Intimate Partner Violence and Mental Health Problems in Married Women in Rural Central India: A Community-based Cross-sectional Study

Abstract

Intimate partner violence (IPV) is a significant social issue affecting women in rural India, with deleterious consequences for their physical and mental health. The “mental health problems and psychosocial factors associated with IPV” is an under-researched topic in Central India. The cross-sectional observational descriptive study was part of a project aimed at strengthening the health sector response to gender-based violence. Eighty consenting women from 19 villages in a district in Central India, who acknowledged experiencing IPV, participated in the study. A predesigned and pretested sociodemographic questionnaire, the WHO multicountry women’s questionnaire, and self-report scales for depression, anxiety, stress, and post-traumatic stress disorder (PTSD) were used to interview the women. The mean age of the respondents was 31.13 ± 6.96 years. The majority of the women (95%) experienced severe physical violence. In addition, a majority of these women simultaneously faced emotional abuse, whereas more than one-third suffered from sexual abuse from their partners. Self-reporting measures showed that nearly two-thirds of the participants had PTSD and moderate-to-severe depression and anxiety. A substantial number of study participants believed that IPV is a private matter for a couple and justified violence if the wife was unfaithful, disobedient, or neglectful of children and household duties. The under-reporting of IPV, presence of misconceptions, and high prevalence of associated mental health problems among IPV-affected women highlight the need for interventions tailored to the needs of battered women.

INTRODUCTION

Intimate partner violence (IPV), encompassing physical, psychological, or sexual abuse inflicted by a husband or male partner, constitutes a significant social issue in India.[1] According to the National Family Health Survey-5, the prevalence of intimate partner violence among married Indian women stands at 29.3%.[2] Among the various forms of domestic violence, physical violence ranks highest at 29.2%, followed by emotional violence at 13.2% and sexual violence at 6.7%.[3] IPV has been linked to adverse outcomes including physical injuries, reduced access to healthcare services, and mental health disorders such as depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation and attempts.[4,5,6] Research indicates that more than half of women experiencing physical or sexual violence suffer from PTSD,[7] with depression also commonly co-occurring and significantly correlating with PTSD. Depression can exacerbate vulnerability to further violence by impairing social and occupational functioning.[8,9]

Understanding the patterns of IPV, women’s responses, psychosocial factors, and associated mental health issues among rural women in Central India is crucial for developing tailored awareness and management strategies. Hence, this study aims to describe the forms and characteristics of IPV and associated mental health problems among rural women.

METHODOLOGY

This research was part of the project titled “Strengthening Health Sector Response to Gender-Based Violence During the COVID-19 Pandemic,” which was conducted in seven tertiary-level hospitals across various regions of India. It entailed a cross-sectional, observational descriptive study performed by the Department of Community Medicine at a rural tertiary healthcare center in a district in Central India. The study commenced after approval from the institutional ethics committee, and data collection was undertaken by two clinical psychologists, one male and one female, specifically recruited for this purpose.

The public health system in the district comprises 27 primary healthcare centers and 81 subcenters dedicated to providing healthcare services to the rural populace. Accredited Social Health Activist (ASHA) from all subcenters identified women they knew to be experiencing intimate partner violence (IPV) and shared their names with the clinical psychologists. Subsequently, the psychologists visited these women’s households and extended invitations to participate in the study. Eighty women residing in 19 villages across the district, who acknowledged experiencing violence and consented to be interviewed, were included in the study.

The interview

The women were interviewed using the WHO multicountry study women’s questionnaire for IPV and validated self-report scales for stress, depression, anxiety, and post-traumatic stress disorder. The average duration required for completing the interview of one woman was nearly two hours. The data were electronically entered in Google Forms during the interview.

