Violence Against Widows in Nepal: Experiences, Coping Behaviors, and Barriers in Seeking Help

Understanding Nepali widows' experiences for the adaptation of an instrument to assess Prolonged Grief Disorder

The experience of grief varies across different cultures and contexts. Women in Nepal who lose their husbands confront discrimination, social isolation, and abuse that influence their experience of grief. Through eight focus group discussions with Nepali widows, we elicited socially sanctioned grief reactions and local idioms used to describe common cognitive, behavioral, and emotional symptoms of grief. Accordingly, modifications to an existing instrument for Prolonged Grief Disorder, the PG-13, are suggested to capture grief symptoms as experienced by Nepali widows. Items in the PG-13 were translated to colloquial Nepali and adapted to maintain comprehensibility, acceptability, relevance, and completeness. Based on the grief-related issues reported in the focus group discussions, the addition of five new items and a new criterion to capture symptoms related to social discrimination are proposed. Widows perceived elevated symptoms one year after the loss to be problematic. It is thus recommended that the duration criterion in the original PG-13 be adjusted from at least six months to at least one year after the loss. These proposed modifications to the instrument should be validated through future psychometric testing.

Social determinants of impaired functioning among Nepali widows: A mixed methods study

Despite considerable stigmatisation of widows in Nepal, little is known about factors affecting their ability to function in society. Using mixed methods, we studied psychosocial factors associated with impaired functioning among Nepali widows. For the qualitative analysis, we analysed 3 focus groups, 25 in-depth interviews, and 12 key-informant interviews. The quantitative analysis was based on data from 204 widows. Odds ratios were calculated linking psychosocial exposures to impaired functioning using adjusted logistic regression models. Low social support (aOR = 2.35, 95% CI: 1.2, 4.6, generally; aOR = 3.3, 95% CI: 1.7, 6.42, specifically from family members), experiences of discrimination (aOR = 2.97, 95% CI: 1.43, 6.14), and low life control (aOR = 4.3, 95% CI: 1.86, 10.1) were risk factors for impaired functioning. Qualitative findings suggested how discrimination and lack of control contribute to impaired functioning. Support from the husband's family appeared to be more important to a widow's functioning, compared to from her own parents. Knowledge about risk factors for impaired functioning can help inform interventions for Nepali widows.

Violence against women from partners and other household members during COVID-19 in Burkina Faso and Kenya

Background

Global evidence indicates increases in gender-based violence (GBV) during the COVID-19 pandemic following mitigation measures, such as stay at home orders. Indirect effects of the pandemic, including income loss, strained social support, and closed or inaccessible violence response services, may further exacerbate GBV and undermine help-seeking. In Kenya and Burkina Faso, as in many settings, GBV was prevalent prior to the COVID-19 pandemic. Studies specific to COVID-impact on GBV in Kenya indicate mixed results and there remains a lack of evidence from Burkina Faso. Our study takes a comprehensive lens by addressing both intimate partner violence (IPV) and non-partner household abuse through the COVID-19 pandemic in two priority settings.

Methods

Annual, national cross-sections of women ages 15–49 completed survey data collection in November–December 2020 and December 2020–March 2021; the GBV module was limited to one woman per household [Kenya n = 6715; Burkina n = 4065]. Descriptive statistics, Venn diagrams, and logistic and multinomial regression characterized prevalence of IPV and other household abuse, frequency relative to the COVID-19 pandemic, help-seeking behaviors, and predictors of IPV and household abuse across the socioecological framework.

Results

In both settings, past-year IPV prevalence exceeded non-partner household abuse (Kenya: 23.5%_IPV, 11.0%_household; Burkina Faso: 25.7%_IPV, 16.2%_household). Over half of those affected in each setting did not seek help; those that did turned first to family. Among those with past-year experiences, increased frequency since COVID-19 was noted for IPV (16.0%_{Burkina Faso}; 33.6%_Kenya) and household violence (14.3%_{Burkina Faso}; 26.2%_Kenya). Both context-specific (i.e., financial autonomy in Burkina Faso) and universal (i.e., COVID-related income loss) risk factors emerged.

