Violence Against Women in India: An Analysis of Correlates of Domestic Violence and Barriers and Facilitators of Access to Resources for Support

Abstract

Purpose:

Domestic violence (DV) is a significant public health problem in India, with women disproportionately impacted. This study a) identified risk and protective correlates of DV and, b) barriers and facilitators for seeking and receiving help for DV among women in India.

Methods:

A systematic search of 5 databases was performed to identify correlates of DV in the quantitative literature. The search resulted in inclusion of 68 studies for synthesis. For qualitative exploration, data were collected from 27 women in India.

Results:

While factors such as social norms and attitudes supportive of DV were both risk correlates and barriers to addressing DV, omen’s empowerment, financial independence and informal sources of support were both protective correlates of DV as well as facilitators in addressing DV.

Conclusions:

Strong efforts in India are needed to reduce DV-related risk factors and strengthen protective factors and enhance access to care for women in abusive relationships.

Domestic violence (DV) is a global social problem with devastating physical and mental health effects on individuals experiencing victimization. India suffers a high burden of DV against women. In the 2019-2021 India National Family Health Survey (NFHS-5), 32% of ever-married women in India reported experiencing physical, sexual, or emotional violence by their current or former husband. Women’s experiences of any DV varied across states or union territories, with the highest prevalence in the southern state of Karnataka (48%) (International Institute of Population Sciences, 2022). According to the National Crime Records Bureau (2019) report, approximately 31% of the cases reported under crimes against women were classified under DV (i.e., the category of cruelty by husbands or his relatives). A systematic review of 137 quantitative studies examining DV experiences of Indian women identified that median and range of lifetime estimates of multiple forms of DV among women were 41% (18-75%) and past year estimates were 30% (4-56%) (Kalokhe et al., 2017). Of note is that women in rural areas were more likely than those in urban areas to experience DV victimization (36% versus 28%) (International Institute of Population Services, 2017).

DV has been defined as “all acts of physical, sexual, psychological or economic violence that occur within the family or domestic unit or between former or current spouses or partners, whether or not the perpetrator shares or has shared the same residence with the victim” (Chernikov & Goncharenko, 2021; p.811). The United Nations defines DV as a “pattern of behavior in any relationship that is used to gain or maintain power and control over any intimate partner.” “This includes any behaviors that frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure, or wound someone” (United Nations, n.d.; 1^st para). In India, the definition of DV under the Protection of Women from Domestic Violence Act (PWDVA) (2005) is in consonance with the UN definition of DV. DV in Indian context is defined as “harming, injuring, or endangering the health, safety, life, limb or well-being, whether mental or physical, of the aggrieved person” (The Gazette of India, 2005; p. 3). Similar to the UN definition, the definition of DV in India includes actual or the threat of physical, sexual, economic and/or psychological harm perpetrated on the woman by her spouse or intimate partner (The Gazette of India, 2005). However, the perpetrators of DV in Indian context expands the global definition to include both spouse and/or in-laws (Sabri et al., 2015; Sabri & Young, 2021). Additional behaviors included in DV in India are honor killings, unwarranted dowry demands and related harassment by husband and/or in-laws (Bhandari & Hughes, 2017; Sabri et al., 2015; Sabri & Young, 2021; The Gazette of India, 2005). Entrenched patriarchy, rigid gender norms and unequal power and control between spouses are some of the factors that play a role in perpetration of DV by the spouse and/or by spouse’s family members (i.e., in-laws) (Bhandari & Hughes, 2017; Rai & Choi, 2021; Ragavan & Iyengar, 2020; Sabri & Young, 2021). DV has a devastating impact on physical and mental health of women. Furthermore, experiences of DV are associated with prolonged trauma, decreased self-worth, emotional distress (Campbell, 2002; Centers for Disease Control and Prevention, 2008; Sabri et al., 2014) and extreme consequences such as, homicides and suicides (Sabri et al., 2015; Sabri & Young, 2021). A large number of DV-related deaths have been reported in India, with most frequently identified motive being dowry demands followed by a history of DV or harassment and family conflict (Sabri et al., 2015).

Correlates of Domestic Violence

Identifying correlates of DV can be useful for developing prevention and intervention efforts for DV in India. Research has associated several factors operating at multiple levels of the socio-ecological model (societal, community, relationship, and individual) with DV among women (World Health Organization (WHO), 2020). In the Indian context, the correlates of DV at the societal level include patriarchal attitudes and beliefs, social and cultural norms (e.g., dowry) as well as justification of violence against women when they deviate from gender inequitable norms (Koenig et al., 2006; Sabri et al., 2015; Sabri et al., 2021). At the community level, residence in slums with concentrated poverty, stigma of DV, and limited access to resources can enhance women’s exposures to DV (Sabri & Campbell, 2015). Gender-role expectations and partner/husband’s and in-laws’ characteristics and behaviors (e.g., husband’s controlling behavior, both emotional and financial, (Bhandari & Hughes, 2017; Dalal & Lindqvist, 2012) are examples of factors at the relationship level and personal history factors, such as low socio-economic status are factors at the individual level (Sabri et al., 2014; Sabri et al 2021).

Barriers and Facilitators of Help-seeking or Addressing Abuse

Despite the high prevalence estimates of DV, there is under-reporting of cases of DV in India. Culturally, women bear the burden of upholding family values and honor. The importance of keeping family consistency, honor and preserving the public image of a happy, healthy, and successful family, can lead to underreporting of DV by survivors (Husain, 2019). The Indian cultural values as well as perception of DV as more of a private or family matter (Nigam, 2017) impact reporting or help-seeking as well as receiving help for abuse. The rigid gender-roles for men and women, and patriarchal values can cause women to occupy a lower social standing compared to men (Rai & Choi, 2021; Rai, 2020; Panchanadeswaran & Koverola, 2005; Sabri, Simonet et al., 2018; Sabri, 2014). This lower status is one of the barriers to help-seeking. Marriage in the Indian community is distinct from the American culture, which is a union of families rather than two individuals. Often the couple has had limited contact prior to the marriage festivities (Sharma et al.,2013). The salience of family honor (Izzat) and the expectations attached to being a good daughter-in-law can deter women from disclosing matters relating to domestic abuse outside of the home, further reducing the likelihood of seeking help (Gangoli & Rew, 2011; Mahapatra & Rai, 2019; Raghavan & Iyengar, 2020). Living in joint families with in-laws may also be a risk factor due to high instances of in-laws’ abuse, therefore living separately from in-laws may serve as a protective factor in certain cases where partner is not abusive and only in-laws are abusive (Raj et al., 2011; Ragavan & Iyengar, 2020; Rai, 2020; Vindhya, 2007). In-laws’ behaviors such as instigating fights between the couple have also been found to contribute to abuse of women by a partner (Sabri & Young, 2021).