Tools

WHO multicountry women’s questionnaire

The WHO multicountry women’s questionnaire comprises 11 sections and has been extensively standardized and validated across different countries in varied sociocultural contexts.[10]

Depression Anxiety and Stress Scale-21 (DASS-21)

The DASS-21 is a set of three self-report Likert-type scales with seven questions each, validated for the measurement of depression, anxiety, and stress.[11] Each item is scored in the range of zero (“Did not apply to me at all”) to three (“applied to me very much for most of the time”), and the summation of scores is used for final interpretation.

Impact of Events Scale-Revised version

The revised version of Impact of Events Scale (IES-R) is a 22-item Likert-type questionnaire previously validated for assessment of PTSD in the victims of violence.[12] The total score of 33 or above is considered the best cutoff for the presence of PTSD.

Statistical analysis

Data analysis was performed in Statistical Package for Social Sciences Software (SPSS version 23) for applying descriptive and inferential statistics. Nonparametric tests (Mann-Whitney U and Spearman rank-order correlation analysis) were used for the bivariate analysis of data.

RESULTS

Demographic characteristics

The mean age of the women was 31.13 ± 6.96 years, with the majority having received at least a primary school education (N = 79, 98.7%). In most cases, the women’s husbands were chosen by their parents, and approximately one-fifth (18.8%) of them were unaware of their partner’s choice in marriage. Sixty-six percent of the women reported giving dowry at the time of marriage, with half of them believing it had a positive impact on their married life, and the remaining half thinking dowry has no impact on married life. Notably, none of the women acknowledged the negative impact of dowry custom on married life (Tables provided in Supplementary Files).

Forms of intimate partner violence

Table 1 illustrates the instances of physical, sexual, and emotional violence perpetrated by the women’s intimate partners. Emotional violence was reported by 93.8% of the women, sexual violence by 38.8%, and economic violence by 85.5%. The majority of women reported experiencing slapping (98.8%), fist hits (93.8%), or pushing (82.5%) by their partners. More than half reported severe forms of violence such as kicking, dragging, choking, or burning, and a notable minority (10%) mentioned threats or use of weapons by their partners. Ninety-five percent of the reported violence was categorized as severe. A significant portion (36.3%) of these women were forced into sexual intercourse, and nearly a quarter (23.8%) engaged in sexual relations out of fear of violence. Among women engaged in income-generating activities, approximately one-fifth were forced to share their earnings with their partners, and a quarter (23.8%) were refused to continuing their work by their partner.

Table 1:

Types of intimate partner violence in women

Type of violence	Frequency (%) (n=80)
Physical violence	80 (100)
Emotional violence	75 (93.8)
Sexual violence	31 (38.8)
Economic violence	68 (85.5)
Acts of physical violence
Slapped or thrown something at person	79 (98.8)
Pushed/shoved with blunt object	66 (82.5)
Hit with fist	75 (93.8)
Kicking, dragging or beating up	45 (56.3)
Chocked or burnt on purpose	25 (31.3)
Use of weapon or threaten of the same	8 (10)
Acts of sexual violence
Forcing to have sexual intercourse	29 (36.3)
Women do sex out of fear of partner’s response to denial	19 (23.8)
Female has to do sexual act which she finds degrading or humiliating	3 (3.8)
Violence while being pregnant
Number of women admitting to have faced violence during present or past pregnancy	32 (41.6)
Partner kicked or punched in the abdomen	5 (6.3)
Violence increased during pregnancy	1 (3.1)
Violence reduced during pregnancy	15 (46.9)
Violence remained unchanged during pregnancy	16 (50)
Severity of violence
Moderate	4 (5)
Severe	76 (95)
Acts of emotional abuse by partner/husband
Insult	75 (93.8)
Belittlement/humiliation	70 (87.5)
Intimidation/scare	50 (62.5)
Threats of harm	28 (35)
Controlling behaviors of partner/husband
Keeps her from seeing friends	36 (45)
Restricts her contact with family	33 (41.3)
Insists on knowing where she is all the time	35 (43.8)
Ignores/treats her indifferently	41 (51.2)
Is suspicious that she is unfaithful	40 (50)
Gets angry is she speaks with others	38 (47.5)
Controls her access to healthcare	16 (20)
Autonomy to spend self-earned money (n=46)
Can spend full amount by self	33 (71.7)
Have to give a part to husband	9 (19.5)
Have to give all the money to the husband	4 (8.6)
Number of women who were refused to work by partner	19 (23.8)
Husband takes earnings of a woman forcibly against her will (n=80)
Once or twice	28 (35)
Several times	13 (16.3)
Many times	6 (7.5)
Husband does not give money for household expenses (n=80)
Once or twice	30 (37.5)
Several times	16 (20)
Many times	12 (15)
Women who feel they cannot raise enough money in case of an emergency (n=80)	68 (85)

