Domestic violence among women in slums: scope for public health intervention

INTRODUCTION

Domestic violence as a major human rights violation and public health issue, incurring significant costs on individuals, families, communities, and societies, has gained prominence in academic scholarship and policymaking since a few decades.^1,2 Intimate partner violence is domestic violence perpetrated by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviors. Population-level surveys reveal that globally, almost one-third of women aged 15-49 years and in a relationship, have faced physical and/or sexual domestic violence or abuse.³ In India, the National Family Health Survey (NFHS-4) reports 28.8% and 22% of women being subjected to physical and/or sexual intimate partner violence in their lifetimes and in the twelve months preceding the survey, respectively.⁴ The partial findings from the fifth round of the survey indicate a rise in domestic violence among married women in some states of the country.⁵ Similarly, the National Crime Records Bureau (NCRB) 2019 data show that around 31% of the 4.05 lakh cases under crimes against women/cruelty by husbands are registered under Section 498A of the Indian Penal Code. In other words, spousal violence tops the list of categories of violence against women in India.⁶ Domestic violence takes direct and indirect toll on victims’ long-term physical and psychosocial health. Public health research on the topic drawing from an interdisciplinary pool of knowledge has focused on the health, safety and well-being of victims as well as on the intersection of individual attitudes and interpersonal and community-level factors like social norms and practices.^7,8

Slums have been defined as those residential areas where dwellings are unfit for human habitation for reasons of dilapidation, overcrowding, faulty arrangements and designs of buildings, narrowness or poor arrangement of streets, lack of ventilation, light, sanitation facilities, or any combination of these factors which are detrimental to safety, health and morals.⁹ It is to be noted that 65.49 million people in India live in 13.9 million households that have been enumerated as slums across 2,613 cities and towns. The slum population constitutes 17.4% of the total urban population in the country.¹⁰ Slum life has been challenging for the urban poor in so far as housing and living conditions are concerned. Factors like low income, limited education, insufficient nutrition, overcrowding, alienation, social instability, and insecurity lead to high susceptibility to physiological and psychological stress among the slum-dwelling population.^11,12

Slums characterized by such material and social configurations provide scope to understand the phenomenon of domestic violence among women as intertwined with the larger community processes and also in relation to the degree of availability of legitimate resources.^13,14 There are various studies that show the ubiquity of domestic violence in slums in India. The estimates of ever-experienced domestic violence faced by women living in such settings have ranged from 21.2%, 36.9%, 54% to as high as 61.2%.^15,16 Alcoholism, poverty, illiteracy, unemployment of husband, accusations of failing to become an ideal wife, extra-marital affairs of husbands, suspicions on wives, dowry, and the expectation of a son have been demonstrated as key reasons for perpetrating domestic violence against women in slums. Less educational attainment of spouse, less satisfaction with wedding-related gifts provided by the bride's family, poorer conflict negotiation skills, and greater acknowledgment of domestic violence occurrence in family and friends have also been found to increase the risks of violence. Fear of retaliation, societal reasons, respect for parents, concern for children and economic dependence compel battered women to continue remaining in abusive relations. Poor knowledge of rights and laws and lack of adequate access to support services are some of the other reasons.^17,18 A higher prevalence of domestic violence in the slum population as compared to the general population has also been reported.^19,20

Though there has been a surge in empirical research on domestic violence, there remains scope to explore the epidemiology of domestic violence, specifically its manifestation in the lives of slum-dwelling women in India and its implications on public health.

Aim

The present study aims to explore the pathways to and experiences of domestic violence among women in the context of specific realities of a slum in the city of Kolkata, India. It analyzes women’s perceptions of domestic violence and examine their personal coping mechanisms, including the scope for community-based social support and public health interventions.

METHODS

Study participants

A qualitative exploratory research design was used to understand experiences of domestic violence among 30 married women residing in a slum of Ward 13 of the Kolkata Municipal Corporation, which mostly consists of residents who migrated from villages of neighboring districts of West Bengal in search of work and eventually settled in the city. All the women interviewed were Hindus. They had children and resided with their husbands and in-laws. Five participants were homemakers while the others worked as house-helps or caregivers of older persons in the neighborhood. Their husbands did not have regular income and mostly worked on a contractual basis as car drivers, masons or security guards. The socio-demographic characteristics of the women are presented in Table 1 given below.

