physical IPV and violencerelated injuries in a cross-cultural sample, which have also been identified as risk factors for intimate partner homicides (IPH) in the United States. For instance, in the United States, researchers have found that partner’s alcohol use, forced sex, jealousy, controlling behaviors, and separation are associated with increased risk of IPH (Campbell et al., 2003). Our findings support these findings and we found additional risk factors for severe physical IPV (e.g., women’s employment) that apply to women in India. One of the limitations of the study is that all of the measures were self-reported and not all measures were derived from standardized instruments, which could have resulted in misclassification and non-comparability or results to other studies that have used standardized instruments. Further, due to secondary analysis, we were limited to variables that were available in the dataset and could not assess other potential risk factors at the exosystem and macrosystem levels (e.g., community sanctions and norms). In addition, the study was cross-sectional and we are unable to determine the direction of causality. In future studies, researchers should use a longitudinal design in order to identify precursors of severe physical violence and violence-related injuries.
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Study Implications An ecological, person-in-environment framework can be used to identify factors associated with severe IPV for women in multiple contexts. Some of these risk markers of violence are more static (e.g., women’s history of witnessing IPV in childhood) while others are dynamic (e.g., partners’ use of alcohol), and each can be potential areas of intervention. Practitioners might use these findings to identify women at-risk for experiencing severe violence/injuries and to help them develop safety plans. Health care providers are the main institutional contact for women experiencing IPV in India (Chibber, Krishnan, & Minkler, 2011), and research confirms women’s acceptance of IPV screening in the health care sector (Decker et al., 2013). However, limited information regarding the perpetrator, location of the incident or possible future risk of harm to the woman is recorded (Jaswal, 2000). In a study of medical records from 1997–1999 in a health facility in Mumbai, India, IPV was found to be a causal factor of injuries in 53% of the probable (i.e., 38.8% cases established through other sources) and recorded cases of IPV; yet, IPV was actually mentioned in only 13.5% of these cases (Jaswal, 2000). Clearly, improvements must be made to the assessment and intervention of IPV in healthcare and social settings in India. Prevention strategies may include promoting public education and awareness that there is no justification for the use of violence and the importance of seeking help for abuse. Although policies are in place to address IPV in India, there is a gap between enactment and implementation. Many women in India still adhere to traditional cultural expectations and are socialized to accept violence in their lives. Indian women may be hesitant to report IPV due to sociocultural norms and the tendency of the legal system to trivialize IPV (Kimuna et al. 2012). It is necessary to ensure adequate implementation of policies and to make sure that law enforcement officers are receptive to the needs of women’s experiences of IPV (Kimuna et al, 2012). Health care settings may play an important role in protecting women from severe violence and injuries in India. In a U.S. multi-site study, 41% of the women who were killed by their partners had been seen in the health care system in the year prior to their murder (Sharps, Koziol-McLain et al., 2001). Policies to screen women for IPV in healthcare settings may help identify women in abusive relationships and to prevent future harm (Boinville, 2013). Policies are needed to hold perpetrators accountable through the criminal justice system and to enhance provisions for victims’ safety. It is necessary to empower victims to reduce their dependence on dangerous abusive partners through education and employment opportunities. Further, policies and programs that promote healthy relationships and improved access to socioeconomic and educational opportunities for at-risk families may reduce the risk of severe physical IPV/injuries or IPHs in Indian families.