*The severity of the violence has been calculated as per the responses to item 705. The women responding “yes” to 705 (a or b) and “no” to 705 (c-f) have been categorized as moderate violence and those with response in “yes” to 705 (c-f) have been categorized as severe violence

Injuries and physical problems in women because of IPV

Pain (46.3%) and dizziness (41.3%) were prevalent, with around 35% experiencing difficulty in walking and performing daily activities. Nearly 59% of women reported sustaining injuries because of partner violence, with burns, abrasions, bruises, and cuts being the most frequent. Although 68% of injured women sought healthcare services, only 20 women (42.5%) disclosed the real cause of their injuries to healthcare providers. (Tables provided in Supplementary Files)

Attitude and response of women toward IPV

The attitudes and responses of women to violence are presented in Table 2. More than half of the women experiencing domestic violence believed that family matters should remain within the family, and nearly one-third (31.3%) hesitated to seek intervention from individuals outside the family regarding domestic violence issues. A majority of the women (71.3%) believed that a husband is justified in resorting to violence if the wife is unfaithful in the relationship. Approximately 77% of the women disclosed their experiences of IPV to relatives and acquaintances, with parents being the most frequently approached (60%), followed by close friends (23.7%). Less than a quarter sought professional help from services such as health centers (22%) and police (12.5%). Fear of consequences (31.3%) and fear of jeopardizing the relationship (25%) were the most common reasons preventing women from seeking professional assistance.

Table 2:

Attitude and response of women to IPV

	Frequency (%) (n=80)
Attitude statement
A good wife obeys her husband even if she disagrees	26 (32.5)
Family matters should not be discussed outside the family	46 (57.5)
It is important for man to show his wife who is the boss	21 (26.3)
A woman should not be able to choose her own friends if the husband disagrees	27 (33.8)
It is wife’s obligation to have sex even if she does not want	21 (26.3)
If a man mistreats his wife outsiders should not intervene	25 (31.3)
Attitude Percentage of women who agree that a man has good reason to beat his wife if:
Wife does not complete household work	21 (26.3)
Wife disobeys her husband	23 (28.7)
Wife refuses sex	0 (0)
Wife asks her husband about other women	2 (2.5)
Husband suspects infidelity	5 (6.3)
Husband finds out that wife is unfaithful	57 (71.3)
Married woman can refuse sex if:
She does not want to	77 (96.3)
He is drunk	75 (93.8)
She is sick	80 (100)
He mistreats her	74 (92.5)
Response of women to domestic violence
Perceived effect of violence on physical or mental health
No effect	6 (7.5)
A little effect	32 (40)
A lot of effect	42 (52.5)
How does the violence affect work life?
No work life	27 (33.7)
Not disturbed	9 (11.2)
Interrupt the work by partner	1 (1.2)
Unable to concentrate	37 (46.2)
Unable to work/sick leave	18 (22.5)
Lost confidence in own ability	29 (36.2)
Who have you told about the violence?
No one	19 (23.7)
Friends	19 (23.7)
Parents	48 (60)
Brother/sister	10 (12.5)
Husband’s family	11 (13.7)
Neighbours	20 (25)
Use of services
Police	11 (13.8)
Health center	17 (21.3)
Social services	0
Legal services	0
Court	3 (3.8)
Shelter	0
Local leader	1 (1.3)
Women’s organization	7 (8.8)
Priest	0
Total	39 (48.7)
Reasons to seek help
Encouraged by friends and family	6 (7.5)
Could not endure more	24 (30)
Afraid he would kill her	16 (20)
He threatened to kill her	2 (2.6)
Saw that children suffering	1 (1.3)
Afraid she would kill him	1 (1.3)
Reasons not to seek help
Do not know	3 (3.7)
Fear of consequences	25 (31.2)
Violence not a problem	20 (25)
Embarrassed/ashamed	2 (2.6)
No hope of help	4 (5)
Fear of loss of relationship	20 (25)
Fear of losing children	5 (6.2)
Bring bad name to family	12 (15)

