Community interventions to prevent violence against women and girls in informal settlements in Mumbai: the SNEHA-TARA pragmatic cluster randomised controlled trial

The Wall of Silence: Perceived Barriers to Gender-Based Violence Disclosure among Women in the Perinatal Period

STUDY BACKGROUND

Gender-based violence is a global concern. The perinatal period is a crucial time for early identification of the harmful impact of violence on the well-being of both mothers and infants. However, it has been observed that many women choose not to disclose their experiences to their healthcare providers.

PURPOSE

To gain insight into this issue, a study was conducted to explore the perspectives of both survivors and healthcare providers regarding the barriers to disclosure.

METHODS

Through the utilization of a thematic analysis approach, a total of 28 interviews were conducted, involving 12 survivors and 16 healthcare providers.

RESULTS

Data analysis revealed barriers to disclosure at the individual, community, and healthcare system levels.

CONCLUSION

Health-care providers have a pivotal role in creating an atmosphere where women are encouraged to break the silence and a paradigm shift in the health system approach towards GBV is necessary.

Prevalence and risk factors of physical violence against husbands: evidence from India

As the proportion of women being victims of spousal violence in India is higher than men, laws are usually framed to safeguard women. However, men who have experienced physical spousal violence are not unheard of. The study aims to provide the nationwide prevalence of physical violence against husbands and the risk factors for such violence, using large-scale nationally representative 'National Family Health Survey' (NFHS 4) data. The study used descriptive, bivariate, logistic, and multilevel regression models with a random intercept clustering within states and households to explain the physical violence against husband. Sample size for the analysis was 62,716 currently married women aged 15-49 years. Findings revealed that in most of the states of India, physical spousal violence has increased over time. Behavioural characteristics like marital control, alcoholism, and childhood experience of parental violence have a consistent and strong role in explaining the experience of physical violence across states. With age, experience of violence against husbands increases. Differences in socio-economic characteristics do not have unidirectional effect on violence experienced by husbands across regions of India. Working women who are earning cash and having access to mobile phones perpetrate more physical violence in selected regions. Education shows a gradient on such violence perpetration, indicating that only after achieving a certain level of education, chances of violence reduce. Regionally contrasting social and economic risk factors in explaining violence strengthen the argument that violence is space and culture-specific, and development alone may not resolve violence unless the system is addressing the behavioural aspects. There is a need for supporting men experiencing domestic violence within the existing system facilities. Revisiting the present domestic violence laws and programmes for inclusivity is the need of the hour.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Healthcare Providers' Perceptions and Experiences of Training to Respond to Violence against Women: Results from a Qualitative Study

Healthcare providers (HCPs) can support women affected by violence, providing a safe way for women to disclose experiences of violence and mitigating violence against women (VAW) through the identification of cases in routine clinical practice. We conducted in-depth interviews and focus group discussions with HCPs in three tertiary facilities in Maharashtra, India, who had participated in training using the World Health Organization curriculum, adapted for the Indian context. n = 21 HCPs participated in in-depth interviews and n = 10 nurses participated in two focus group discussions. The respondents indicated that the training approach and content were acceptable and that the skills learned during the training were feasible to implement. A shift in perspective from viewing VAW as a private issue to understanding it as a health issue facilitated HCPs' response. The training enabled HCPs to recognize barriers faced by women in disclosing violence and their role in supporting disclosure. HCPs reported barriers to providing care for survivors of violence, including a lack of human resources, the time during regular clinical practice, and a lack of strong referral networks. These data can be utilized to inform other efforts to train HCPs in facilities in this setting and provide evidence for ways to improve health systems' responses to VAW in low-and middle-income country settings.