Even with regards to help-seeking, informal help-seeking through friends and family members is more common than formal help-seeking through DV agencies or other professionals (Decker et al., 2013; Mahapatro & Gupta; 2014). According to the NFHS-4 data, about 86% of women in India who experienced DV victimization did not seek help and about 77% of them did not mention the incident to anyone (International Institute of Population Services, 2017). Among the 14.3% of women who did seek help, 7% sought formal help through authorities, the police, lawyers, and social service agencies, whereas 90% of those who sought help received it from their immediate family (International Institute of Population Services, 2017).

Study Rationale

Drawing from the socio-ecological model (World Health Organization, WHO, 2021), we conducted a systematic review to examine factors at multiple levels that shape risk and protective factors for DV as well as influence help seeking and access to services. The socio-ecological model is a prevention framework that can help identify factors at various levels: societal, socio-cultural, community, relationship, and individual, while informing prevention approaches. This model accounts for the interplay of factors at various levels and allows us to “understand the range of factors that put people at risk for violence or protect them from experiencing or perpetrating it” (CDC, n.d., 2^nd para, WHO, 2021).

Relying on the socio-ecological framework, the literature for the systematic review was compiled to identify most frequently reported risk and protective correlates. The goal was to move beyond static (unchangeable) risk factors to identify dynamic (or changeable) risk and protective factors or actions that can decrease risk for women. For example, dynamic risk factors such as alcohol or drug use or hesitancy to seek help, can be addressed by reducing alcohol or drug use (Dutta et al., 2016; Mahapatro et al., 2012), and promoting help seeking which may have a strong protective effect against DV. Findings from the existing literature on dynamic risk and protective factors can be part of safety planning interventions for abused women in India. Many studies have examined correlates of DV in India. However, there has not been a systematic review of quantitative literature identifying risk and protective correlates of DV at multiple levels of the socio-ecological model. Further, although studies have examined patterns of help-seeking among abused women in India, to the best of our knowledge, studies have not explored barriers and facilitators of help-seeking or addressing DV among women using a socio-ecological approach. Therefore, the present study adds to the existing literature on DV in India by conducting a systematic review and a qualitative study to examine a) risk and protective correlates of DV, and b) barriers and facilitators for help-seeking or addressing abuse among women in India at the socio-cultural, community, and individual levels.

While the systematic review of quantitative studies helped identify correlates of DV to highlight groups at risk and factors that could be protective, the qualitative exploration identified barriers and facilitation of seeking and receiving help for DV. These two separate analyses could provide insight into the target areas of prevention and intervention collaboratively, as well as strategies to strengthen access to care among women in abusive relationships in India. The integration of these two strands of data is vital for not only identifying risk factors of victimization but for also highlighting barriers for help-seeking, that may collaboratively be discouraging women from seeking help. Victimization within Indian households can manifest in complex ways that is distinct from Western communities, therefore, merely examining risk factors without understanding barriers is only solving part of the problem. Through our integrated approach, we advance existing evidence by providing an insight into risk factors and barriers, that can both impede help-seeking.

Method

Systematic Review of Quantitative Studies on Risk and Protective Factors for DV in India

To examine risk and protective correlates of DV, a systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (Moher et al., 2015). The PRISMA checklist (Page et al., 2021) is included in appendix. The following databases were searched: PubMed New, CINAHL, Embase, Web of Science, and PsychInfo. The five databases were chosen in consultation with an experienced university librarian. The databases selected were identified as one of the most comprehensive social science databases for published peer-reviewed literature on the topic under investigation in this study. The terms related to correlates such as “risk,” “protective factors,” “barrier,” and “facilitator,” were combined using the Boolean connector “OR.” The violence-related terms such as “Domestic Violence” “Intimate Partner Violence” and “Battered women” were also connected using the Boolean connector “OR”. The terms related to correlates and violence and Indian setting (e.g., “India”) were combined using the Boolean connector “AND.” Detailed search terms are included in appendix.

Peer reviewed studies were included if they were: 1) quantitative or mixed methods studies that reported quantitative findings, 2) included quantitative outcomes of domestic violence and/or examined correlates of DV, 3) were conducted in India, and 4) were published in English. Studies were eliminated if they: 1) did not report results on DV as an outcome, 2) were published before 2010, and 3) were only qualitative analyses or systematic and literature reviews. The articles were imported into Covidence (Covidence Systematic Review Software, n.d.), and duplicates were identified and removed. To reduce risk of bias, two members of the research team conducted independent screening of titles and abstracts for inclusion and exclusion. The full text of selected articles was thoroughly reviewed for data extraction. Any disagreements regarding inclusion and exclusion criteria and extracted data were discussed in individual meetings and resolved. Correlates of DV included factors at the socio-cultural, community and individual levels of the socio-ecological model such as availability of services, help seeking behaviors, safety strategies used by women, and beliefs and attitudes. Figure 1 presents the flowchart of the article selection process.

Figure 1.

PRISMA Flow Diagram of Study Selection

Qualitative Exploration of Barriers and Facilitators for Help-seeking or Addressing Domestic Violence among Women in India

Qualitative data was collected from women survivors of DV from two regions in India: Delhi and Uttar Pradesh. Participants were recruited using purposive and snowball sampling techniques (Trochim & Donnelly, 2008). Recruitment strategies included flyers, word of mouth, snowball sampling and assistance from a women’s health clinic in Delhi run by a non-profit called MAMTA Health Institute for Mother and Child. For eligibility, women had to be 18 years or older, in an intimate partner relationship for 6 months or more with a history of DV, and India as the country of birth. After obtaining oral consent, seventeen individual in-depth interviews and a focus group (n=10) were conducted in-person using semi-structured interview and focus group guides, at a safe and convenient location for the participants. Women who participated in the focus group did not participate in the individual interviews. A trained doctoral-level interviewer conducted the focus group and interviews. Utilizing two data-gathering methods (focus group and interviews) enhanced the credibility and trustworthiness of our study findings. While focus groups were helpful in gaining insight into women’s shared understanding of issues related to DV, and group understanding of barriers and facilitators of women’s help seeking and access to resources, in-depth interviews provided a deeper understanding of women’s experiences, attitudes, and beliefs about DV and help seeking.