Mental health problems and the associated factors in victims of IPV

Table 3 presents the mental health problems encountered by the participants. Nearly 95% of women who experienced physical violence exhibited symptoms of depression on the DASS-21 scale. In addition to depression, 80% of women reported experiencing anxiety, and nearly 94% suffered from psychological distress. Post-traumatic stress disorder (PTSD) was observed in 68.8% of women, with 51.2% exhibiting severe symptoms. Depression was significantly associated with both physical (P value 0.021) and psychological forms of violence (P value 0.004), shared experiences (P value 0.007), and perceived financial inadequacy (P value 0.006). Women subjected to sexual violence (P value 0.017) and those reluctant to disclose family affairs to outsiders (P value 0.045) reported significantly higher anxiety scores on the DASS-21. Pregnancy (P value 0.045), having a partner with alcohol dependence (P value 0.002), considering domestic violence a private matter (P value 0.004), and experiencing sexual violence (P value 0.04) were significantly associated with PTSD. (Inferential statistics tables provided in Supplementary Files)

Table 3:

Mental health problems in women in domestic violence

	Frequency (%) (n=80)
Depression
None	5 (6.3)
Mild	20 (25.0)
Moderate	38 (47.5)
Severe	15 (18.8)
Extremely severe	2 (2.5)
Anxiety
None	16 (20.0)
Mild	7 (8.8)
Moderate	30 (37.5)
Severe	11 (13.8)
Extremely severe	16 (20.0)
Stress
None	5 (6.3)
Mild	20 (25.0)
Moderate	38 (47.5)
Severe	15 (18.8)
Extremely severe	2 (2.5)
Post-traumatic stress disorder
Present	55 (68.8)
Absent	25 (31.3)
PTSD by severity
PTSD, a clinical concern	16 (20)
Confirmed PTSD	14 (17.5)
Severe PTSD	41 (51.2)

DISCUSSION

This study assessed the types and impact of intimate partner violence among rural women in Central India. Our findings revealed that nearly two-thirds of the women were required to provide dowry. The inability to meet the high monetary expectations associated with dowry is a recognized factor contributing to IPV.[13] Surprisingly, none of our participants acknowledged the negative ramifications of giving dowry on their lives. Half of the participants believed it positively affected the married life, and the remaining women believed there was no effect of dowry on marriage. Such beliefs indicate societal acceptance of this practice, which may underpin the perpetuation of oppression and abuse against women.[14] Similarly, the practice of arranged marriages, where partners are chosen by parents or guardians, has been linked to higher levels of violence compared with mutually agreed love marriages.[15] This correlation was evident in our study, where more than 90% of women had their marital partners chosen by their parents.