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REFERENCES Abraham, M. 1998. Speaking the unspeakable: Marital violence against South Asian immigrant women in the United States. Indian J Gend Stud 5:215–41. Ackerson, L. K., I. Kawachi, E. M. Barbeau, and S. V. Subramanian. 2008. Effects of individual and proximate educational context on intimate partner violence: A population-based study of women in India. Am J Public Health 98:507–14. Barrett, B. J, N. Habibov, and E. Chernyak. 2012. Factors affecting prevalence and extent of intimate partner violence in Ukraine: Evidence from a nationally representative survey. Violence Against Wom 18:1147–76. Boinville, M. 2013. Screening for domestic violence in health care settings. ASPE Policy Brief . Retrieved April 5, 2013 from http://aspe.hhs.gov/hsp/13/dv/pb_ screeningDomestic.cfm Brown, S. L., and J. R. Bulanda. 2005. Relationship violence in young adulthood: A Comparison of daters, cohabitors, and marrieds. Bowling State University, Center for Family and Demographic Research working paper 06–06. Buzawa, E. S., and C. G. Buzawa. 2013. What does research suggest are the primary risk and protective factors for intimate partner violence and what is the role of economic factors. J Policy Anal Manag 32:128–37. Campbell, J. C., N. E. Glass, P. W. Sharps, K. Laughon, and T. Bloom. 2007. Intimate partner homicide: Review and implications for research and policy. Violence, Trauma, Abuse 8:246–69. Campbell. J. C., D. Webster, J. Koziol-McLain, C. Block, D. Campbell, M. A. Curry, et al. 2003. Risk factors for femicide in abusive relationships: Results from a multisite case control study. Am J Public Health 93:1089–97. Charlette, S. L., B. Nongkynrih, and S. K. Gupta. 2012. Domestic violence in India: Need for public health action. Indian J Public Health 56:140–5. Chibber, K. S., S. Krishnan, and M. Minkler. 2011. Physician practices in response to intimate partner violence in Southern India: Insights from a qualitative study. Women Health 51:168–85. Chin, Y.-M. 2012. Male backlash, bargaining, or exposure reduction? Women’s working status and physical spousal violence in India. Journal of Population Economics 25:175–200. Dalal, K. 2011. does economic empowerment protect women from intimate partner violence? J Inj Violence Res 3:35–44. Dalal, K., and K. Lindqvist. 2012. A national study of the prevalence and correlates of domestic violence among women in India. Asia-Pac J Public He 24:265–77. Davar, B. V. 1995. Mental illness in Indian women. Econo Polit Weekly 30:2879–86. Davis, J., and E. Briggs. 2000. Witnessing violence fact sheet. Retrieved January 16, 2013 from http://www.musc.edu/vawprevention/research/witnessing.shtml Decker, M., S. Nair, N. Saggurti, B. Sabri, M. Jethva, A. Raj, et al. 2013. Violencerelated coping, help-seeking and health care based intervention preferences among perinatal women in Mumbai, India. J Interpers Violence 28:1924–47. Garcia-Moreno, C., H. A. F. M. Jansen, M. Ellsberg, L. Heise, and C. Watts. 2005. WHO multi-country study on women’s health and domestic violence against women. Retrieved April 2, 2013 from http://www.who.int/gender/violence/ who_multicountry_study/en/
Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
298
B. Sabri et al.
Heise, L. L. 1998. Violence against women: An integrated, ecological framework. Violence Against Wom 4:262–90. Henning, K., H. Leitenberg, P. Coffey, T. Turner, and R. T. Bennett. 1996. Long-term psychological and social impact of witnessing physical conflict between parents. J Interpers Violence 11:35–51. Hindin, M., S. Kishor, and D. L. Ansara. 2008. Intimate partner violence among couples in 10 DHS countries: Predictors and health outcomes. Retrieved February 6, 2013 from http://pdf.usaid.gov/pdf_docs/pnadn620.pdf International Center for Research on Women. 2006. Child marriage and domestic violence. Retrieved February 6, 2013 from http://www.icrw.org/files/images/ Child-Marriage-Fact-Sheet-Domestic-Violence.pdf International Institute for Population Sciences and Macro. 