Sexual Harassment among Female Healthcare Workers, its Consequences and Barriers in Seeking Help in India’s Health Sector

Abstract

Introduction:

Women in healthcare sector, due to their gendered roles and long working hours, are more vulnerable to sexual harassment (SH). This study investigates the prevalence of SH among female healthcare workers (HCWs) in India, explores barriers to seeking help and examines the consequences on their lives.

Method:

A mixed method study was conducted over one year enrolling female healthcare workers from government and private settings. Quantitative data was collected via face-to-face interviews and Google forms using revised Sexual Experiences Questionnaire (SEQ)-5. This was followed by focus group discussions to gain a deeper understanding of barriers in seeking help and the effects on personal and social life, utilizing framework analysis.

Results:

High prevalence was seen, 50.7% % (95% CI: 46.7–54.8) in the last 12 month, and 92.2% (95% CI: 89.8–94.1) of HCWs ever experienced SH. While 47.1% were aware about legal provisions, only 17.4% who experienced SH reported to the authorities. Fear, distrust in authority and redressal system, lack of knowledge and support, emotional and psychological barriers, and societal stigma emerged as major barriers in reporting such incidents and seeking help. SH had a huge effect on their personal and social lives, with some HCWs even leaving their jobs.

Conclusions:

High prevalence and poor knowledge and underreporting necessitate stricter enforcement of SH regulations. Pre-employment briefings on workplace SH, regular sensitization sessions on reporting mechanisms, and creating a supportive work environment are crucial. This will encourage female HCWs to come forward and report such incidents, without any fear of victimization and stigmatization.

INTRODUCTION

The Indian health sector, which used to be male dominated, has undergone a significant transformation, with women increasingly assuming diverse roles, from doctors and nurses to pharmacists, technicians, and managers. Accredited Social Health Activists (ASHA), the backbone of India’s rural healthcare system, are all women. This dynamic environment encourages teamwork, requiring professionals from various disciplines and hierarchy working together in delivering 24/7 patient care. However, amidst these demanding conditions, women healthcare workers (HCWs) encounter numerous challenges, with sexual harassment (SH) being a particularly prevalent issue, with recent incidents at Kolkata highlighting disturbing situation underscore the need for urgent action.

SH refers to inappropriate, unwelcome sex-related behavior at work perceived as offensive by the recipient and that exceeds the individual’s coping resources or threatens their well-being.[1,2] Although, it is pervasive issue across professions, is particularly prevalent in health care due to gendered roles and long working hours. Women HCWs often encounter unwanted advances or inappropriate behavior from colleagues and superiors, including comments of a sexual nature, physical contact, and requests for sexual favors. These experiences create an uncomfortable and unsafe work environment, affecting their well-being.

Researchers suggested the widespread occurrence of harassment, often linked to perceived tolerance, male dominant workplaces, hierarchical system, and normalized male perspectives, most of them are prevalent in health sector.[2,3] A survey by Oxfam India revealed that 17% of working women reported workplace SH experiences.[4] Studies conducted across India have documented a varied prevalence of SH among female HCW, with as high as 57.0%.[5] Notably, international studies too documented higher incidence.[6,7,8] Despite the alarming rates, the National Crime Records Bureau report indicated that only a meager 29.2% of incidents are reported to legal authorities.[9] Fear of retaliation, shame, guilt, mistrust in organizational response, and concerns about not being believed or taken seriously hinder reporting.[10]

Investigating SH in the Indian healthcare settings presents unique challenges due to potential ambiguity in definitions and women’s reluctance to share their experiences. Furthermore, SH can have serious consequences on their physical, mental or emotional health, potentially hindering their equal participation in the workplace. Thus, we did this study to observe prevalence of SH, barriers to seeking help, understanding coping mechanism and effect on their personal and social life. To gain a deeper understanding of these issues, based on review of literature we have developed a conceptual framework [Figure 1] that explores the context of SH, coping mechanisms employed by victims, the barriers to reporting, and the consequences on their lives.[2,11,12]

Figure 1.