Most respondents in our study experienced severe levels of violence. These women voluntarily disclosed information about IPV to ASHA workers, confirming previous observations that women often report violence after enduring multiple severe assaults.[16] A multisite household survey identified underreporting of domestic violence among women, mainly because of associated stigma and fear of relationship repercussions.[17] Our study replicated these findings, as only a quarter of the women sought professional help for their issues, citing fear of relationship loss or adverse consequences as major deterrents. A majority of the respondents who suffered physical violence also endured emotional abuse such as insults, belittlement, humiliation, or controlling behavior from their partners. A study from eastern India similarly reported psychological violence as the most prevalent form of IPV.[18]

Approximately one-fourth of our study participants experienced economic abuse, such as being prohibited from working, having money forcibly taken away, or not receiving a fair share of household finances. This economic violence perpetuates social inequality and exacerbates poverty among women, increasing their vulnerability to physical and psychological abuse.[19]

In this study, more than 70% of women justified IPV as a reasonable response to spousal infidelity, and more than 25% believed disobedience to be a reasonable ground for violence by the partner. These findings are aligned with a systematic review of 56 international studies, which concluded that more than half of the women justified the domestic violence by the intimate partner. Disobedience to the husband, not completing the household work, a refusal for sex, infidelity, and neglecting children were the commonest justifications endorsed by the women for the IPV.[20]

More than two-thirds of the respondents had PTSD (66%), depression (68%), and anxiety (70%). These figures match the previous community studies conducted on women facing violence and are far higher than the general population prevalence of depression (8-10%) and anxiety (15-20%).[21,22] A systematic review of studies of PTSD in India found PTSD to have a higher prevalence in the cases of abuse (>50%) compared with natural disasters and man-made accidents.[23] Our findings exceed the observations of Tolmen and Rosen who claimed that IPV victims are twice as likely to contract mental health problems compared with the general population.[24] The bivariate analysis showed that depression in these women was significantly associated with the reluctance in sharing the information of domestic violence with others and perceived financial insecurity. Similarly, Jones et al.[25] had observed that lack of social support and safety concerns usually underlie the mental health problems in battered women. We found PTSD was more likely in the women if the husband had alcohol dependence. Previous studies have shown that wives of the individuals abusing alcohol are vulnerable to domestic violence and physical and emotional problems.[26]

Limitations

The generalizability of the findings in this study is limited by the fact that the sample consisted only of women who voluntarily reported experiencing violence. In addition, the self-rated questionnaires used in the study can only screen for, rather than definitively confirm, the presence of mental health problems.

Key Messages

• Intimate partner violence is under-reported and is associated with a high magnitude of mental illnesses among the victims.

• The attitude of justifying the violence and avoidance of seeking professional help increases the vulnerability to the IPV.

• Social acceptance of dowry custom may result in perpetuating the IPV in women living in rural India.

Financial support and sponsorship

This project was funded by the World Health Organisation, India country office [APW 202110223 of 2021].

Conflicts of interest

There are no conflicts of interest.

SUPPLEMENTARY FILES

Title: Intimate Partner Violence and mental health problems in the married women in rural Central India: A community based cross sectional study

Table 1:

Demographic characteristics

Characteristic	Number (Percentage) (n=80)
Age – Mean age in completed years (SD)	31.13 (6.96)
Educational status
Primary school	22 (27.5)
Secondary school	46 (57.5)
Higher	11 (13.8)
Illiterate	1 (1.3)
Marital status
Ever married	79 (98.8)
Currently married	79 (98.8)
Divorced/Separated	1 (1.2)
Who chose partner?
Mutually decided with the partner	3 (3.8)
Parents of respondent	75 (94.9)
Partner’s parents	1 (1.3)
Number of women not asked about the marriage choice of partner prior to marriage	15 (18.8)
Number of women who had to pay dowry/bride price	53 (66)
Attitude about impact of dowry on married life? (For the women who had to pay dowry) (n=53)
Positive impact	29 (54.7)
Negative impact	0 (0)
No impact	24 (45.3)
Number of women attending a social group or organisation	36 (45)
Frequency of contacting family of birth
Once a week	55 (68.8)
Once a month	19 (23.8)
Once a year	5 (6.3)
Never	1 (1.3)