2007. National Family Health Survey (NFHS-3), 2005-06. Mumbai, India: IIPS. ICF International. 2012. Demographic and health surveys methodology. Survey Organization Manual. Retrieved May 6, 2013 from http://www.measuredhs. com/pubs/pdf/DHSM10/DHS6_Survey_Org_Manual_7Dec2012_DHSM10.pdf Jaswal, S. 2000. Health records and domestic violence in Thane District, Maharashtra. In Domestic violence in India a summary report of four records studies, Burton, B., Duvvury, N., Rajan, A., & Varia, N. Washington, DC: International Center for Research on Women [ICRW], 2000 May. 6-14. (Domestic Violence in India 2; USAID Cooperative Agreement No. FAO-A-00-95-00030-00). Jeyaseelan, L., S. Kumar, N. Neelakantan, A. Peedicayil, R. Pillai, and N. Duvvury. 2007. Physical spousal violence against women in India: Some risk factors. J Biosoc Sci 39:657–70. Johnson, H. 2001. Contrasting views of the role of alcohol in cases of wife assault. J InterpersViolence 16:54–72. Jun, H., J. W. Rich-Edwards, R. Boynton-Jarrett, and R. J. Wright. 2008. Intimate partner violence and cigarette smoking: association between smoking risk and psychological abuse with and without co-occurrence of physical and sexual abuse. Am J Public Health 98:527–35. Kamat, U., A. M. A. Ferreira, D. D. Motghare, N. Kamat, and N. R. Pinto. 2010. A cross-sectional study of physical spousal violence against women in Goa. Healthline 1(1):34–40. Karhad, B. D. 2013. Statistical review of the problem of crime against women in India. JASCR IV(1–2):13–9. Kelly, J. B. and M. P. Johnson. 2008. Differentiation among types of intimate partner violence: Research update and implications for interventions. Fam Court Rev 46:476–99. Kimerling, R., J. Alvarez, J. Pavao, A. Kaminski, and N. Baumrind. 2007. Epidemiology and consequences of women’s revictimization. Women’s Health Issues 17(2):101–6. Kimuna, S. R., Y. K. Djamba, G. Ciciurkaite, and S. Cherukuri. 2012 Domestic violence in India: Insights from the 2005–2006 National Family Health Survey. J Interpers Violence 28:773–807. Kishor, S., and K. Johnson. 2004. Profiling domestic violence—Multi-country study. Calverton, MD: ORC Macro. Retrieved December 3, 2012 from http://www. measuredhs.com/pubs/pdf/OD31/OD31.pdf
Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
Risk for Severe Violence and Injuries
299
Krishnan, S., C. H. Rocca, A. E. Hubbard, K. Subbiah, J. Edmeades, and N. S. Padian. 2010: Do changes in spousal employment status lead to domestic violence? Insights from a prospective study in Bangalore, India. SocSci Med 70:136–43. Krug, E. G., J. A. Mercy, L. L. Dahlberg, and A. B. Zwi. 2002. The world report on violence and health. Lancet 360(9339):1083–8. Kyriacou, D. N., D. Anglin, E. Taliaferro, S. Stone, T. Tubb, J. A. Linden, et al. 1999. Risk factors for injury to women from domestic violence. New Engl J Med 341(25):1892–8. Martin, S. L., A. M. Tsui, K. Maitra, and R. Marinshaw. 1999. Domestic violence in northern India. Am J Epidemiol 150:417–26. McFarlane, J., A. Malecha, J. Gist, K. Watson, E. Batten, I. Hall, and S. Smith. 2005. Intimate partner sexual assault against women and associated victim substance use, suicidality, and risk factors for femicide. Issues Ment Health Nurs 26:953–67. National Center for Injury Prevention and Control. 2012. Understanding intimate partner violence: Factsheet 2012. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved June 14, 2013 from http://www.cdc.gov/ violenceprevention/pdf/ipv_factsheet2012-a.pdf Naved, R. T., S. Azim, A. Bhuiya, and L. A. Persson, 2006. Physical violence by husbands: Magnitude, disclosure and help-seeking behavior of women in Bangladesh. Soc Sci Med 62:2917–29. Panchanadeswaran, S., and C. Koverola. 2005. The voices of battered women in India. Violence Against Wom 11:736–58. Pandey, G. K., D. Dutt, and B. Banerjee. 2009. Partner and relationship factors in domestic violence: Perspectives of women from a slum in Calcutta, India. J Interpers Violence 24:1175–91. Peek-Asa, C., A. Wallis, K. Harland, K. Beyer, P. Dickey, and A. Saftlad. 