A framework of context, coping, barrier and impact of sexual harassment among female health care workers

MATERIALS AND METHODS

Study design and population

This was a mixed-method study employing an explanatory sequential design with cross-sectional quantitative survey followed by qualitative focus group discussions (FGDs). As a part of Indian Council of Medical Research (ICMR) funded project, we recruited women HCWs across India from January to December 2021. The target population included women working in healthcare settings, directly or indirectly involved with the provision of health as doctors, nurses, allied health workers, and auxiliary staff working in government or private healthcare settings. Efforts were made to ensure a comparable proportion of participants from different categories.

Sample size

Based on existing literature reporting a prevalence range of 17%–75% for SH,[8,13] we assumed a median prevalence of 50%. Using Schwartz formula n = z²p (1- p)/d², with 95% confidence interval, 10% relative error, and a design effect of 1.5, we calculated sample size of 576. Anticipating potential nonresponse, we aimed to collect data from 600 participants. To have representativeness, we aimed to have sufficient numbers from different part of country, sections, and type of occupation. [Supplementary Figure S1 ^{(203.8KB, tif)} ]

Definition

We adopted the definition of SH as outlined in The Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act 2013.[1,2] This includes following ‘unwelcome’ acts or behavior:

• Physical contact and advances;

• Demand or request for sexual favors;

• Sexually suggestive remarks

• Showing pornography,

• Any other unwelcome physical, verbal or nonverbal conduct of sexual nature.

Fitzgerald and Schulman had divided such behavior into the following two broad categories[11]:

1. Priori: unsolicited, asking for sexual favors, often refer to ‘quid pro quo’

2. Empirical: It is categorized into five subset and was basis of Sexual Experiences Questionnaire (SEQ)-5 questionnaire we used.

   1. Gender harassment: includes generalized sexual remarks and behaviors to communicate degrading or sexist attitude towards women.

   2. Seducing behavior: includes inappropriate and offensive sexual advances to seduce a woman.

   3. Sexual bribery: soliciting sexual activity for some benefit to the woman.

   4. Sexual coercion: includes a threat of punishment for non-compliance to sexual demands.

   5. Sexual imposition: attempts to touch, kiss, grab, or actual sexual assault against the victim’s wishes.

Study tool

In the first phase, quantitative data collection was done using a self-administered questionnaire collecting socio-demographic characteristics and determining the prevalence of SH using revised Fitzgerald SEQ-5.[11] It is a 28-item self-reported inventory covering five dimensions of SH, with each dimension measured by a subscale. It measures response on a Likert scale with options of marking - Never, Once, More than once, and No response. The questions avoid using the word “sexual harassment”, acknowledging the ambiguity surrounding the concept. The focus is on specific behaviors instead of labels. This SEQ-5 has been validated and demonstrates good reliability in various settings (Cronbach’s α 0.86–0.922).[14,15] The Supplementary Table 2 shows individual questions and subcategories along with their responses.

Study plan and collection

Initially, we collected the data online using Google Forms, distributed through email, personal and WhatsApp messages, to ensure nationwide coverage. However, due to the high non-response rate, the approach shifted to physical data collection. A data collector visited healthcare institutions in Delhi, Guwahati, Kolkata, Jaipur, and Hyderabad, and women HCWs were recruited after obtaining permission from relevant authorities. Analysis of quantitative data was done and shared with investigators, and to understand barriers to seeking help, coping, and consequences of SH, an FGD tool was developed. In the second phase, qualitative data collection was done with two FGDs, among doctors and nurses along with paramedical workers. These sessions aimed to explore coping and the consequences of SH on their life. The FGDs were led by two investigators (AT and VG), a female medical doctor and a male social activist, fluent in the local language (Hindi), and trained in qualitative research methods. A semi-structured interview guide with broad open-ended questions was used, and an audio recording was done with the participants’ consent. [See Figure S1 ^{(203.8KB, tif)} and Figure S2 ^{(242.2KB, tif)} in supplementary files]