Participant characteristics are presented in Table 1. Participants (n=27) were, on average, 34.6 years old (SD=11.1). All participants reported being in a heterosexual relationship with an abusive male partner. Sixty-seven percent were married (n=18), 29.6% (n=8) were divorced or separated, and one woman was widowed, with average relationship length being 15.71 years (SD=9.89). Most participants reported physical abuse (92.3%, n=24), sexual abuse (52%, n=13), and psychological abuse (95.5%, n=21). Only 11.1% (n=3) completed high school, with remaining women educated under high school (48.1%, n=13) and 40.7% (n=11) having no schooling or education. Our sample size of 27 participants was adequate to reach data saturation. Saturation was achieved when no new information or themes were identified (Charmaz, 2006). The study was approved by the institutional review board of the home institution of the lead author (IRB00046370).

Table 1.

Participant Demographics

	n (number of participants)	%
Age (Mean, SD)	34.6 (11.06)
Employed	9	33.3%
Married	18	67%
Divorced or separated	8	29.6%
Widowed	1	3.7%
Relationship Length (Mean, SD)	15.71 (9.89)
Number of children (Mean, range, SD)	3.33 (1-10) (2.25)
Education
Under high school or no education	24	88.8%
High school	3	11.1%
Reported abuse
Physical	24	92.3%
Sexual	13	52%
Psychological	21	95.5%

In the parent study, both the interview and focus group guides included questions on perceptions and experiences of abuse including risk factors for abuse, strategies and resources used for coping, help seeking patterns, needs for services and overall health. The quantitative questionnaires were used to collect information such as age, income, marital status, and level of education. The study completed data collection when it appeared saturation had been reached and there was no emergence of new findings. Both the focus group and the interview sessions lasted for 60-90 minutes. The sessions were audio-recorded using digital recorders. Data was collected in Hindi and the transcripts were translated and back translated in English (Behr, 2017; Brislin, 1970). Each participant received Rs. 1400 (approx. 19.4 USD) for compensation of their time. All study procedures were approved by the institutional review board of the primary author.

Data was analyzed using a hybrid process of deductive and inductive thematic analysis procedure underpinned by the socioecological framework identifying multilevel barriers and facilitators for help-seeking and addressing abuse. The process involved manually listing of a priori themes based on the socio-ecological framework, and independent coding of the transcripts by two coders (1 PhD level and 1 masters’ level coders), with simultaneous development of inductive themes in the process. Inconsistencies in coding and any discrepancies in content and meaning of each code was resolved in individual meetings. An audit trail through detailed notes of data collection experiences and thoughts, and analytic triangulation with the two coders established trustworthiness of the data (Saldana, 2013).

To identify commonalities in findings from the systematic review and the qualitative interviews, the quantitative and qualitative data was analyzed separately. This was followed by reviewing the content to identify similarities and differences in the barriers and facilitators of addressing abuse in the qualitative data and risk (barriers) and protective (facilitators) correlates of addressing DV in the systematic review. Since the purpose of analysis using the two sources of data was different, we identified commonalities in areas such as correlates of DV also being a barrier to addressing abuse of help seeking and protective factors identified in the systematic review also being a facilitator for addressing abuse of seeking help. For example, our systematic review findings identified attitudes supportive of IPV as a risk correlate for DV. Similarly, the qualitative findings revealed justification of wife beating as a barrier to help seeking or addressing abuse. Using a comparative method, we were able to compare findings across themes and the quantitative findings from the systematic review.

Results

Systematic Review Findings

Risk and Protective Correlates of DV

The initial search across the different databases identified 1851 articles, with additional 14 identified through hand searching the references in the retrieved articles. After removing duplicates (n=851), 1014 abstracts and titles were screened for relevance. This screening resulted in 92 articles that were retained for full text review. After full text review, 63 articles were selected for inclusion and synthesis (Figure 1). Drawing from the socio-ecological model, risk, and protective correlates of DV in the articles were identified at the socio-cultural, community, relationship or interpersonal and individual levels (Table 2). The most frequently reported risk correlates of DV at the sociocultural level were norms and attitudes that supported violence against women, male dominance, and ideals of masculinity (n=13). Further, cultural practice of dowry, where husband/in-laws were dissatisfied with the dowry amount (n=6) also resulted in increased DV and women’s deaths. At the interpersonal level, the most frequently reported risk correlates of DV were partner’s characteristics such as alcohol dependence, smoking, substance abuse and/or gambling/betting practices (n=32). Other partner characteristics associated with DV included their low education (n=10), unemployment or having an unskilled occupation (n=9) and controlling behaviors (n=8). A larger family with more children (n=11) was also associated with increased risk for DV. At the individual level, the most frequently reported correlates that were associated with enhanced risk for DV were women being employed or having higher earnings than their partner (n=21), women coming from a low socioeconomic status or standard of living (n=18), having no or low education (n=17), being married at a younger age (<18 years, n=9) and living in a rural setting (n=7). The findings on education were mixed with some studies (n=5) reporting that women’s higher education was associated with their greater exposure to DV and others reporting no or low education as a risk factor for DV. Other reported correlates associated with enhanced risk for DV included women’s HIV positive status, and childhood exposures to DV.

Table 2.