Love Shouldn't Hurt - E le Sauā le Alofa: Co-designing a theory of change for preventing violence against women in Samoa

Despite the widespread adoption of Theories of Change (ToC) for programme evaluation, the process of collaboratively developing these theories is rarely outlined or critical analysed, limiting broader methodological discussions on co-production. We developed a ToC as part of E le Sauā le Alofa ('Love Shouldn't Hurt') - a participatory peer-research study to prevent violence against women (VAW) in Samoa. The ToC was developed in four phases: (1) semi-structured interviews with village representatives (n = 20); (2) peer-led semi-structured interviews with community members (n = 60), (3) community conversations with 10 villages (n = 217) to discuss causal mechanisms for preventing VAW, and (4) finalising the ToC pathways. Several challenges were identified, including conflicting understandings of VAW as a problem; the linearity of the ToC framework in contrast to intersecting realities of people's lived experiences; the importance of emotional engagements, and theory development as a contradictory and incomplete process. The process also raised opportunities including a deeper exploration of local meaning-making, iterative engagement with local mechanisms of violence prevention, and clear evidence of ownership by communities in developing a uniquely Samoan intervention to prevent VAW. This study highlights a clear need for ToCs to be complemented by indigenous frameworks and methodologies in post-colonial settings such as Samoa.

Domestic Coercive Control and Common Mental Disorders Among Women in Informal Settlements in Mumbai, India: A Cross-Sectional Survey

Coercive control behaviors central to the abuse of power appear more frequent than other types of domestic violence, but little is known about its frequency, features, and consequences for women in India. We aimed to examine the prevalence of domestic coercive control and its association with physical, sexual, and emotional domestic violence in the preceding year and symptoms of depression, anxiety, and suicidal thinking. In a cross-sectional survey, we interviewed 4,906 ever-married women aged 18-49 years living in urban informal settlements in Mumbai, India. We developed a 24-item scale of coercive control, assessed physical, sexual, and emotional violence using existing questions, and screened for symptoms of depression with the Patient Health Questionnaire (PHQ9), anxiety with the Generalized Anxiety Disorder (GAD7) questionnaire, and suicidal thinking with questions developed by the World Health Organization. Estimates involved univariable and multivariable logistic regression models and the prediction of marginal effects. The prevalence of domestic coercive control was 71%. In total, 23% of women reported domestic violence in the past 12 months (emotional 19%, physical 13%, sexual 4%). Adjusted models suggested that women exposed to controlling behavior had greater odds of surviving emotional (aOR 2.1; 95% CI 1.7, 2.7), physical (1.4; 1.0, 1.9), and sexual (1.8; 1.1, 3.0) domestic violence in the past 12 months; and higher odds of a positive screen for moderate or severe depression (1.7; 1.3, 2.2), anxiety (2.1; 1.3, 3.1), and suicidal thinking (1.7; 1.2, 2.3), and increased with each additional indicator of coercive control behavior. When women reported 24 indicators of coercive control, the adjusted predicted proportion with moderate or severe depressive symptoms was 60%, anxiety 42%, and suicidal thinking 17%. Inclusion of coercive control in programs to support domestic violence, would broaden our understanding of domestic abuse to resemble most victims experience and improve interventions.

Mechanisms for community prevention of violence against women in low- and middle-income countries: A realist approach to a comparative analysis of qualitative data

Growing evidence suggests that community-based interventions in low- and middle-income countries (LMICs) can effectively address harmful social norms that promote or sustain gender inequality and drive violence against women (VAW). However, understanding what actions communities are already taking to address harmful social norms and prevent VAW is an essential first step for intervention development. Towards this goal, drawing on collective action theory, we conducted a realist analysis of secondary qualitative data collected with communities in India, Afghanistan, Peru and Rwanda. We coded interview and focus-group data from 232 participants to identify the contexts, mechanisms and outcomes (CMO) relevant for community action. We synthesized CMO configurations from each dataset into a conceptual framework composed of three middle-range theories of mechanisms driving community action to prevent VAW in LMICs. Our results highlight the importance of dedicated spaces for discussing VAW, VAW leaders as positive role models, and community perceptions of VAW as a problem worthy of intervention. In Rwanda and Peru, there was strong evidence to support the operation of these mechanisms. Contextual factors, including national and local policy and programmes targeting VAW, activated mechanisms that led to community action. In India and Afghanistan, evidence for the presence of these mechanisms was weaker, with social norms about women's position and violence being a private family matter preventing communities from addressing violence. Despite contextual differences, our data demonstrated communities in all four settings were somewhere along a pathway of change towards VAW prevention. This supports the need to build future prevention interventions on pre-existing mechanisms that trigger community action, rather than implementing existing interventions without local adaptation. Our conceptual framework serves as a tool for assessing these mechanisms of community action as part of intervention development research, centring community knowledge and fostering local ownership for more relevant and sustainable VAW prevention interventions.

