Intimate partner violence against women in slums in India.

The study by Begum and colleagues1 in this issue is of public health significance because it contributes to the body of evidence on socio-demographic factors related to intimate partner violence among women from urban slums in India. Such knowledge is needed for developing prevention and intervention strategies for abused women in slum settings. Further, it focuses on women in the reproductive age group, which is a high risk age group for intimate partner violence2 and related reproductive health concerns such as unintended pregnancies, sexually transmitted diseases and pregnancy complications3. Intimate partner violence and related fear limits women's ability to negotiate safe sex behaviours (e.g. condom use) and places them at risk for poor reproductive outcomes. Violence against women is a significant public health problem in India with prevalence estimates ranging from 6 per cent in one State (i.e. Himachal Pradesh) to 59 per cent in another (i.e. Bihar)4,5. Prevalence rates of intimate partner violence are approximately the same or lower/higher in slums areas than in the non-slum areas. In the National Family Health Survey (NFHS-3), the prevalence of violence against married women in various slum areas in India was reported to be between 23 and 62 per cent6. In the study by Begum et al1, nearly a quarter of the women in the slums reported experiencing violence by an intimate partner. The factors associated with intimate partner violence were early marriage, husband's alcohol use, women's employment, and justification of wife beating1. Indian women are exposed to intimate partner violence due to factors operating at multiple contextual levels in their lives. For instance, in India, factors such as cultural practice of dowry7, growing up witnessing violence8, presence of multiple children in the family9, forced sex10, partners’ threats of harm, jealousy and controlling behaviours11,12, and residence in areas with high murder rates13 have been found to be positively associated with intimate partner violence. Most of the risk factors for intimate partner violence identified in slums appear to be similar to those identified in non-slum settings in India. For example, women's employment has been found to be a risk factor for intimate partner violence in both slums and non-slum settings in India10,14,15,16,17. In Indian families with patriarchal norms, women with higher income or status relative to their partners are more likely to be seen as gender deviant and to face violence. Despite haing resources superior or sometimes equal to their abusive partners, women are unable to use those resources to reduce intimate partner violence17. Many risk factors for intimate partner violence are driven by patriarchal socio-cultural norms. Norms related to gender roles, community attitudes and the broader social context, including the media, play a significant role in the acceptance and promotion of intimate partner violence18,19. Women are lauded for silently suffering intimate partner violence but still staying home and not desisting from their expected roles as wives, mothers or daughters20. Although intimate partner violence occurs in all settings, abused women from the slums face distinct barriers in obtaining support and services, and, therefore, are especially at risk for poor health outcomes of intimate partner violence. Slum environment is characterized by low socio-economic status, unhealthy living conditions, and lack of basic services. These aspects play a role in women's vulnerability to abuse and their inability to break free from abusive relationships. Factors that enhance the stress level of families have been shown to increase the probability of intimate partner violence9. Research in the US suggests that features of the environment (e.g. poor housing) create situations of distress, dissatisfaction, stress and rage, which increase the likelihood of intimate partner violence21. Socio-economically disadvantaged neighbourhoods are associated with limited social ties/social control and increased social isolation, which limits an abused woman's ability to call upon resources to address intimate partner violence21. In a study of married men in India (N=4520), residence in areas characterized by high violent crime rates was found to be significantly associated with perpetration of both physical and sexual intimate partner violence against women13. Co-residence with in-laws who support/incite intimate partner violence is another factor related to violence against women22. Thus, environmental level factors need consideration in understanding intimate partner violence among women in slums. Slums, in the Indian census, have been defined as residential areas which are unfit for human habitation by reasons of dilapidation, overcrowding, lack of ventilation, electricity or sanitation facilities23. The neighbourhoods are so densely populated that intimate partner violence, though deemed a “private” matter, is often witnessed by neighbours and passers-by. However, because of community, family, and individual acceptance of intimate partner violence, women in the slums are often rendered more vulnerable and stigmatized for leaving abusive relationships24. Women may not disclose abuse due to fear of retribution by family and community members. A large scale study, based on socio-contextual framework, is needed to investigate (i) multiple factors in the slum environment that place women at risk for intimate partner violence, and (ii) how these factors differ from non-slum environments in India. A socio-contextual framework can provide a more comprehensive examination and understanding of slum women's exposure to intimate partner violence and areas of prevention and intervention for health care practitioners and policymakers. Health care providers are the main institutional contact for women in abusive relationships25. Thus, health care settings (particularly reproductive care settings) should play a significant role in reaching out to slum women who are at risk of or affected by intimate partner violence. Professionals providing services must be trained in screening for intimate partner violence and providing appropriate referrals. Empowerment through educational and employment opportunities can help women break free from abusive relationships. However, empowerment needs to be tied with awareness/prevention education to address cultural values and norms that place women, who leave abusive situations, at risk for further violence/marginalization by family and community.