Findings from the Systematic Review

Levels	Risk correlates (n=Number of studies)	Protective correlates (n=Number of studies)
Socio-cultural Level	Attitudes supportive of IPV, male dominance, failure to attain husband ideal/ acceptance of violence and social norms (n=13) 2,5,14,18,19,26,29,32,38,48,50,60,63; Dowry (n=6) 3,4,7,15,26,51; Practice of arranged marriage (n=1) 34	Greater gender equity ideology (n=1) 17
Community Level		Social support from the community (n=1) 56
Relationship/Interpersonal Level (Partner/Family)	Partner’s addiction problem (n=32) 3,5,6,7,11,14,17,20,21,23,24,25,28,29,30,32,33,34,35,36,38,41,42,46,50,53,55,56,58,59,60,61; controlling behavior (n=8) 9,13,26,28,32,38,50,61; unemployment or financial stress (n=9) 11,12,21,24,30,31,43,48,59; low education (n=10) 11,24,29,30,41,50,53,59,60,63; partner’s engagement in multiple relationships (n=3) 11,33,56; higher age of partner (n=3) 41,59,60 ; More children in the family (n=11) 1,2,3,7,16,24,28,31,33,41,42; At least one female child (n=4) 15,21,28,62; Length of relationship (Mixed findings: longer duration >3-5 years (n=5) 2,3,24,31,50 and shorter duration < 3 to 5 years (n=3) 7,40,53; Family type (Mixed findings: nuclear (n=4) 20,28,41,59; joint (n=1) 21; controlling behaviors of in-laws (n=1) 46 ; female headed household with wife being the main source of income (n=4) 12,13,28,57	Longer duration of marriage > 5 years (n=2) 20,34; Wife’s joint control of partner’s income and joint household decision making (n=5) 9,39,45,55,63; Partner’s skilled employment or higher earnings (n=2) 6,29; In-laws providing financial support) (n=1) 25
Individual Level (Woman’s Characteristics)	Women’s employment (Mixed findings: Employment (n=21) 3,6,8,10,11,12,13,14,16,29, 30,31,33,34,39,41,43,45,46,50,57, Unemployment (n=2) 20,59; Education (Mixed findings: No or low education (n=17) 2,7,9,16,21,26,28, 29,34,38,41,50,53,55,57,59,60, Higher education (n=5) 6,15,40,52,54; Low socio-economic status (n=18) 1,2,7,13,14,16,21,24,30,32,40,41,46,47,50,55,59,60; Women’s minor age at marriage <18 years (n=9) 2,5, 20,28,29,32,33,44,45; Previous miscarriage or death of a child (n=2) 8,14; unwanted pregnancy (n=2) 8,17; wife’s contraception use to prevent pregnancy (n=2) 10,17; separated/divorced (n=2) 1,50; refusal of sex to a male partner (n=1) 63 Age (Mixed findings: Increase in age (n=5) 3,7,29,30,57, Larger age gap between partners (n=2) 2,51; Residence (Mixed findings: Rural residence (n=7) 2,16,28,41,42,57,60; Urban residence (n=2) 3,5; Poor mental health (n=1) 39; Substance abuse problems (n=2) 30,60; HIV positive status (n=6) 1,10,37,41,42,61; History of abuse by non-partners (n=1) 61; childhood exposure to DV (n=6) 28,32,41,50,60,61; Seeking help for DV (n=2) 33,50; Sexual & financial autonomy and freedom of movement (n=5) 2,28,43,45,54	Woman’s higher education (n=12) 2,3,4,20,28,29,33,34,38,39,55,57; Household decision making, sexual & financial autonomy and freedom of movement (n=7) 2,8,12,19,28,50,63; Woman’s age at marriage > 18 years (n=5) 9,10,20, 25,39; property ownership (n=2) 39,56; Exposure to mass media educating about DV, legal aspects to seek help, knowledge about outside world and challenging social norms (n=2) 28,55; high socio-economic status (n=5) 3,6,29,36,56; (Employment Mixed findings: Employed (n=5) 9,28,33,38,52, unemployed (n=2) 34,55; Urban residence (n=4) 29,50,52,55

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The systematic review was also used to identify correlates at different levels that could protect women from DV or prevent future DV. At the sociocultural and community levels, greater gender equity ideologies (n=1), and wife’s social support from the community (n=1) respectively, were found to be protective against women’s victimization by DV. At the interpersonal/relationship level, empowerment where wives had joint control of partner’s income and made joint household decisions (n=5) were significant protective factors. At the individual level, women who had higher education (n=12), were married at >18 years of age (n=5), were empowered in household decision making, had sexual and financial autonomy and freedom of movement (n=7), were employed, or had higher earnings than their partner (n=5), and who came from higher socioeconomic statuses were at a reduced risk of DV.

Although the findings on correlates such as women’s education and empowerment were mixed with these correlates reported as risk correlates in some studies and protective correlates in other studies, most studies reported these as protective. For example, empowerment in household decision making, financial and sexual autonomy, and freedom of movement was more frequently reported as protective (n=7) than as a risk factor for DV(n=5). Similarly, a woman’s higher education was more frequently reported as protective (n=12) than a factor that enhanced risk for DV (n=5). However, most studies reported women’s employment being significantly associated with increased DV (n=21) than reducing the risk for DV (n=5).

Qualitative Findings

Barriers for Seeking or Receiving Help for DV

At the socio-cultural level, adherence to patriarchal norms, family honor and justification of wife beating were barriers to seeking or receiving help for DV. At the community level, factors related to police involvement and inadequate help from police were significant barriers. At the relationship level, family obligations were a barrier. Barriers at the individual level was identified as learned helplessness (Table 3).

Table 3.