Intimate partner violence against women with disability and associated mental health concerns: a cross-sectional survey in Mumbai, India

OBJECTIVES

The risk of intimate partner violence (IPV) against women with disability is believed to be high. We aimed to compare the prevalence of past-year IPV against women with and without functional difficulties in urban informal settlements, to review its social determinants and to explore its association with mental health.

DESIGN

Cross-sectional survey.

SETTING

Fifty clusters within four informal settlements.

PARTICIPANTS

5122 women aged 18-49 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used the Washington Group Short Set of Questions to assess functional difficulties. IPV in the past year was described by binary composites of questions about physical, sexual and emotional violence. We screened for symptoms of depression using the Patient Health Questionnaire-9 and of anxiety using the Generalised Anxiety Disorder-7. Multivariable logistic regression models examined associations between functional difficulties, IPV and mental health.

RESULTS

10% of participants who screened positive for functional disability had greater odds of experiencing physical or sexual IPV (adjusted OR (AOR) 1.68, 95% CI 1.23 to 2.29) and emotional IPV (1.52, 95% CI 1.16 to 2.00) than women who screened negative. Women who screened positive for functional disability had greater odds than women who screened negative of symptoms suggesting moderate or severe anxiety (AOR 2.50, 95% CI 1.78 to 3.49), depression (2.91, 95% CI 2.13 to 3.99) and suicidal thinking (AOR 1.94, 95% CI 1.50 to 2.50).

CONCLUSIONS

The burden of IPV fell disproportionately on women with functional difficulties, who were also more likely to screen positive for common mental disorder. Public health initiatives need to respond at local and national levels to address the overlapping and mutually reinforcing determinants of violence, while existing policy needs to be better utilised to ensure protection for the most vulnerable.

Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

BACKGROUND

Across the globe, gender disparities still exist with regard to equitable access to resources, participation in decision-making processes, and gender and sexual-based violence. This is particularly true in fragile and conflict-affected settings, where women and girls are affected by both fragility and conflict in unique ways. While women have been acknowledged as key actors in peace processes and post-conflict reconstruction (e.g., through the United Nations Security Council Resolution 1325 and the Women, Peace and Security Agenda) evidence on the effectiveness of gender-specific and gender-transformative interventions to improve women's empowerment in fragile and conflict-affected states and situations (FCAS) remains understudied.

OBJECTIVES

The purpose of this review was to synthesize the body of evidence around gender-specific and gender-transformative interventions aimed at improving women's empowerment in fragile and conflict-affected settings with high levels of gender inequality. We also aimed to identify barriers and facilitators that could affect the effectiveness of these interventions and to provide implications for policy, practice and research designs within the field of transitional aid.

METHODS

We searched for and screened over 100,000 experimental and quasi-experimental studies focused on FCAS at the individual and community levels. We used standard methodological procedures outlined by the Campbell Collaboration for the data collection and analysis, including quantitative and qualitative analyses, and completed the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to assess the certainty around each body of evidence.

RESULTS

We identified 104 impact evaluations (75% randomised controlled trials) assessing the effects of 14 different types of interventions in FCAS. About 28% of included studies were assessed as having a high risk of bias (45% among quasi-experimental designs). Interventions supporting women's empowerment and gender equality in FCAS produced positive effects on the outcomes related to the primary focus of the intervention. There are no significant negative effects of any included interventions. However, we observe smaller effects on behavioural outcomes further along the causal chain of empowerment. Qualitative syntheses indicated that gender norms and practices are potential barriers to intervention effectiveness, while working with local powers and institutions can facilitate the uptake and legitimacy of interventions.