Data collection and analysis

Purposive sampling was used to identify the participants who were married for a minimum period of five years. Face-to-face interviews using an unstructured interview schedule were held with each participant in the local community club during the period January to March 2020. The questions were mostly open-ended which gave adequate scope to the participants to narrate their experiences. Each interview lasted between one to 1.5 hours. Informed consent was obtained from each woman prior to the interview. Given the sensitivity of the topic, participants were informed of the voluntary nature of participation. Confidentiality of their responses was ensured.

Thematic analysis of the narratives was used in analyzing data to identify, analyze and report repeated patterns.²¹ The researchers engaged in coding under potential themes and subthemes in relation to the entire dataset based on the underlying meanings implicitly discovered through the subjective understandings of the participants. The interview transcripts originally in Bengali were translated into English and a coding system was organized to manually develop codes and themes from recurring and significant insights and passages, capturing experiences of violence as revealed in the narratives.

RESULTS

This section presents the major thematic findings of the study. Nine categories emerged from the interviews which were then condensed into three themes as shown below.

Categories- physical battering, forceful sexual acts, lack of contraception, early marriage, absence of financial autonomy, past exposure of husbands to violence, chronic pain and health concerns, irregular access to legal and health services and acceptance of fate.

Themes- encountering routinized violence, retrospection on the nature of marriage and negotiating with health consequences of violence.

Encountering routine violence

All participants revealed that they faced frequent and systematic assaults including slapping, pushing, punching on the chest, and pulling hair by their husbands. These injuries led to pain, cuts on their foreheads, bleeding from the nose, swelling, and even fractures. Participants also expressed how they feel perpetually threatened by their husbands, especially under the influence of local alcohol or other addictive substances. Many women worked as house helps or informal caregivers but they had no control over financial matters. Their earnings were handed over to their husbands, who took decisions on financial expenditures, thereby reducing women to complete economic dependence on their spouses who did not have any regular employment. Two women narrated incidents of allegedly being trafficked by their husbands. A majority of the women also confirmed that their husbands had encountered patterns of violence between their parents in the past.

Retrospection on the nature of marriage

The women in the study reflected upon the circumstances in which they got married and used that as the vantage point to carve out their status within the institution of marriage. It was found that a majority of the participants got married around the age of 14 years, an intermediary stage of puberty. Some marriages took place against the wishes of parents as a result of which women had to sever ties with their natal families. Some perceived marriage as an escape from the already difficult circumstances in families of orientation, or were driven by romanticism and urge to start a conjugal family early in life, with the assumption that marriage would possibly secure happiness and economic well-being. Violence, both physical and sexual, lies within the larger logic of marital relationship that exists between the partners. The women mentioned that their husbands were suspicious about them and abused them when they spoke with others, irrespective of the person being of the opposite or same sex, their neighbour or relative.

Negotiating health consequences of violence

Most of the women reported poor general health and chronic ailments such as body pain, nausea and gastrointestinal problems. The women also faced difficulty in carrying out daily activities as a result of injuries caused by particularly overt violent encounters. The victims also said that they often suffered from gynecological problems due to sexual violence. Unprotected and painful intercourse caused vaginal inflammation, lower abdominal pain and reproductive tract infections. Eight women said that excessive use of birth control pills affected their menstrual cycles. Victims also experienced stress due to the violence. The situation undermined their sense of security and confidence, some even mentioning how during certain points in their lives, they felt severely depressed. Some participants revealed the lack of support to address the issue of domestic violence and also shared that they had to visit a nearby clinic or government hospital for treatment of their injuries. During the medical interactions, they only made cursory references to the violence which caused the injuries.

DISCUSSION

The lived experiences of women enabled them to evaluate their own existence in the everydayness of inequality and continuous context of intimidation, which manifested in the patterned forms of physical and sexual violence. Consistent with existing literature, the study found evidence that a majority of husbands of the participants faced similar violence during their childhood and the past traumatic event triggered violence presently on their wives, reinforcing the role of childhood experiences in the etiology of relationship aggression. It was clearly evident that all the participants in the study started their families before the legal age of marriage. In many cases, the bride and groom were mere functionaries within a larger exchange. Such decisions to enter into roles of adulthood, along with poverty and lack of social security, the overarching patriarchal structures had its specific implications on the eventual marital relationship as well as on the scope for spousal violence. Though laws like

The Right to Education Act, 2009 and The Prohibition of Child Marriage Act, 2006 exist in India, early marriages are still rampant. While girls are usually judged for readiness for marriage on reaching puberty, attaining womanhood, and capacity to take up household responsibilities; for boys, it is primarily driven by attaining economic independence.²²

In slums, however, dropping out of education is very common even among boys in the urge to take up a job in the informal sector and support their families. The participants in the study chose marriage over the completion of education with the hope of a secure future with their partners. The role of holistic education for girls becomes critical to empower them with life skills, knowledge, and awareness about their health (including reproductive health), legal rights, and issues of gender equality, which can influence their life choices and decision-making capacities. Standard resource theory predicts that education and employment act as protective mechanisms against abuse, beyond their effect on income and wealth consistent with a household bargaining model. For the women under study, working outside families and a monthly income did not shield them from economic abuse as a constituent of violence, which establishes that the relationship between resources and violence is not necessarily linear, and comes with a possibility of a backlash, whereby increased resources lead to more abuse for women.

The Protection of Women Against Domestic Violence Act 2005 does not address such deep-seated cultural presumptions and power structures and attitudes regarding the position of women, which create impediments to reform.²³ Being a civil law, there is a tendency not to ‘interfere’ with domestic matters when violence is seen as a private act and this indirectly reconfigures the social norms of patriarchy. The implementation generally involves the police trying to settle the case without registering a complaint or at the most warning or detaining the abuser for a night, rarely putting the aggrieved woman in touch with the protection officer appointed in the jurisdiction of every judicial magistrate.²⁵

The study also revealed the association between violence victimization and an array of adverse health outcomes and the need for recognition of domestic violence in healthcare settings. Though some women mentioned accessing local clinics and hospitals due to overt violence-related injuries, none of them mentioned that they were asked to disclose in detail the incident of violence. The major lacuna is the lack of specific indicators and systematic documentation of data and of violence in clinical settings to identify protocols for screenings and referrals, develop and enhance programmes and policies. Primary healthcare workers, general practitioners, and emergency departments stand in key positions to routinely ask questions about violence, diagnose victims and refer them to appropriate services within and beyond healthcare. The question of preparedness and skills for identifying and responding to victims emerge crucial here.

Limitations of the study

The sample size of the present study had been limited to 30 women owing to the qualitative nature of the research. The small scale of study does not allow for generalizability of results. There also remains further scope for examining and comparing experiences of domestic violence in relation to various factors.

CONCLUSION

Women who participated in this study had a wealth of experience of domestic violence. Physical violence as well as forceful and unwanted sexual encounters characterized the everyday realities of the women. Women reported pain and physical injuries, as well as gynecological health problems due to physical and sexual violence. They were in perpetual stress, with some reporting having developed suicidal tendencies at certain points in their lives. Their narratives indicate how specific realities of urban slums like poverty, inadequate education, and early marriages created sustained trajectories of vulnerabilities and domestic violence. However, coping with patriarchal impositions and spousal violence included an acceptance of fate and resolution to stay in the marriage and ensure the well-being of their children.

Knowledge about and trust in the legal mechanisms were largely missing. Systematic healthcare utilization and public health interventions were also not reported. The narratives of women reveal the need for strengthening legislative efforts and fruitful conversations involving both men and women in the community around child marriage, gender equality, family planning, and reduction of harmful drinking. Simultaneously, addressing social inequalities and improving slum infrastructure to improve everyday urban community life also need to be examined closely in the agenda of addressing the issue of domestic violence. It is also imperative to move beyond solely a justice system approach and promote collaboration with preventive health and minimizing health effects of domestic violence. Health promotion based on an evidence-based intervention model is crucial for building the capacity to recognize signs of violence and to equip survivors of violence with knowledge, skills, resilience, and supportive environments. An inter-sectoral and integrated approach underpinned by a strong universal health system is critical to addressing the issue of domestic violence.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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