Participant Quotes

Barriers for Seeking or Receiving Help for DV	Illustrative Quotes
Patriarchal Norms and Justification of Wife Beating	Problems happen because no one listens to the woman (Participant 2).
	If the wife does something wrong. Like if she goes in the wrong road, or if she is using up the money for expenses, or if she is not fulfilling her responsibilities in the house. Then, the husband is compelled to hit her. Then he’s right to hit her because it’s for a reason. Then it’s fine (Participant 14).
Need to Protect Family Honor	My parents had told me that whoever I marry, with honor I have to spend the rest of my life with him, and so it was nothing but this honor that I was after… I’m not afraid of people. I just want to maintain the honor of my maternal home, my parents, and my in-laws (Participant 1).
	My mother would tell me before marriage, that I should be able to tolerate. I should remember that I need to stay with my husband for the rest of my life, whether it’s for better or for worse. If a woman considers her husband her life, she will have a fulfilled life (Participant 4).
	Three times I came home. They [parents] tried to convince me and then sent me back (Participant 14).
Perceptions of the Police	So much has happened to me, but even then, I didn’t call the police (Participant 1).
	Someone who is fed up with her husband would call the police. But even in a situation like that, no one calls the police (Participant 9).
	Many times, I thought I should get him beaten a little by the police; that would straighten him up. But I never got the courage (Participant 10).
	Anywhere you go, people just listen to money. Whether it be at the police station, or anything, you just give them money and tell them what to do and they do it. No one listened to me (Participant 2).
	We went to the police station. I put in an application here, and then they buried it for 20,000 rupees (approx. 265.9 USD) (Participant 5).
	I had the letter the police wrote. I could not file a complaint because my husband could be at the police station waiting for me. He would just beat me and drag me back to his home (Participant 5).
Family Obligations	I left so many times. Sometimes for 15 days at a time to a month, I would go stay with my mother. I planned on leaving him, I even told them to bring my children to me, but then I kept going back for my children. (Participant 11)
	I realized that I live for my children and husband, so I have to compromise to be with them. Before I thought I could earn myself and live on my own, but that’s no more (Participant 3).
Learned Helplessness.	Why would I call this life successful? When I’ve endured so much, what is left (Participant 1)?
	I kept everything within me. I think about things, but I don’t respond to anything, regardless of how anyone treats me. I’m very timid (Participant 2).
	When I was being beaten, the people at home would look on and laugh at me, so why would I do anything for anyone else. The neighbors would look at the spectacle, as if it’s something I deserve (Participant 1).
Facilitators for Seeking or Receiving Help for DV	Illustrative Quotes
Community Resources	There is so much persecution of women, so services should definitely be there… the government should do something to make us safe (Participant 3).
	There should be help for women whose husbands abuse them. They should teach the husbands. For some days, they should lock them up and beat them, so they understand what the pain is like. And since he threatens to leave me, there should be endeavors like MAMTA (non-profit) to help women. If he tells me to leave, then I have somewhere to go where they would help me. (Participant 4)
	The government should provide services to help unemployed men get jobs. There should also be services to help pay the fees for children’s education and give jobs to those providing for children. Children should also receive uniforms from the government to attend school. (Participant 3)
	She should file a complaint with the police. There are a lot of women who have this problem, and it’s been solved. The police can figure out what the fight is about, and can talk to them both and find the problem. (Participant 12)
Support from Family, Friends and Neighbors	My family hasn’t changed at all. They are exactly as they were before. They try to support me as much as possible. They never make me feel like I’m an outsider after marriage. They will do whatever I need, I just need to tell them. I am not forced to do anything. (Participant 5)
	My family was with me. They supported me through everything. Whenever I told them anything, they said to leave, get educated and become independent (Participant 6).
	Whenever something happened, Mummy and Papa would do something such as getting me money, or if the children needed clothes, then Mummy and Papa would get that done for them. My husband did nothing (Participant 14).
	My dad sent them a notice saying that if my sister-in-law or mother-in-law hit me, or if anything happened to me, then they [in-laws] would be responsible. He would send me back if they signed the notice. Then they stopped hitting me. (Participant 3)
	My friend told me to fight and stay happy. Whatever happened, happened, but the future shouldn’t be worsened by it. You only get one life. I share everything with him, and he gives me the strength to fight (Participant 2).
	Some people would see him hitting me with a slipper and snatched the slipper away from him. A few other people, when they saw him insulting me, they would come between us and save me (Participant 1).
Economic Independence	It doesn’t matter that my husband doesn’t give me money, because I can work hard and earn my own money. In Delhi (India), no one stays hungry, people work hard and earn their food, they’ll do anything like scrubbing people’s floors. (Participant 1)
	I’m good at cooking, and I know how to do beauty parlor work very well. I feel like the day I try doing a job, I’ll save myself from him (Participant 2).
Inner Strengths	I take responsibility for my children. I fulfill my duties as a wife in society. I have the strength to fight life’s problems (Participant 3).
	I would say that women should stand up for themselves. These days, men aren’t everything, women also have a voice. They need to take their rights. They should stand up against the things happening to them, so that the same things don’t happen to other people (Participant 2).
	She shouldn’t tolerate the injustice. She should become independent. It depends on the husband’s temperament; we can’t say anything about him. I have no idea how to handle that (Participant 6).
	I went to the center because regardless of whether my husband liked it or not, I wanted to be able to stand on my own two feet. Once I am independent, I won’t listen to anyone, I won’t be backed into a corner. I’ll be able to feed my own children. That’s why I went to the center and learned to sew (Participant 4).
Religion/Faith	It is only because of my courage that I’m able to survive on my own, otherwise I don’t have a father’s or mother’s or anyone’s support. It’s only because God has given me so much courage, that I can survive on my own (Participant 1).
	I would talk to her about my problems and how I dealt with it. You never know, Allah may remove all her problems as well (Participant 9).

Patriarchal Norms and Justification of Wife Beating.

Some women (n=5) did not seek help for abuse or try to help other women facing abuse because of their justification of wife beating. Being raised in a society with strict gender norms, abuse was normalized in their families. Overall adherence to such norms was also a barrier to women receiving help for abuse: Problems happen because no one listens to the woman (Participant 2).

Commonly identified reasons for justification of abuse by women were if a woman is having an affair, not taking care of her family, talking back to her husband or in-laws, spending money, or making any mistake. One participant justified that it was acceptable for men to mildly abuse their wives during an argument and that the wife should not argue back to prevent further abuse. These participants felt that if the woman made no mistake, then the abuse was unacceptable. For example, a participant shared:

If the wife does something wrong. Like if she goes in the wrong road, or if she is using up the money for expenses, or if she is not fulfilling her responsibilities in the house. Then, the husband is compelled to hit her. Then he’s right to hit her because it’s for a reason. Then it’s fine

(Participant 14).

Need to Protect Family Honor.

Family honor prevented some women (n=4) from seeking help for abuse. Stigma of IPV and blaming the woman and her parents for her abusive situation led women to continue to endure abuse and kept them from seeking help. One participant stated that:

My parents had told me that whoever I marry, with honor I have to spend the rest of my life with him, and so it was nothing but this honor that I was after… I’m not afraid of people. I just want to maintain the honor of my maternal home, my parents, and my in-laws

(Participant 1).

One participant described how her mother talked to her about staying in a marriage because that was essential for a girl to live a fulfilled life.

My mother would tell me before marriage, that I should be able to tolerate. I should remember that I need to stay with my husband for the rest of my life, whether it’s for better or for worse. If a woman considers her husband her life, she will have a fulfilled life

(Participant 4).

Lack of parents’ support and their need to protect their image in the community was also a barrier to addressing abuse: Three times I came home. They [parents] tried to convince me and then sent me back (Participant 14).

Perceptions of the Police.

When asked about asking police for help, some women identified that if the abuse was severe or if they felt that their life was in danger, then they should contact the police. However, the same women (n=6) shared their hesitancy in reaching out to the police. One factor was the perception that their situation did not warrant police involvement: So much has happened to me, but even then, I didn’t call the police (Participant 1). Another participant stated: Someone who is fed up with her husband would call the police. But even in a situation like that, no one calls the police (Participant 9). Lack of courage was another barrier: Many times, I thought I should get him beaten a little by the police; that would straighten him up. But I never got the courage (Participant 10).

Two participants identified lack of trust in the police and legal system, stating that money played a huge factor in whether their complaints were taken seriously. Anywhere you go, people just listen to money. Whether it be at the police station, or anything, you just give them money and tell them what to do and they do it. No one listened to me (Participant 2).