CONCLUSIONS

We observe gaps of rigorous evidence in certain regions (notably MENA and Latin America) and in interventions specifically targeting women as actors of peacebuilding. Gender norms and practices are important elements to consider in programme design and implementation to maximise potential benefits: focusing on empowerment only might not be enough in the absence of targeting the restrictive gender norms and practices that may undermine intervention effectiveness. Lastly, programme designers and implementation should consider explicitly targeting specific empowerment outcomes, promoting social capital and exchange, and tailoring the intervention components to the desired empowerment-related outcomes.

Social and Psychological Readiness to Take Collective Action Against Violence Against Women: A Mixed Methods Study of Informal Settlements in Mumbai, India

Past failures to mobilize communities in collective action against violence against women (VAW) have been ascribed to contextual challenges, but researchers have not systematically mapped community capacity for collective action against VAW. We conducted a mixed methods study in Mumbai, India using quantitative data from a household survey (n = 2,642) and qualitative data from 264 community meetings. We found attitudes supporting gender inequality and violence coexisted with significant enthusiasm and support for collective action against VAW. These findings open up avenues for policymakers to treat communities as less vulnerable and more capable of changing situations and problems that affect them.

mHealth for Anemia Reduction: Protocol for an Entertainment Education-Based Dual Intervention

Background

More than half of the women of reproductive age (aged 15-49 years) are anemic in India. The uptake of and adherence to iron folic acid (IFA) supplements remain low despite sustained efforts to increase their use. With India’s burgeoning digital environment, mobile phones offer a potential medium for increasing their uptake, especially when combined with interactive voice messages that deliver entertaining stories infused with norms-based educational messages.

Objective

This study aims to investigate whether a norms-based entertainment education mobile health intervention can increase self-efficacy for IFA adherence among women of reproductive age in Odisha, India.

Methods

Mobile reduction in anemia through normative innovations (mRANI) is a randomized 2-arm study that includes assessments before and after the intervention. All study participants will be recruited from the intervention arm of the parent reduction in anemia through normative innovations trial only. Although the usual practice is to randomize participants either to a treatment arm or a usual care control arm, we will assign the mRANI control group to another entertainment education–based treatment group that is designed to improve bystander intervention to reduce violence against women. Data collection for the mRANI study is embedded in the parent trial and will include baseline and end line assessments. The primary outcomes are self-efficacy for IFA adherence and violence against women–related bystander intervention. The inclusion criteria for the mRANI study are participation in the parent trial and phone ownership. Women (approximately n=400) who meet the mRANI inclusion criteria will be randomly assigned to the IFA arm or the bystander arm. Ordinary least squares regression with robust SEs will be conducted to assess between-group comparisons at the end line. A mediation analysis will be conducted to examine whether social norms and interactivity mediate the relationship between intervention exposure and primary outcomes in both arms. Real-time monitoring data will offer insights into intervention receptivity and audience engagement.

Results

Data collection for the mRANI study is integrated within the parent trial. Household surveys were conducted between February and March of 2021. Responses on the mRANI study’s primary and secondary outcomes were collected from 381 participants. The data analysis is expected to be completed by October 2021.

Conclusions

This study will provide evidence on whether a mobile health norms–based entertainment education intervention can increase self-efficacy for IFA adherence and violence against women–related bystander intervention.

International Registered Report Identifier (IRRID)

PRR1-10.2196/26252

Optimal design of cluster randomized trials allowing unequal allocation of clusters and unequal cluster size between arms

There are sometimes cost, scientific, or logistical reasons to allocate individuals unequally in an individually randomized trial. In cluster randomized trials we can allocate clusters unequally and/or allow different cluster size between trial arms. We consider parallel group designs with a continuous outcome, and optimal designs that require the smallest number of individuals to be measured given the number of clusters. Previous authors have derived the optimal allocation ratio for clusters under different variance and/or intracluster correlations (ICCs) between arms, allowing different but prespecified cluster sizes by arm. We derive closed-form expressions to identify the optimal proportions of clusters and of individuals measured for each arm, thereby defining optimal cluster sizes, when cluster size can be chosen freely. When ICCs differ between arms but the variance is equal, the optimal design allocates more than half the clusters to the arm with the higher ICC, but (typically only slightly) less than half the individuals and hence a smaller cluster size. We also describe optimal design under constraints on the number of clusters or cluster size in one or both arms. This methodology allows trialists to consider a range for the number of clusters in the trial and for each to identify the optimal design. Except if there is clear prior evidence for the ICC and variance by arm, a range of values will need to be considered. Researchers should choose a design with adequate power across the range, while also keeping enough clusters in each arm to permit the intended analysis method.