Table 2:

Injuries and physical problems in women facing intimate partner violence

	Frequency (%) (n=80)
Symptom
Poor self-report of health	1 (1.3)
Problem walking	28 (35)
Problem carrying out daily activities	27 (34)
Pain	37 (46.3)
Problem in memory	17 (21.3)
Dizziness	33 (41.3)
Vaginal discharge	18 (22.5)
Ever Injured	47 (58.8)
Frequency Among women ever injured (n=47)
Once or twice	27 (57.4)
Several (3-5) times	17 (36.2)
Many (>5) times	3 (6.4)
Type of Injury (n=47)
Cuts, puncture, bites	17 (36.1)
Abrasions, bruises	27 (57.4)
Sprain, dislocations	1 (2.1)
Burn	32 (68)
Deep cuts	2 (4.2)
Fracture	1 (2.1)
Loss of consciousness (n=47)
< 1 h	7 (14.8)
>1 h	3 (6.3)
Never	37 (78.7)
Use of health care services for injuries (n=47)
Used health care services	32 (68.1)
Hospitalisation due to injuries	7 (14.8)
Told health care worker the real cause for injury	20 (42.5)

Table 3.

Correlates of mental health problems in Women facing IPV

	Stress	Anxiety	Depression	PTSD
Spearman correlation
Age	0.037 (0.744)	0.105 (0.352)	0.092 (0.418)	0.167 (0.138)
Education level	0.077 (0.49)	0.006 (0.95)	0.041 (0.72)	0.016 (0.88)
Physical Violence	0.118 (0.298)	0.065 (0.568)	0.257 (0.021*)	0.12 (0.288)
Psychological Violence	0.141 (0.213)	0.133 (0.239)	0.32 (0.004*)	0.148 (0.19)
Sexual Violence	0.154 (0.173)	0.265 (0.017*)	0.16 (0.155)	0.23 (0.04)
Problem performing activities	0.173 (0.12)	0.056 (0.62)	0.084 (0.46)	0.052 (0.64)
Pain/Discomfort	0.126 (0.264)	0.019 (0.870)	0.001 (0.995)	0.094 (0.406)
Cognitive Problems	0.113 (0.317)	0.163 (0.149)	0.087 (0.443)	0.016 (0.885)
Partner drinks alcohol	0.027 (0.81)	0.172 (0.12)	0.204 (0.069)	0.334 (0.002*)
Mann Whitney test
Attitude that domestic violence is private	581.5 (0.319)	486 (0.045)	550 (0.18)	401.5 (0.004*)
Ever Injured due to violence	599.5 (0.082)	661.5 (0.26)	619 (0.12)	640 (0.18)
Whether used health care services	192 (0.268)	163 (0.077)	173 (0.124)	193.5 (0.288)
Open up about the truth of injuries	44.5 (0.7)	27.5 (0.12)	44 (0.68)	46.5 (0.81)
Telling others about Domestic Violence	537 (0.62)	533.5 (0.6)	343 (0.007*)	551 (0.74)
Autonomy to spend money	209 (0.89)	142.5 (0.077)	156.5 (0.15)	123.5 (0.026*)
Freedom to work	517 (0.53)	520 (0.56)	429 (0.10)	550.5 (0.82)
Perceived Financial security	296.5 (0.12)	404.5 (0.96)	204.5 (0.006*)	296 (0.13)
Family of Origin living close	462 (0.004*)	634.5 (0.249)	712.5 (0.708)	697.5 (0.601)
Regularly attending a social group	671.5 (0.239)	787.5 (0.965)	750.5 (0.687)	599 (0.061)
Dowry Given In Marriage	705 (0.914)	572 (0.142)	675.5 (0.683)	644.5 (0.469)
Current Pregnancy	127 (0.22)	98.5 (0.07)	113.5 (0.14)	87 (0.045*)

P (*<0.05) mentioned in parenthesis