Conclusion

Past-year IPV and household violence against women in Kenya and Burkina Faso were prevalent, and in some cases, intensified during the COVID-19 pandemic. Across settings, help-seeking from formal services was notably low, likely reflecting shame, blame, and stigmatization identified as barriers in pre-COVID literature. Both primary prevention and survivor-centered support services, including those related to economic empowerment, should be integrated within COVID-recovery efforts, and extended into the post-pandemic period to fully meet women’s safety needs.

Lived Experiences of Widows of Armed Conflict in Kashmir: A Qualitative Study

Armed conflicts create significant risks on almost every section of the society, as new forms of violence arise and the existing ones get exaggerated. In Kashmir, the long-standing conflict has resulted in the number of widows, orphans and enforced disappearance; however, little in-depth attention has been given in the literature on widows to the impact of this conflict. This present study examined the lived experiences of Kashmiri widows who had lost their husbands to the on-going conflict. Using the snowball sampling approach, 12 women were recruited for the face-to-face in-depth interviews. The findings of the study gained an in-depth understanding of the experiences of violence, deprivation, social stigma and psychological trauma, followed by their strategies for coping and struggle for justice. Widows are the worst hit victims of armed conflict and, therefore, inclusive interventions are needed to enhance the status of widows in a long run.

Adaptation and psychometric validation of the Prolonged Grief Disorder scale among widows in central Nepal

BACKGROUND

Symptoms of grief vary by culture and societal reactions to death may be gender specific. We aimed to validate a Nepali language version of the Prolonged Grief-13 item scale (PG-13) among widows.

METHODS

We tested two adapted versions of a Prolonged Grief Disorder (PGD) instrument with 204 Nepali-speaking widows: one was a Nepali translation of the original PG-13 items, while the other contained five additional items derived from qualitative research. We evaluated internal consistency, factor structure, and construct and criterion validity.

RESULTS

Participants were on average 44 years old (SD=9.3), completed 6.7 years of school (SD=3.3) and had survived their husbands by 10 years (SD=8.1). Thirteen percent met global criteria for PGD. The removal of one original PG-13 item (felt emotionally numb) from both versions due to poor discriminant validity resulted in 12- and 17-item versions. Exploratory factor analysis supported a one-factor structure for the PG-12 and PG-17. Both versions of the scale exhibited high internal consistency (0.89 and 0.93 respectively). Confirmatory factor analysis suggested that symptoms of PGD were distinct from post-traumatic stress disorder (PTSD), anxiety and depressive symptoms. The PG-12 had lower sensitivity (74.1%) but higher specificity (83.6%) compared to the PG-17 (81.5% and 73.5% respectively).

LIMITATIONS

Psychosocial counselors' clinical interview global ratings were used as the standard for comparison in criterion validity analyses. Generalizability to other socio-cultural (e.g. non-widowed, low-caste) populations and men in Nepal cannot be assumed.

CONCLUSIONS

Results indicate satisfactory psychometric properties and validity of both versions of the PG instruments, supporting their use with Nepali speaking widows.

Feasibility of implementing a culturally adapted Prolonged Grief Disorder scale in the mental healthcare system in Nepal

BACKGROUND

Nepali widows have a high prevalence of mental disorders, including prolonged grief disorder (PGD). Despite the considerable needs that Nepali widows have for mental health services, resources for mental health in Nepal are limited, amplifying the importance of accurate screening and diagnosis. The objective of this study was to explore the feasibility of implementing a culturally adapted Prolonged Grief Scale (PG-12/17-N) and provide actionable recommendations for its implementation.

METHODS

Twenty-five mental health service providers in Kathmandu and Chitwan, Nepal were interviewed using a semi-structured guide based on selected constructs from the Consolidated Framework for Implementation Research. Qualitative data were inductively and deductively coded and analyzed to identify prominent themes.

RESULTS

Providers reported that the main advantages of the scale were the need to identify widows at risk, cultural relevance, easy language, and inclusion of detailed and specific symptoms. Perceived weaknesses included the complexity in response options and scoring, length, item redundancy, overlap with depression symptoms, and lack of somatic symptoms. Providers discussed the need for training, supervision, and a referral and detection system required to implement the scale in Nepal. Further development of a brief version of the scale as a routine screener may facilitate detection and referral to care.

CONCLUSION

Based on the results showing need to address PGD in Nepali widows, further efforts are needed to increase awareness about PGD and develop evidence-supported treatments for PGD, after which screening could be made routine for widows.