Data analysis

Quantitative data collected through the questionnaire were entered in MS Excel, cleaned, and analyzed using IBM SPSS version 21. The SEQ-5 had four likert scales, but we clubbed the responses into Present (once/more than once) or Absent (never) while removing the no response for that particular subcategory analysis. The categorical variables and proportions were represented by a percentage (%). For qualitative data analysis, FGDs were transcribed verbatim, and translated into English. Using the ‘framework approach’ based on workplace sexual harassment coping strategic framework[12] [Figure 1], the responses were coded and categorized for subsequent interpretations. The third investigator (YA) reviewed the analysis and discrepancies were resolved by consensus. The study utilized a Consolidated Criteria for Reporting Qualitative Research checklist for reporting.[16]

Ethical consideration

The study was approved by the Institutional Ethics Committee. Informed consent was obtained from participants by a participant information sheet integrated into the Google Form or obtained in writing during physical interviews. Confidentiality was ensured by not collecting any personal identifiers. Written consent was obtained for FGD. After the data collection, infographics and existing legislation on SH were shared with participants.

Reflexivity statement: During the conceptualizing of this study, the authors recognized the widespread prevalence of SH. They acknowledge that their perspectives, backgrounds in medical expertise, and healthcare experience may influence data collection, analysis, and interpretation and could introduce biases.

RESULTS

Out of the 601 respondents, 266 (44.3%) belonged to the age group 26–50 years. More than half of the subjects were married (57.1%) and 44.7% of them were doctors. Other sociodemographic details are given in Supplementary Table S1.

Our study revealed a prevalence of sexual harassment (SH) among female healthcare workers (HCWs) in India. Within the past year, 50.7% [(95% confidence interval (CI): 46.7–54.8) (305/601)] of female HCWs reported experiencing SH, while a staggering 92.2% (95% CI: 89.8–94.1) had experienced SH at some point in their careers. Gender harassment was the most common type reported in the past year at 45.4% [(95% CI: 41.3–49.5) (266/581)], while a concerning 18% (108/579) of participants expressed experiencing more serious forms of SH, including sexual imposition (deliberate touching and intercourse). [Figure 2] A detailed breakdown of these types is provided in Supplementary Table S2. Despite the high prevalence of SH, a mere 17.4% of harassed participants reported the incidents to authorities. Furthermore, in 41.9% of reported cases, no action was taken. Figure 3 illustrates the various coping mechanisms employed by victims of SH. Of those cases that were reported to authorities, only 41.9% were not acted upon.

Figure 2.

Sexual harassment experienced by female health care workers at workplace in last 12 months and ever along with categorization in five dimensions based on Fitzgerald SEQ-5 (N = 601). Missing and nonresponse to item were excluded while calculating individual percentages

Figure 3.

Harassment coping adopted by study participant who experienced sexual harassment at workplace (N = 534) based on workplace sexual harassment coping strategic framework[12]. Missing and nonresponse to item were excluded while calculating individual percentages

Table 1 shows the framework analysis of the FGDs with HCW identified key barriers to seeking help by the victims of SH. We categorized the barriers into five categories -fear (of retaliation), distrust (in the reporting system), knowledge and resource deficits, emotional and psychological barriers, and societal stigma. Victims were left distressed, anxious, and disturbed which affected their work life and social life as well to the extent that few reported leaving their jobs after the incident, and others reported avoiding people, especially males. [Table 2]

Table 1.

Barriers to seeking help by the victims of sexual harassment

Categories	Sub - categories	Quotes
Fear of Retaliation	Academic/Professional Consequences	Q1 “if that particular person is my teacher and what might happen, he can give me less marks or (cough) and the person might have a grudge against me because thing can open up and he will know that I complain against him.” – 28 year doctor, govt medical college
	Future Career Limitations	Q2 “Sometimes the victim is threatened by seniors that complaining against such incidents would spoil the name of the department and which can have bad implications against the victims in future”. - – 35 year doctor, private hospital
	Social Ostracization	Q3 “It will go into a legal sort of thing which is very long process, and in that you have to prove yourself in front of everyone and what if you are not able to prove yourself” – 35 year administrative staff. And Q2
Lack of Trust in the Reporting System:	Trivialization of Complaints	Q4 “it’s not a big deal” – 26 year doctor, private medical college, referred to the initial response of authorities, when she reports the offence.
	Weak Grievance or Distrust in redressal process	Q5 “sometimes it is the fear of reaction to the people who we are complaining (implying committee), sometimes they try to ignore such things and they do not take it as serious as we are reporting to them.” – 27 year doctor, private medical college And Q3 (see previous)
	Confidentiality Concerns	Q6 “first thing is that what if I just go and complain but there is no action taken against it and if the incident leaks out and its out among your friends” – 30 years medical doctor i
	Lack of Supportive Supervisor	Q7 “On complaining to my head of department, I was prevented to lodging the complaint and she tried to resolve the issue internally as she was scared of spoiling the name of department. She also said nothing will happen by lodging complaint as she had be in similar situation in the past.” 35 years medical doctor
	Insufficient Training	Q8 If the incidents happen to us then we will report to seniors first but I don’t know how we can do this in our college, which means what is the exact procedure.” – 40 year hygiene staff.
	Lack of Accountability	Q9 “Sometimes the victim is threatened by seniors that complaining against such incidents would spoil the name of the department and which can have bad implications against the victims in future”. - – 35 year doctor, private hospital
Knowledge and Resource Deficits:	Limited Awareness of Sexual Harassment & SH Act	Q10 “My supervisor kept making comments and touching me. I thought it was just part of the job. When I talked with you, I feel it was sexual harassment” - 38 year administrative staff.
	Inadequate Access to Support Services	Q11 “In the institution you don’t know where to go? There was a point mentioned that ragging is not only about mentally torturing you, it is also about sexual harassment which is included in this.” 27 years medical doctor
Emotional and Psychological Barriers:	Shame and Humiliation	Q4 & Q6 (see previous)
	Self-Blame and Doubt	Q12 “Going to the police or authority, other people will ask for evidence or proof” – 30 year Nurse, govt hospital And Q10
	Fear of Reliving the Trauma	Q3 (see previous)
Societal Stigma:	Fear of Social Isolation	Q14 “It is like you will be on your own no one will be there to support you” – 39 year social health worker Q15 “this is a very sensitive issue. So nobody will take part and support you” – 27 year medical doctor
	Normalization of Harassment	Q10 (see previous)

Table 2.

The consequences of sexual harassment on victims’ personal and social life

Categories	Sub - categories	Quotes
Job Related	Withdrawal Decreased Satisfaction Reduced Productivity	- left the previous workplace - Aggression and revengeful. Work-life hampered - restricted my activities “I reported to the higher authorities who told us to ignore & move on & they also said you are a female you should learn to ignore this will happen to everywhere.”
Health Related	Physical Mental	- Disturbed sleep, social circle, and work - Shocked, disturbed, angry “I have been feeling depressed, noxious”
Psychological	Life satisfaction Stress Traumatic - PTSD	- avoiding people. - fearful anxious, poor concentration in studies. - don’t talk to anyone and get panicked and stressed’ “It had led to many rumours because of which I have been looked down.”

DISCUSSION

Our study investigated the prevalence and consequences of sexual harassment (SH) among women healthcare workers (HCWs) in India. The findings reveal high rates of inappropriate coping mechanisms and significant barriers to seeking help.

Prevalence of sexual harassment

Our study found high rates of SH in women in healthcare settings, with 50.7% of them experiencing it in the past year, and the overwhelming majority (92.1%), reported ever experiencing it. These findings are alarming but frankly not unexpected, considering the revelations brought to light by the recent #MeToo movement and incident at a medical college in Kolkata. Further, these rates align with previous research conducted in India and globally. They have varied prevalence from 57.0% among HCW in Kolkata,[5] 58.0% of female surgeons from America[8] and nurses from Egypt,[6] while as high as 75.3% among medical and nursing students from Malaysia[7] However, compared to some studies, our findings suggest a higher prevalence of SH among HCWs in India.[13,17,18] This discrepancy may be attributed to factors such as India’s patriarchal social structure, the potentially precarious position of female HCWs, and the working environment they encounter and lack of awareness. Among the types of SH, gender harassment was most frequently reported. While most form of SH is done to obtain sexual cooperation, gender harassment aims to demean or create a hostile environment based on someone’s gender. This should not diminish the seriousness of gender harassment. It can be a persistent and psychologically damaging form of abuse, yet many organizational policies remain weak on addressing it or fail to cover it altogether.[19]

Of our study participants, despite being educated, the majority were unclear of the actual definition of SH and the SH Act 2013. Previous studies have also documented that female HCWs in India are often unaware of what constitutes SH in the workplace,[12] Furthermore, in the qualitative study, female HCWs expressed that any seminars on SH were never organized by their employer nor did they attend it anywhere in their lifetime. These factors further contribute to the overall understanding of the issue and underscore the urgent need for increased awareness, training, and comprehensive policies addressing SH within healthcare settings. The tool we used (SEQ) is a checklist-based assessment, which is considered to be known to potentially overestimate the phenomenon.[20] However, given the low awareness levels, a checklist questionnaire should provide a more accurate picture of the prevalence of SH in this context. Thus, there is an immediate need to educate the Female HCW and make them aware of what is SH and its legal provisions. Building on the recommendations of previous researchers, this education package should be based on gender equality and shed light on deep-rooted patriarchal structures in India.[21]

Reporting to authorities and barriers in seeking help

Less than one-fifth of the SH victims reported to authorities. Underreporting of SH is well-known and documented by many researchers across the globe.[8,22,23] A survey by the Indian Bar Association in 2017 also documented that 70% of working women do not report SH, due to victim’s lack of trust, fear of retaliation, hostile environment, blame shaming, bystander effect, and masculine culture.[10] Other factors may also contribute including a lack of support from colleagues and superiors, the perception that reporting harassment will have negative consequences for their careers, and the stigma associated with speaking out about their experiences.[24,25] This reluctance to report harassment is a significant concern, as it may contribute to a culture of impunity for perpetrators and prevent women from accessing justice. Our analysis identified fear, lack of trust, lack of knowledge, emotional and psychological barriers, and societal stigma as the major barriers to reporting, aligning with findings from previous research.[10,24] We observed our framework to be useful in understanding the barriers to seeking help. While we observed that some victims did report incidents and knew about legal provisions and ‘Sakhi’a one-stop center, there is a clear need to educate them through induction training and regular awareness sessions on how to report properly.

Consequences of SH and coping adopted.

Experiencing SH has a huge effect on a person’s quality of life.[22] Our study found that HCW women adopted various mechanisms during coping after the event. We utilized the workplace SH coping strategic framework developed by Worke 2021,[12] which identified four dimensions normalisation, engagement, help-seeking, and detachment. One-third challenge the perpetrators in engagement, while few normalize and seek help. The majority of them did not bother after the event, while many women could not express their coping mechanisms. We agree with previous researchers that these coping strategies are insufficient and need to provide information to the victims post-event.[12] Few have suggested that non-acknowledging an experience of harassment is often adopted by women as a coping mechanism.[26]

The study participant expressed that they were in distress after SH and felt “been feeling depressed, noxious”. Others identified disturbed work-life and social life and distrust following SH with one expressing “Higher authorities told us to ignore and move on and they also said you are a female you should learn to ignore”. Literature highlights that there is a huge impact of SH on women, which ranges from distressed, anxious, and stress to depression, Post-Traumatic Stress Disorder (PTSD) and even suicides.[3,13,15,24] It may affect their work life and social life as well to the extent that few reported leaving their job after the incident, and others reported avoiding people, especially males. This affected their self-respect and left the feeling of distrust against male colleagues and authorities for taking no action. Moreover, it can cause burnout, hinder career growth, reduce job satisfaction, and contribute to attrition and turnover.[3]

Our study has a few limitations. First, our sample might not accurately represent all female HCWs in India due to our use of convenient sampling, despite our efforts to collect data from all four geographical zones of the country. Additionally, relatively high non-response rates associated with online data collection may further limit the generalizability. To address this, we supplemented our online survey with face-to-face interviews, which may have introduced bias. Further, our study relied on self-reported measures of SH through a SEQ checklist, which could be influenced by social desirability bias, and overestimations of outcome.[7,20] Notably, the Fitzgerald SEQ tool used for data collection is widely utilized and validated in various settings.[15] Further, our qualitative data was collected in North India, due to language barriers and resource limitations. Finally, our study encompassed a diverse population of HCWs representing various categories, which may vary in the prevalence of SH.

CONCLUSION

The study uncovers the high prevalence of workplace sexual harassment in the Indian healthcare sector, profoundly affecting female employees. Many victims experience feelings of distrust, distress, and disruption in both their work and personal lives. Despite this, a significant portion of healthcare workers are unaware of legal procedures and provisions, including India’s Prevention of Sexual Harassment at Workplace (POSH) Act. To address these issues, the study calls for comprehensive education for all HCW, both male and female, increased sensitization efforts, strengthened legal safeguards and redressal mechanisms, and the creation of a supportive organizational culture. Additionally, conducting national-level surveys can help document the prevalence of sexual harassment, raise awareness, and drive advocacy efforts.

Key messages

• Alarmingly high rates of sexual harassment affect female healthcare workers in India.

• Lack of awareness and support lead to underreporting and significant psychological impact.

• Urgent action is needed to create a safe and respectful work environment.

Conflicts of interest

There are no conflicts of interest.

SUPPLEMENTARY FILES

1. FRAMEWORK

We developed a framework to provide a holistic perspective on sexual harassment (SH) experienced by female healthcare workers (FHCWs) in India. This framework encompasses the various stages a victim might go through, starting with the underlying context and environmental factors that contribute to SH. These factors include:

• Institutional Space: The specific healthcare workplace environment where the FHCW works.

• Societal Roles and Stereotypes: Prevalent societal attitudes towards women and healthcare professions in India.

• Environmental and Individual Factors: A combination of workplace dynamics and individual vulnerabilities.

The interplay of these factors can lead to five different types of sexual harassment experienced by FHCWs which are discussed in detail in definitions.

1. Gender Harassment

2. Seducing Behaviour

3. Sexual Bribery

4. Sexual Coercion

5. Sexual Imposition: (Detailed definitions is provided in main text).

As a result of SH, victims often experience distress, anxiety, and social and work-life disruptions. Using the 'framework approach' based on workplace sexual harassment coping strategic framework 15, we categorised various coping strategies depending on their environment, such as actively engaging with the situation, seeking help from others, detaching emotionally, or normalizing the experience. The impact of SH can be significant, affecting personal well-being, health, and social life. Finally, the framework explores the barriers that prevent victims from reporting SH and seeking help.

2. PLAN OF THE STUDY AND DATA COLLECTION

Supplementary Table S1.

Sociodemographic profile of study participants

Sociodemographic profile	Frequency*/Mean	Percentage/Standard deviation
Age^ (Mean±SD)	32.0	8.0
<25	94	15.6
25-35	306	50.9
36-49	129	21.5
>50	20	3.3
Education
Primary	56	9.4
Secondary	76	12.7
Graduate	263	44.1
Postgraduate and above	202	33.8
Occupation
Doctor	268	44.6
Nurse	145	24.1
Paramedic	58	9.7
Other helping staff	115	19.1
Field health worker	13	2.2
Marital status
Married	327	57.1
Unmarried	224	39.1
Divorced/Widow/Separated	22	3.8
Caste
General	343	63.8
OBC	105	19.5
ST/SC	90	16.7
Duration at present organization^
<1	90	18.2
1-10	314	63.6
>10	90	18.2

*Nonresponse entries were excluded. ^in years

Supplementary Table S2.

Sexual harassment experienced at the workplace by female health care workers in last 12 months (using revised SEQ-5)

Has any male employee/employer or any other male in your workplace in the last 12 months ever	Yes	No	No Response
Gender Harassment
Told any suggestive stories or offensive jokes?	141 (23.5%)	418 (69.6%)	40 (6.7%)
Make Crudely sexual remarks?	101 (16.8%)	457 (76.0%)	44 (7.3%)
Make Seductive remarks?	96 (16.0%)	458 (76.2%)	47 (7.8%)
Stared, leered, and ogled at you?	180 (30.0%)	375 (62.4%)	46 (7.7%)
Displaying or using sexist material or pornography	45 (7.5%)	509 (84.7%)	47 (7.8%)
Treated “differently” due to gender?	188 (31.3%)	370 (61.6%)	43 (7.2%)
Passed Sexist remarks about your behavior and career options?	146 (24.3%)	409 (68.1%)	46 (7.7%)
Seduction
Unwanted discussion of personal or sexual matters?	57 (9.5%)	459 (76.4%)	38 (6.3%)
Unwelcome seductive behavior?	69 (11.5%)	492 (81.9%)	40 (6.7%)
Unwanted sexual attention?	52 (8.7%)	477 (79.4%)	41 (6.8%)
Attempts to establish a sexual relationship, despite discouragement.	41 (6.8%)	518 (86.2%)	42 (7.0%)
Invasion of privacy (repeated requests for calling, dates, “dropping in”)	111 (18.5%)	452 (75.2%)	40 (6.7%)
Sexual insinuations or innuendos?	54 (9.0%)	502 (83.5%)	45 (7.5%)
Crude or offensive sexual remarks about the respondent to others?	63 (10.5%)	493 (82.0%)	45 (7.5%)
Sexual rumours spread about the respondent?	56 (9.3%)	498 (82.9%)	47 (7.8%)
Sexual bribery
Attempted any subtle bribery for sexual cooperation?	27 (4.5%)	537 (89.4%)	37 (6.2%)
Taken direct bribery?	16 (2.7%)	537 (89.4%)	48 (8.0%)
Engaged in unwanted sexual behavior due to promises of Reward for sexual favour?	23 (3.8%)	535 (89.0%)	43 (7.2%)
Actually, rewarded for sexual cooperation?	23 (3.8%)	533 (88.7%)	43 (7.2%)
Sexual Coercion-
Given any subtle threats of retaliation for noncooperation?	34 (5.7%)	516 (85.9%)	51 (8.5%)
Given direct threats?	26 (4.3%)	522 (86.9%)	53 (8.8%)
Engaged in unwanted sexual behavior due to threats of retaliation?	19 (3.2%)	524 (87.2%)	57 (9.7%)
Actually experienced negative consequences for sexual noncooperation?	20 (3.3%)	521 (86.7%)	60 (10.0%)
Sexual Imposition
Tried deliberate touching?	101 (16.8%)	441 (73.4%)	59 (9.8%)
Make any unwanted attempts to touch or fondle?	101 (16.8%)	445 (74.0%)	57 (9.5%)
Tried forceful attempts to touch or fondle?	52 (8.7%)	497 (82.7%)	52 (8.7%)
Attempted at intercourse that resulted in the respondent crying, pleading or physically struggling?	18 (3.0%)	530 (88.2%)	53 (8.8%)
Criteria question
Been sexually harassed?	43 (7.2%)	480 (79.9%)	78 (13.0%)

Figure S1

Flow of study participants during study period

Figure S2

Four zones of study and study sites for participants enrolments

Funding Statement

ICMR.

Ethical Approval: Jamia Hamdard Institutional Ethics Committee, New Delhi, India