2011. rural disparity in domestic violence: Prevalence and access to resources. J Womens Health 20:1743–9. Pratt, C., and K. Deosaransingh. 1997. Gender differences in homicide in Contra Costa County, California: 1982–1993. Am J Prev Med 13(suppl no. 6):19–24. Reckdenwald, A., and K. F. Parker. 2010. Understanding gender-specific intimate partner homicide: A theoretical and domestic service-oriented approach. J Crim Just 39:951–8. Sabri, B., J. C. Campbell, and C. Dabby. in press. Gender differences in intimate partner homicides among ethnic subgroups of Asians. Violence Against Wom. Sharps, P. W., J. C. Campbell, D. W. Campbell, F. A. Gary, and D. W. Webster. 2001. The role of alcohol use in intimate partner femicide. Am J Addiction 10: 122–5. Sharps, P. W., J. Koziol-McLain, J. C. Campbell, J. McFarlane, C. Sachs, X. Xu. 2001. Health care providers’ missed opportunities for preventing femicide. Prev Med 33:373–80. Sreeramareddy, C. T., R. R. Shidhaye, and N. Sathiakumar. 2011. Association between biomass fuel use and maternal report of child size at birth-an analysis of 2005–2006 India Demographic Health Survey data. BMC Public Health 11(403):1–10. Stark, E., and A. Flitcraft. 1996. Women at risk: Domestic violence and women’s health. Thousand Oaks, CA: Sage Publications.
Downloaded by [Universidad de Sevilla] at 10:00 13 November 2014
300
B. Sabri et al.
Stith, S. M., D. B. Smith, C. E. Penn, D. B. Ward, and D. Tritt. 2004. Intimate partner physical abuse perpetration and victimization risk factors—A meta-analytic review. Aggress Violent Beh 10:65–98. Straus, M. A. 1979. Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. J Marriage Fam 41(1):75–88. Straus, M. A. 1990. Measuring intrafamily conflict and violence: The Conflict Tactic (CT) Scales. In Physical violence in American families: Risk factors and adaptations to violence in 8,145 families, ed. M. A. Straus and R. J. Gelles, 29–47. New Brunswick, NJ: Transaction Publishers. Sudha, S., and S. Morrison. 2011. Marital violence and women’s reproductive health care in Uttar Pradesh, India. Womens Health Iss 21:214–21. Thompson, M. P., and J. B. Kingree. 2006. The roles of victim and perpetrator alcohol use in intimate partner violence outcomes. J Interpers Violence 21:163–77. United Nations International Children Emergency Fund. 2005. Early marriage: A harmful traditional practice: A statistical exploration. New York, NY: UNICEF. Retrieved April 1, 2013 from http://www.unicef.org/publications/files/ Early_Marriage_12.lo.pdf United Nations Office on Drugs and Crime. 2011. 2011 Global study on homicide: Trends, contexts, data. Retrieved April 13, 2013 from http://www.unodc.org/ documents/data-and-analysis/statistics/Homicide/Globa_study_on_homicide_ 2011_web.pdf United Nations Statistics Division. 2009. Methodological overview of surveys on violence against women. Retrieved January 10, 2013 from http://unstats.un.org/ unsd/demographic/meetings/vaw/docs/Paper1.pdf. Vindhya, U. 2000. Dowry deaths in Andhra Pradesh, India. Violence Against Wom 6:1085–108. Weinsheimer, R. L., C. R. Schermer, L. H. Malcoe, L. M. Balduf, and L. A. BloomfieldA. 2005. Severe intimate partner violence and alcohol use among female trauma patients. The J Traum 58:22–9. Whitaker, D. J., T. Haileyesus, M. Swahn, and L. S. Saltzman. 2007. Differences in frequency of violence and reported injury between relationships with reciprocal and nonreciprocal intimate partner violence. Am J Public Health 97:941–7. Wiltsey, M. T. 2008. Risk factors for intimate partner homicide. Doctoral Dissertation. Retrieved January 30, 2013 from http://idea.library.drexel.edu/bitstream/1860/ 2713/1/Wiltsey_Michael.pdf World Health Organization/London School of Hygiene and Tropical Medicine. 2010. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: World Health Organization. Retrieved February 10, 2013 from http://www.who.int/violence_injury_prevention/ publications/violence/9789241564007_eng.pdf