Similarly, another participant cited how she did file a formal complaint, but her husband and his family had bribed the police, so she never received any help: We went to the police station. I put in an application here, and then they buried it for 20,000 rupees (approx. 265.9 USD) (Participant 5).

Fear of retaliation from the abuser was another barrier. For some women abuse increase with reporting: I had the letter the police wrote. I could not file a complaint because my husband could be at the police station waiting for me. He would just beat me and drag me back to his home (Participant 5).

Family Obligations.

Some women (n=2) reported staying in their abusive marriages and not seeking help because of their children and the perception that leaving the abuser will only hurt the children. Their children were dependent on them and would need their father for financial support.

I left so many times. Sometimes for 15 days at a time to a month, I would go stay with my mother. I planned on leaving him, I even told them to bring my children to me, but then I kept going back for my children.

(Participant 11)

Another woman identified how she lost her individuality and had to change her life to suit her family obligation. She was not independent because she had to be there for her children, and husband. As a result, she was not able to pursue a career or support herself, which was a barrier to seeking help for abuse in marriage: I realized that I live for my children and husband, so I have to compromise to be with them. Before I thought I could earn myself and live on my own, but that’s no more (Participant 3).

Learned Helplessness.

Several women (n=5) were not able to seek help or leave their abuse because of their learned helplessness. Because they have endured abuse for so long and have not been able to change their current situation, they did not try to seek help. Additionally, the way they coped with the abuse prevented them from seeking help. Not feeling empowered or strong enough has forced them to stay in the relationship with their abuser. One participant felt that her life was unsuccessful and lost faith in other possibilities: Why would I call this life successful? When I’ve endured so much, what is left (Participant 1)? Four women specifically cited how their timid and obedient personality prevented them from standing up for themselves. These women were not as confident and accepted that this was their life. For example, a participant shared: I kept everything within me. I think about things, but I don’t respond to anything, regardless of how anyone treats me. I’m very timid (Participant 2).

One participant was never supported by her neighbors or people who witnessed the abuse. This discouraged her and prevented her from helping herself as well as other women who could be experiencing abuse: When I was being beaten, the people at home would look on and laugh at me, so why would I do anything for anyone else. The neighbors would look at the spectacle, as if it’s something I deserve (Participant 1).

Facilitators for Seeking or Receiving Help for DV

Participants shared that factors that facilitated help seeking and receiving help for abusive situations involved available resources in the community, support from family, friends and neighbors and economic independence. Other facilitators of addressing abuse were women’s own strengths and use of religion or faith to cope with abusive situations.

Community Resources.

According to participants (n=4), having support from the community and government could help them become economically independent, empowered, and provide an opportunity to live abuse-free lives. A participant highlighted the need for services for safety: There is so much persecution of women, so services should definitely be there… the government should do something to make us safe (Participant 3). Another participant stated that the services should focus on abuser’s behavior as well as supporting the woman being abused:

There should be help for women whose husbands abuse them. They should teach the husbands. For some days, they should lock them up and beat them, so they understand what the pain is like. And since he threatens to leave me, there should be endeavors like MAMTA (non-profit) to help women. If he tells me to leave, then I have somewhere to go where they would help me.

(Participant 4)

Financial stress in the family being a significant risk factor for abuse of women, a need was highlighted for policies to meet basic needs:

The government should provide services to help unemployed men get jobs. There should also be services to help pay the fees for children’s education and give jobs to those providing for children. Children should also receive uniforms from the government to attend school.

(Participant 3)

Although there was hesitancy in reaching out to the police for help, one participant stated how important it is for women in abusive relationships to get the police involved in order to find a solution to their problem:

She should file a complaint with the police. There are a lot of women who have this problem, and it’s been solved. The police can figure out what the fight is about, and can talk to them both and find the problem.

(Participant 12)

Support from Family, Friends and Neighbors.

Although, there were instances when women in abusive relationships were not supported by their family and friends due to family honor or societal expectations, still several women (n=10) experienced support from their parents, siblings, and friends. This support was perceived as important for these women because their parents could question their husbands and his family, provide her shelter when the abuse was unbearable, and allowed her to seek help.

Contrary to what some women said about family honor and expectations, this participant stated:

My family hasn’t changed at all. They are exactly as they were before. They try to support me as much as possible. They never make me feel like I’m an outsider after marriage. They will do whatever I need, I just need to tell them. I am not forced to do anything.

(Participant 5)

Family was a source of resilience and empowerment:

My family was with me. They supported me through everything. Whenever I told them anything, they said to leave, get educated and become independent (Participant 6).Another participant also stated how her parents supported her by providing her with money and supplies for her and her children while she was with her husband: Whenever something happened, Mummy and Papa would do something such as getting me money, or if the children needed clothes, then Mummy and Papa would get that done for them. My husband did nothing (Participant 14).

For one woman, getting her family involved helped stop the abuse:

My dad sent them a notice saying that if my sister-in-law or mother-in-law hit me, or if anything happened to me, then they [in-laws] would be responsible. He would send me back if they signed the notice. Then they stopped hitting me.

(Participant 3)

Additionally, friends have been a source of moral support helping women build the strength to stand up for themselves and finding resources to support them. My friend told me to fight and stay happy. Whatever happened, happened, but the future shouldn’t be worsened by it. You only get one life. I share everything with him, and he gives me the strength to fight (Participant 2).

In some cases, neighbors and people outside the family intervened to help women being abused: Some people would see him hitting me with a slipper and snatched the slipper away from him. A few other people, when they saw him insulting me, they would come between us and save me (Participant 1).

Economic Independence.

Women expressed that economic dependence and poverty were one of the main reasons why they continued to endure abuse in marriages. Financial independence (n=2) was perceived as a factor in ability to address abuse:

It doesn’t matter that my husband doesn’t give me money, because I can work hard and earn my own money. In Delhi (India), no one stays hungry, people work hard and earn their food, they’ll do anything like scrubbing people’s floors.

(Participant 1)

Another participant believed that economic independence could protect her from her abuser: I’m good at cooking, and I know how to do beauty parlor work very well. I feel like the day I try doing a job, I’ll save myself from him (Participant 2).

Inner Strengths.

Although learned helplessness prevented women from seeking help, women who were empowered and more resilient were able to leave their abuser (n=4). They were able to stand up for themselves and face the challenges in their lives. One participant stated that she felt she was resilient and strong enough to face her issues. She also had the confidence in her abilities and her role as a mother and wife: I take responsibility for my children. I fulfill my duties as a wife in society. I have the strength to fight life’s problems (Participant 3).

When asked what advice they had for other women, three participants who left their abuser stated very strongly that women have rights as well and a sense of individuality. They deserved justice, and these participants felt that women need to stand up for themselves. They supported women becoming more resilient and empowered, so they did not have to keep enduring their abuse. For example, one participant stated.

I would say that women should stand up for themselves. These days, men aren’t everything, women also have a voice. They need to take their rights. They should stand up against the things happening to them, so that the same things don’t happen to other people

(Participant 2).

Another participant echoed the same sentiment: She shouldn’t tolerate the injustice. She should become independent. It depends on the husband’s temperament; we can’t say anything about him. I have no idea how to handle that (Participant 6).

One participant shared how her urge to be independent and support herself and her children led her to seek help through a center (non-profit organization) for support. It was important for her to have her own source of income and she was empowered enough to seek that support.

I went to the center because regardless of whether my husband liked it or not, I wanted to be able to stand on my own two feet. Once I am independent, I won’t listen to anyone, I won’t be backed into a corner. I’ll be able to feed my own children. That’s why I went to the center and learned to sew

(Participant 4).

Religion or Faith.

Religions and faith were strong factors in how women coped with their abuse. Additionally, many women (n=8) said that religion and their faith was a source of happiness and strength and offered other women to turn to their faith as advice. These participants stated how God gave them the strength to endure the challenges they faced with their abuser and his family. They believed that praying would eventually stop their abuse and lessen their problems. Religion helped these women stay grounded and, in some situations, it was a source of resilience for these women. For example, a participant shared.

It is only because of my courage that I’m able to survive on my own, otherwise I don’t have a father’s or mother’s or anyone’s support. It’s only because God has given me so much courage, that I can survive on my own

(Participant 1).

When asked if they have advice for other women experiencing abuse or ways to help them, women also suggested that faith and prayer will help them with their problems: I should tell her my solutions. I would talk to her about my problems and how I dealt with it. You never know, Allah may remove all her problems as well (Participant 9).

Discussion

We will now discuss our findings from both the systematic review and qualitative data utilizing a socio-ecological framework. Interestingly, in our systematic review, economic independence was a risk factor of DV victimization at the individual level. While economic independence can help women break free from abuse, women’s employment was the most frequently reported factor that was associated with women’s experiences of DV. in the quantitative literature. Since we could not establish cause and effect due to cross-sectional nature of the studies reviewed, it is possible that DV may have caused some women to secure employment as a means of financial support. For employment to serve a protective role, there is need for awareness and modified cultural norms against rigid gender roles (Dalal, 2011; Sabri et al., 2014). We also noticed that partner’s addiction (e.g., substance abuse), controlling behaviors and having more children in the family were the most frequently reported correlates of DV at the interpersonal level. Partner’s problem with addiction, financial stress along with the responsibility of large number of children in the family as an added source of stress can further contribute to DV in families as seen in previous research (Campbell et al., 2003; Sabri, Nnawulezi, et al 2018).

In our qualitative analysis, we found barriers and facilitators of women’s help-seeking or confronting abuse. Some of these were adherence to patriarchal norms and justification of wife beating. Similar factors of supporting male dominance and attitudes supportive of violence against women, were also found to be significantly associated with enhanced risk for DV in the quantitative literature. Violence normalized as an everyday occurrence is a part of patriarchal ideology prominent in the Indian society, which impacts women’s willingness to address abuse in their lives. Further, in a collectivist society such as India, the norms and ideals surrounding appropriate behaviors and roles of women are often associated with the honor and reputation of the entire family (Stephens & Eaton, 2020). Thus, many women continue experiencing abuse in the name of protecting family honor or Izzat (Sabri & Young, 2021).

We observed thorough our qualitative findings that hesitancy to involve police was found to be an additional barrier to help-seeking. One of the reasons for hesitancy was inadequate response of the police including failure to act against the perpetrators and/or dismissing complaints through bribery. The findings on hesitance to call the police are similar to survivors of DV in other countries, including the U.S. (Hayes, 2013; Rai et al., 2022; Yoshihama et al., 2013). Women may not seek help because of the fear of repercussions of involving the police or due to minimization of DV by the police. Further, focus of the criminal justice/law enforcement system on isolated incidents do not capture the complexities of DV situations and how ongoing power and control and other systems of oppression can impact women in abusive relationships (Hayes, 2013). This incident-based focus of the police can be a barrier to help for women who have been living in abusive environments, with lack of support from their families and communities. The lack of support and inadequate help from the police can also be attributed to norms and attitudes that support male dominance in the family and normalize DV as a family matter (one of the risk correlates identified in our systematic review of quantitative literature).

In the qualitative analysis, facilitators of addressing abuse were found to be access to community resources such as resources for economic empowerment, and social support. Other facilitators of addressing abuse were women’s own strengths and use of religion/faith to cope with abusive situations. In the systematic review, women’s high education, empowerment, financial and sexual autonomy, joint household decision making, and high socio-economic status were protective factors against abuse. Social support from neighbors and family were also additional protective factors. Both external and internal sources such as support from family, friends, and neighbors as well as religious faith and beliefs have also been found to help abused women in other cultures or countries of origin (Sabri et al, 2020). Thus, key components needed for intervening with abused women in India are programs facilitating overall empowerment including economic independence and encouraging women to access trusted informal sources of support for safety. These components were identified as common protective factors in both our systematic review of existing literature and the analysis of qualitative data (Figure 2).

Figure 2.

An Ecological Framework of Common Risk and Protective Correlates of Domestic Violence in both Quantitative and Qualitative Findings

Strengths and Limitations

An important strength of this study lies in its ability to summarize the correlates of DV, while simultaneously drawing from qualitative experiences about help-seeking. Despite the novel contributions of this research, there are some limitations associated with it. The qualitative portion of the study being limited to northern region of India may impact the transferability of the study results given the geographical and cultural diversity across India. However, the quantitative portion was not limited to any geographical region and used findings across India which strengthens our findings. Systematic reviews while rigorous are associated with the subjectivity of the research team. However, we maintained a detailed record of the decision points for included versus excluded studies for complete transparency. Lastly, multiple points of data are needed to establish consistency of barriers and facilitators for help-seeking which is also a limitation. Notwithstanding the limitations of this study, it is the first one to present findings by drawing from a systematic review and qualitative interviews about the risk and protective factors of DV and barriers and facilitators of help-seeking among Indian women, adding to the new evidence.

Implications for Research and Practice

There is need for additional research with participants across India to have a broader regional representation of barriers and facilitators of addressing abuse among families. Further studies are needed to assess risk and protective factors of DV in under-researched regions in India. Focus group interviews or observations with service providers can also impart a depth of information regarding experiences of abuse. Triangulating information through multiple sources of data collection can be pivotal in strengthening findings. It would also be helpful for scholars in the future to explore the grey literature including agency and other technical reports to investigate the risk and protective factors relating to abuse.

Our findings on risk and protective correlates of DV at multiple levels of the socio-ecology highlight the need for evidence-based DV prevention and intervention approaches to be implemented at multiple levels (e.g., community, society, family) in India. There is a need for approaches that address multiple drivers of DV such as gender inequality and partner’s addiction problem, including the most important drivers of DV in women’s lives. Recent reviews of literature on global interventions identified multiple drivers of violence against women as one of the key characteristics of successful interventions (Kerr-Wilson, 2020). Moreover, the programs could incorporate training of healthcare providers, law enforcement professionals and other providers who encounter survivors of DV so that they can provide trauma-informed services to meet survivors’ needs.

Given the study findings, it is evident that there is an urgent need for change in social norms and practices that promote violence against women. Some study participants described family to be a protective factor and a source of support. Others described family as a deterrent by not allowing women to escape DV. This calls for culturally informed family and community-based intervention programs that address norms promoting gender inequalities and cultural normalization of abuse. Similar interventions have been developed for the South Asian community in other countries including the U.S. (e.g., Yoshihama et al., 2011; Yoshihama & Tolman, 2015). Engaging with family members along with survivors of DV is necessary for a large-scale shift in gender-inequitable norms, norms that place burden of family stability only on women, and norms that dissuade help-seeking. Developing interventions to have conversations around DV and ways in which family members can support individuals experiencing DV can be important in providing timely support to survivors. Bystanders can play an active role in providing support to survivors of DV and encouraging survivors to seek help. Additionally due to the importance of religion in South Asian culture and our findings on religion being a protective factor, faith-based interventions are needed that engage religious leaders in spreading community awareness around issues of DV (Sabri et al., 2018). Interventions addressing traditional gender role expectations without threatening the husband’s position in the family (Sabri et al., 2018) can also play a role in reducing DV among families in India.

Financial independence can increase women’s ability to support themselves and their children once they decide to break free from an abusive relationship. Policies are needed to provide interest free student loans and caretaking facilities along with job assistance programs for women struggling to support themselves. It is also important for government agencies to introduce public provisions such as microfinance or small loans in conjunction with vocational training programs (International Finance Corporation, 2018). Non-governmental organizations, supported by government as well as international funding, can be encouraged to provide livelihood training and employment opportunities to women in DV relationships, so that they have the financial independence and opportunity to escape abusive relationships.

Ultimately, it is vital for community agencies to make women aware of the laws concerning DV in India. There exist legal mechanisms such as the Protection of Women from Domestic Violence Act, 2005 and the Dowry Prohibition Act, 1961. Women experiencing DV may not be aware of the legal recourse available to them, therefore there is a sense of urgency in translating the policies to them. These efforts can be sustained through community awareness drives across India including rural and urban regions. Researchers and practitioners are encouraged to collaborate to engage with communities in unique ways to create awareness around these laws and reduce DV among Indian families.

Conclusion

The findings of our study highlight risk and protective factors of DV and barriers and facilitators of addressing DV. Our findings show that there is need to address risk factors and norms that promote violence against women at all sociological levels. For far too long, Indian women have succumbed to DV, therefore it is imperative for researchers and practitioners to collaboratively develop evidence-informed interventions to help shift harmful norms and address risk factors at multiple levels to reduce the risk of DV victimization. Efforts could be made to strengthen protective factors against DV and establish safe environments for women’s health, safety, and well-being. There is also need for efforts to address barriers and capitalize on the facilitators of seeking or receiving help for women in abusive relationships and empower them to break free from abuse.

Appendix

List of Search Terms

(‘risk’ OR ‘protective factors’ OR ‘barrier*’ OR ‘facilitator*’ OR ‘strategies’ OR ‘strategy’ OR ‘health resource*’ OR ‘intervention*’ OR ‘safety’ OR ‘psychological resilience’) AND (‘domestic violence’ OR ‘intimate partner violence’ OR ‘battered women’ OR ‘spouse abuse’ OR ‘spousal violence’ OR ‘abused women’) AND India

Section and Topic	Item #	Checklist item	Location where item is reported
TITLE
Title	1	Identify the report as a systematic review.	N/A
ABSTRACT
Abstract	2	See the PRISMA 2020 for Abstracts checklist.	Appendix
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of existing knowledge.	6-7
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses.	7
METHODS
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.	9
Information sources	6	Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.	8
Search strategy	7	Present the full search strategies for all databases, registers and websites, including any filters and limits used.	8
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.	9
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.	9
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.	9
	10b	List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.	9
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.	9
Effect measures	12	Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results.	N/A
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).	9
	13b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.	Table 2
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses.	Table 2
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.	8-12
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression).	N/A
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results.	N/A
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).	9
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.	6-9
RESULTS
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.	12, Figure 1; 12-14
	16b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.	N/A
Study characteristics	17	Cite each included study and present its characteristics.	Table 2
Risk of bias in studies	18	Present assessments of risk of bias for each included study.	9
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots.	N/A
Results of syntheses	20a	For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.	N/A
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.	N/A
	20c	Present results of all investigations of possible causes of heterogeneity among study results.	N/A
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.	N/A
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.	N/A
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.	N/A
DISCUSSION
Discussion	23a	Provide a general interpretation of the results in the context of other evidence.	23-24
	23b	Discuss any limitations of the evidence included in the review.	25
	23c	Discuss any limitations of the review processes used.	25
	23d	Discuss implications of the results for practice, policy, and future research.	26-28
OTHER INFORMATION
Registration and protocol	24a	Provide registration information for the review, including register name and registration number, or state that the review was not registered.	N/A
	24b	Indicate where the review protocol can be accessed, or state that a protocol was not prepared.	N/A
	24c	Describe and explain any amendments to information provided at registration or in the protocol.	N/A
Support	25	Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.	N/A
Competing interests	26	Declare any competing interests of review authors.	Title page
Availability of data, code and other materials	27	Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.	N/A

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71

For more information, visit: http://www.prisma-statement.org/