Suicidal ideation among Nepali widows: an exploratory study of risk factors and comorbid psychosocial problems

PURPOSE

Suicide is a leading cause of death among Nepali women of reproductive age. Suicidal ideation has known associations with stressful life events, which Nepali widows disproportionately experience. We aimed to identify risk and protective factors that could lead to effective interventions for this population.

METHODS

To study suicidal ideation in Nepali widows, we collected data from 204 women in urban, semi-urban, and rural areas whose husbands died at least one year prior. The questionnaire included sociodemographic information, the Hopkins Symptom Checklist-25, PTSD Checklist-Civilian Version, Somatic Symptom Scale-8, and the Multidimensional Scale of Perceived Social Support. Overall severity of prolonged grief was assessed by a counselor after completing a structured clinical interview. Using multivariate regression models, we assessed associations of sociodemographic and psychosocial indicators with past-year suicidal ideation. Latent profile analysis was also performed to estimate profiles of comorbidities.

RESULTS

Past-year suicidality was high, with 16.2% (N = 33). Each year increase since husband's death was protective and reduced odds of ideation 8% (95% CI 0.85-0.98) and being educated and of older age also reduced the odds of ideation by 0.21 (95% CI 0.06-0.70), and 0.09 (95% CI 0.01-0.64), respectively. Depression (OR = 6.37, 95% CI 2.78-14.59), PTSD (OR = 3.84, 95% CI 2.15-6.86), prolonged grief (OR = 6.04, 95% CI 3.04-12.00) and anxiety (OR = 6.52, 95% CI 2.96-14.38) were highly associated with suicidality, and mapped onto the three profiles of increasing mental distress severity.

CONCLUSION

Suicide remains a major issue among Nepali widows, showing high comorbidity with other mental disorders. Screening for depression, anxiety, and prolonged grief, may aid in identifying widows at increased risk of suicidal ideation.

Resilience Among Nepali Widows After the Death of a Spouse: "That Was My Past and Now I Have to See My Present"

Responses to the death of a spouse vary; although some are at increased risk of poorer physical and mental health outcomes, others have more resilient responses. In light of the limited scope of research on widows' experiences in Nepal, a setting where widows are often marginalized, we explore themes of resilience in Nepali widows' lives. Drawing from a larger qualitative study of grief and widowhood, a thematic narrative analysis was performed on narratives from four widows that reflected resilient outcomes. Individual assets and social resources contributed to these widows' resilient outcomes. Forgetting, acceptance, and moving forward were complemented by confidence and strength. Social support and social participation were key to widows' resilient outcomes. These four narratives reflect the sociocultural context that shape widows' resilient outcomes in Nepal. Future studies on the emergent themes from this exploratory study will help identify how best to encourage resilient outcomes among widows.

Persistent Complex Bereavement Disorder and Culture: Early and Prolonged Grief in Nepali Widows

OBJECTIVE

Persistent complex bereavement disorder (PCBD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has not been well studied in socioculturally diverse populations. Thus, this qualitative study examined (a) how widows in Nepal understand grief, (b) whether a local construct of PCBD exists, and (c) its comparability with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), terminology.

METHODS

Using an adapted Explanatory Model Interview Catalogue (EMIC) framework, semistructured interviews with 25 widows and 12 key informants, as well as three focus-group discussions (n = 20), were conducted between October 2014 and April 2015. Through an inductive grounded theory-based approach, we used the constant comparative method, iteratively coding transcripts to identify themes and patterns in the data. Also, we created two lists of grief responses, one of early reactions and another all reactions to grief, based on the frequency of mention.

RESULTS

No single term for grief was reported. Widows reported a local construct of PCBD, which was broadly compatible with DSM-5 terminology but with important variation reflecting societal influence. Surviving torture during conflict, economic and family stressors, and discrimination were mentioned as important determinants that prolong and complicate grief. Suicidal ideation was common, with about 31% and 62% of widows reporting past-year and lifetime suicidality, respectively. Findings may not be generalizable to all Nepali widows; participants were recruited from a non-governmental organization, from Kathmandu and its neighboring districts, and were primarily of reproductive age.

CONCLUSIONS

While PCBD symptoms proposed in DSM-5 were mentioned as relevant by study participants, some components may need adaptation for use in non-Western settings, such as Nepal.