Decolonising violence against women research: a study design for co-developing violence prevention interventions with communities in low and middle income countries (LMICs)

BACKGROUND

There has been substantial progress in research on preventing violence against women and girls (VAWG) in the last 20 years. While the evidence suggests the potential of well-designed curriculum-based interventions that target known risk factors of violence at the community level, this has certain limitations for working in partnership with communities in low- and middle-income (LMIC) countries, particularly when it comes to addressing the power dynamics embedded within north-south research relationships.

METHODS

As an alternative approach, we outline the study design for the EVE Project: a formative research project implemented in partnership with community-based researchers in Samoa and Amantaní (Peru) using a participatory co-design approach to VAWG prevention research. We detail the methods we will use to overcome the power dynamics that have been historically embedded in Western research practices, including: collaboratively defining and agreeing research guidelines before the start of the project, co-creating theories of change with community stakeholders, identifying local understandings of violence to inform the selection and measurement of potential outcomes, and co-designing VAWG prevention interventions with communities.

DISCUSSION

Indigenous knowledge and ways of thinking have often been undermined historically by Western research practices, contributing to repeated calls for better recognition of Southern epistemologies. The EVE Project design outlines our collective thinking on how to address this gap and to further VAWG prevention through the meaningful participation of communities affected by violence in the research and design of their own interventions. We also discuss the significant impact of the COVID-19 pandemic on the project in ways that have both disrupted and expanded the potential for a better transfer of power to the communities involved. This article offers specific strategies for integrating Southern epistemologies into VAWG research practices in four domains: ethics, theories of change, measurement, and intervention design. Our aim is to create new spaces for engagement between indigenous ways of thinking and the evidence that has been established from the past two decades of VAWG prevention research and practice.

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

Economic abuse and its associations with symptoms of common mental disorders among women in a cross-sectional survey in informal settlements in Mumbai, India

BACKGROUND

Domestic violence takes a range of interconnected forms, of which economic abuse is common, but less studied than others. We examine the prevalence of economic abuse, its determinants, and its association with symptoms of depression, anxiety, and suicidal ideation.

METHODS

Our cross-sectional survey in informal settlement areas in Mumbai, India, asked women aged 18-49 years 15 questions about acquisition, use, and maintenance of economic resources, demographic and socioeconomic factors, and physical, sexual, and emotional violence. We administered the Patient Health Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7) scales and asked about suicidal thinking. Determinants of economic abuse and its associations with positive screens for depression and anxiety were explored in univariable and multivariable logistic regression models.

RESULTS

Of 4906 ever-married women respondents, 23% reported at least one form of economic abuse by either an intimate partner or another family member. The commonest were denial of property rights (10%), not being trusted with money (8%), and coercive appropriation of belongings (7%). Economic abuse was more commonly reported by widowed, separated, or divorced women than by married women (aOR 12.4; 95% CI 6.4, 24.1), and when their partners used alcohol or drugs (aOR 1.4; 95% CI 1.2-1.7). Women had greater odds of reporting economic abuse if they had suffered emotional (aOR 6.3; 95% CI 5.0-7.9), physical (aOR 1.9; 95% CI 1.4-2.6), or sexual violence (aOR 5.4; 95% CI 3.6-8.1) in the preceding 12 months. Economic abuse was independently associated with positive screens for moderate-severe depression (aOR 2.6; 95% CI 2.0-3.4), anxiety (aOR 2.7; 95% CI 1.9-3.8), and suicidal ideation (aOR 2.2; 95% CI 1.5-3.1). The odds of anxiety and depression increased with each additional form of economic abuse.

DISCUSSION

To our knowledge, this is the first community-based study in India of the prevalence of economic abuse and its associations with symptoms of common mental disorders. It provides empirical support for the idea that economic abuse is at least as harmful to women's mental health as physical violence. Surveys should include questions on economic abuse and prevention and intervention strategies need to help survivors to understand its forms.

Prevalence of domestic violence against women in informal settlements in Mumbai, India: a cross-sectional survey

OBJECTIVES

Domestic violence against women harms individuals, families, communities and society. Perpetrated by intimate partners or other family members, its overlapping forms include physical, sexual and emotional violence, control and neglect. We aimed to describe the prevalence of these forms of violence and their perpetrators in informal settlements in Mumbai.

DESIGN

Cross-sectional survey.

SETTING

Two large urban informal settlement areas.

PARTICIPANTS

5122 women aged 18-49 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence and perpetrators in the last year of physical, sexual and emotional domestic violence, coercive control and neglect. For each of these forms of violence, responses to questions about individual acts and composite estimates.

RESULTS

In the last year, 644 (13%) women had experienced physical domestic violence, 188 (4%) sexual violence and 963 (19%) emotional violence. Of ever-married women, 13% had experienced physical or sexual intimate partner violence in the last year. Most physical (87%) and sexual violence (99%) was done by partners, but emotional violence equally involved marital family members. All three forms of violence were more common if women were younger, in the lowest socioeconomic asset quintile or reported disability. 1816 women (35%) had experienced at least one instance of coercive control and 33% said that they were afraid of people in their home. 10% reported domestic neglect of their food, sleep, health or children's health.

CONCLUSIONS

Domestic violence against women remains common in urban informal settlements. Physical and sexual violence were perpetrated mainly by intimate partners, but emotional violence was attributed equally to partners and marital family. More than one-third of women described controlling behaviours perpetrated by both intimate partners and marital family members. We emphasise the need to include the spectrum of perpetrators and forms of domestic violence-particularly emotional violence and coercive control-in data gathering.

TRIAL REGISTRATION NUMBER

ISRCTN84502355; Pre-results.

Violence against women in urban slums of India: A review of two decades of research

It is estimated that about one-third of women ever experienced violence in their lifetime. India has experienced steady urban growth accompanying increase of urban populations living in slums. Several studies have reported prevalence of various forms of violence in urban slums. To our knowledge, no systematic review has been conducted exclusively reporting violence against women in India's urban slums. The review aims to synthesise the studies of violence against women conducted in the last two decades (2000-2020). We searched PubMed, Scopus and other relevant search engines to identify articles published between years 2000 and 2020, which focused on Indian women slum dwellers' experiences of violence. We included 14 studies, which satisfied the inclusion criteria in this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was used to assess the studies. The prevalence of any form of violence against women, as reported in the studies, ranged from 15% to 59.3%. The major risk factors identified were husband's alcohol abuse, women justifying the violence inflicted on then, low educational levels of both women and men, dowry issues, age difference between the spouses and termination of a previous pregnancy. It is evident from the review that urban slum women experience persistent violence.

Using Participatory Learning and Action in a Community-Based Intervention to Prevent Violence Against Women and Girls in Mumbai's Informal Settlements

For over 3 decades, participatory learning and action (PLA) techniques have been prominent in formative and evaluative studies in community-based development programs in the Global South. In this paper, we describe and discuss the use of PLA approaches at the beginning of a community-based program for prevention of violence against women and girls in Mumbai's urban informal settlements. We adapted six PLA techniques as part of a formative community mobilization and rapid needs assessment exercise, addressing perceptions of violence prevalence, sources of household conflict, experiences of safety and mobility, access to services, preferences for service and support, and visualization of an ideal community free from violence. We describe the collaborative process of developing and implementing PLA techniques and discuss its relevance in generating contextual and grounded understandings of violence as well as in identifying factors which can potentially enable and constrain interventions.

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.919; root mean square error of approximation, 0.036; weighted root mean square residual, 1.949). Comparison of multi-group models across gender, education, caste, and marital status showed little evidence against measurement invariance. Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts.

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.920; root mean square error of approximation, 0.035; weighted root mean square residual, 1.952). Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts.